1 Introduction

The Eastern Mediterranean region is the home of 22 countries. Over half of these countries face a humanitarian crisis [1]. In this context, numerous humanitarian organisations operating in the region have led to a lack of government control over the selection and implementation of programmes and interventions [2]. During this time, adolescents' well-being becomes a critical concern. Adolescents (aged 10–19) are in a crucial stage of development and represent a significant portion of the population in humanitarian settings. Yet, programming and interventions sometimes overlook their health needs [3]. Due to their unique physical and emotional development, adolescents require specialised attention different from that of adults and children [4]. In times of humanitarian crises, some male adolescents are forced to take on the role of head of household. In contrast, female adolescents are at a higher risk of early marriage and gender-based violence [5]. This puts them in more vulnerable situations, which, combined with other factors, contribute to some of the leading causes of death among adolescents in the Eastern Mediterranean Region [6]. These causes include collective violence, road injuries, congenital anomalies, lower respiratory infection, tuberculosis, iron-deficiency anaemia, self-harm, maternal causes, interpersonal violence and major depressive disorders [7].

Health indicators are collected using different health surveys, census data and population-based surveys such as the Demographic Health Survey and the Multiple Indicator Cluster Survey [8]. During humanitarian settings, this can be challenging because of safety and the population's rapidly changing needs. Rapid needs assessments are often relied upon in humanitarian settings and are not widely shared frequently; therefore, there is a lack of standardisation and measurability in these assessments, and they cannot be used to inform policies and programmes [9]. In a previous study done by the researchers, it was found that adolescent health indicators are collected in humanitarian settings, using population-based surveys and are often out of data and not inclusive of both males and females [10]. It is crucial to monitor key adolescent health indicators to strengthen an already weakened health system [11].

It is important, before data collection, to have an understanding of the relevance and feasibility of adolescent health indicators to ensure efficient resource allocation, cultural acceptability and alignment with local priorities. For example, indicators related to sensitive topics require careful consideration to prevent resistance and underreporting. Involving local stakeholders in the future helps promote acceptability and allows for their inputs to ensure the selected indicators align with their values and needs [12]. This need is particularly evident in humanitarian settings, where additional efforts are required to collect and provide accurate, up-to-date data to monitor and evaluate humanitarian actions. However, responsibilities and accountabilities for this study are often unclear [13]. While evidence from non-humanitarian settings may apply to different populations across countries, certain conditions, such as malnutrition, are unique to humanitarian settings [14]. Health indicators are essential for tracking the progress of national health service delivery goals [15]. Unfortunately, only 6% of the Sustainable Development Goal indicators focus explicitly on adolescent health [16].

Considering the surge of non-governmental organisations in the West Bank amid the ongoing humanitarian crisis and the lack of governmental control over available programmes, it is vital to invest time and effort in measuring key indicators. Evidence-based programmes and policies are necessary in this regard. In humanitarian settings like the West Bank, collecting health indicators is hindered by cultural norms and resource limitations, making it important to first identify indicators that are both contextually relevant and feasibly collectable [17]. The Palestinian Coalition of Adolescent Health Launching Event took place in August 2019, bringing together various governmental and non-governmental stakeholders to address the current needs, concerns and perceptions of adolescents and youth in the occupied Palestinian territory. In August 2022, the strategic plan for adolescent and youth health was launched, outlining the current needs of adolescents in the country and establishing the adolescent and youth department within the Ministry of Health. However, the strategy did not specify the key indicators necessary to measure the progress of the implemented programmes or policies.

Recognising the need to address the specific challenges and needs of adolescents, the WHO and United Nations partner agencies established the Global Action for Measurement of Adolescent Health (GAMA) Advisory Group (AG) [18]. Since 2018, the GAMA AG has defined a set of core measurement areas for adolescent health, mapped existing indicators linked to these areas and selected a draft list of priority indicators for adolescent health measurement [19-21]. Using this list to determine which indicators are relevant and feasible, this study provides the exploratory research for evidence-based interventions and a framework for future data collection efforts in similar humanitarian settings [22]. Involving different stakeholders and prioritising a country's adolescent health needs is essential in focusing on adolescent health interventions. This process considers the severity of the country's issues, the availability of interventions, the most affected groups or populations and the feasibility of executing interventions. Collecting data on significant and feasible indicators is crucial [23]. This study aims to determine the perceived relevance and feasibility of collecting a set of adolescent health indicators in the West Bank.

2 Methods

The study employed a structured approach to assess the perceived relevance and feasibility of adolescent health indicators in the West Bank, incorporating stakeholder engagement through a multistep process. Initially, stakeholders were invited to complete a questionnaire designed to evaluate a comprehensive set of indicators based on predefined criteria. Following this, a workshop was convened to critically analyse and validate the findings, fostering collaborative discussion and consensus-building among participants.

The list of indicators was based on adolescent health indicators suggested by the World Health Organization GAMA (WHO GAMA) [12]. Each indicator was translated from English to Arabic and back to English by the researchers to ensure the meaning was preserved, and both languages were included on the ranking sheet provided to stakeholders. The list of indicators and their translations can be found in Annex 1.

Purposive sampling was used to invite the stakeholders to participate. Stakeholder mapping was done in a previous research, which allowed the researchers to have a cumulative list of adolescent health organisations. Participants were directly identified and invited if they were recognised for their involvement in organisations serving adolescent health or contributing to their organisation's Health Information Systems (HIS). Selection criteria focused on their expertise in HIS or their experience working with adolescents. Stakeholders from the Ministry of Health, the Ministry of Education, International and Local organisations, and academic institutes were approached in person or by email to participate in ranking adolescent health indicators. They were informed that the ranking of indicators will allow for the collection of relevant and feasible indicators to establish evidence-based programmes and policies for adolescents to improve adolescent health outcomes. If the participant agreed, a hard copy was physically given to the participant, and a soft copy was then subsequently emailed. Up to three follow-up emails were sent to each participant.

The stakeholders were asked to rate each of the 50 indicators on a 5-point Likert-type scale (5 = strongly agree, 4 = agree, 3 = unsure, 2 = disagree and 1 = strongly disagree) on five criteria. These criteria were (1) Context-specific, (2) Feasibly measurable, (3) Timely collectable, (4) Financial and Human Resources available and (5) Useful and Important. These criteria were based on expert consultation and the literature of the criteria of quality indicators [24]. Table 1 provides a detailed description of how the indicators were assessed.

After each of the ratings, each participant could put in free text comments considering why they rated each indicator or any other comments they wanted to share. They either physically returned the questionnaire with the rating or emailed their selections. Each participant was given 2–3 weeks to return their ratings to the researcher. Reminders were emailed, or participants were called after the requested submission date to ensure their participation. A workshop was held where all stakeholders were invited to participate in the sharing of the preliminary results. A presentation was given on the ranking of the stakeholders, and they were given a chance to discuss any agreements or concerns with the tentative list of indicators.

3 Data Analysis

Using the five criteria listed above, the researchers grouped the indicators into two groups: relevancy and feasibility. Relevancy was determined for each participant by the mean of the context-specific, useful and important responses, and feasibility was determined by the mean score of participants of feasibly measurable, timely collectable, and financial and human resource availability. Then, for each indicator, the meaning of all participants was taken for both relevancy and feasibility. To analyse the results, the following interpretation of values was used: 4.50–5.00 Strongly agree; 3.5–4.49 Agree; 2.51–3.49 Neutral; 1.50–2.49 Slightly agree and 1.00–1.49 Disagree.

An average of 3.5 or higher for each group was considered feasible and relevant because we were interested in the indicators rated Strongly agree (4.50–5.00) and Agree (4: 3.5–4.49). This allows each of the 50 indicators to fall into one of four categories, respectively: feasible and relevant ( < 3.49 and < 3.49), feasible and irrelevant ( < 3.49 and > 3.49), not feasible and relevant ( > 3.49 and < 3.49), and not feasible and irrelevant ( > 3.49 and > 3.49). Descriptive statistical analysis, including the calculation of mean scores and categorisation analysis, was done using Microsoft Excel. All comments left by the participants were compiled and discussed in the workshop that was later held to discuss the preliminary results.

The workshop was audio-recorded with the informed consent of all participants, ensuring that the recording would only be shared with the research team and their contributions would stay anonymous. After the session, the recording was transcribed by a research assistant. An inductive reasoning approach was employed using MAXQDA software to analyse the data. This method allowed themes to emerge from the discussion, reflecting on the participants' insights without preconceived themes.

4 Results

Sixteen of 22 stakeholders (84.2% response rate) returned their questionnaires. All 22 stakeholders were invited to the workshop. Fourteen out of the 16 stakeholders attended the discussion of indicators at the workshop conducted. Stakeholders perceived that out of the 50, 22 were feasible and relevant to be collected in the West Bank. Table 2 describes the 16 stakeholders based on organisational affiliation, experience in HIS or adolescent health and who attended the workshop. Below you will find the different categorisations of indicators.

5 Categorisation of Indicators

The indicators were distributed into eight different content areas: determinants of health, population, mortality, morbidity, sexual and reproductive health, health behaviour and risks, violence and injuries, policies, systems and interventions, and mental health and well-being. No indicator was found feasible and not relevant. There are 11 indicators dedicated to sexual and reproductive health; four were found relevant, and none were found to be feasible. The most feasible indicators are in the categorisation of health behaviour and risks, where out of nine indicators, seven were relevant and six were feasible. One mental health indicator and one violence and injury indicator were found to be both relevant and feasible. The distribution of the indicators and categorisation can be found in Table 3. There were 22 (44%) that were relevant and feasible, no indicators that were not relevant and feasible, 17 (34%) that were relevant and not feasible, and 11 (22%) that were not relevant and not feasible. No content area was found to be fully relevant and feasible.

6 Perceived Relevant and Feasible List of Indicators

Twenty-two indicators were identified to be relevant and feasible. The scores for relevance were much higher than for feasibility. The feasibility scores were borderline (e.g., 3.5) for several of the indicators, such as living with food insecurity, thinness, physical activity, fruit and vegetable servings, physical violence, reporting of suicide and the existence of a functioning national programme. This shows some uncertainty in measuring these indicators and the resources available.

Living with food insecurity was the only indicator to receive a score lower than 4 in relevancy. Table 4 gives a complete description of the included indicators. While there were no quotes from the workshop to explain why stakeholders found these indicators relevant and feasible, their inclusion in the study suggests that they align with their priorities, and the current health system has existing resources for collection. Stakeholders were more interested in discussing why some were not feasible and why some indicators need to be included in the original list of indicators.

7 Relevant but Not Feasible Indicators

Stakeholders ranked 17 out of 50 indicators as what they perceived were relevant but not feasibly collectible in the country. These were mainly due to cultural norms, stigma associated with indicator, and wording of indicators.

8 Wording of Indicators

Some stakeholders saw the wording of psychoactive drug use as a problem. Psychoactive drug use can refer to energy drinks, for example, caffeine intake, as well as the use of illegal substances. It was found that the indicator needed to be clearer if illegal substances were being described here. This shows the importance of developing globally comparable indicators and ensuring their relevance and interpretability in local contexts. Table 5 describes the indicators found to be relevant but not feasible and the reason for their exclusion.

9 Not Relevant and Not Feasible Indicators

There were 11 out of 50 indicators that stakeholders perceived as irrelevant and not feasible to collect in the West Bank. These indicators involve alcohol, unchangeable cultural norms and unavailable practices and services. Table 6 describes all indicators found to be irrelevant and not feasible and why they were excluded.

10 Services/Practice Unavailable

Stakeholders found that it was not relevant and not feasible to collect indicators concerning the HPV vaccine and female genital mutilation. The HPV vaccine is not a service currently offered in the country, and stakeholders described that cervical cancer is also not prevalent. In addition, female genital mutilation is not practised, so they did not find a benefit in measuring this indicator. It is important to continuously assess the situation to ensure the assumption that HPV and female genital mutilation are not relevant to the local context.

11 Additional Indicators for Consideration

This highlights the growing concern over the socio-economic factors affecting adolescents and their well-being. It's important to have this data to address the concern of child labour. Although Palestine currently collects disability indicators, there was agreement that the current indicators were insufficient. This shows that stakeholders are aware of the gap in the current system of the indicators not properly capturing the prevalence, type or impact of disabilities on adolescents. Therefore, an agreement was made to explore the disability indicators with the proper stakeholders to decide which indicators should be included. It was also discussed that electronic cigarettes should be added to the tobacco indicator. Including this indicator is important because it shows that stakeholders are aware that there are newer forms of substance use that are becoming more prevalent, and it is important to monitor.

12 Opportunities and Challenges in the Creation of a National List of Adolescent Health Indicators

This showed that stakeholders found that a standardised indicators list could play a huge role in evidence-based decision-making for adolescent health. The list has the potential to serve as an important catalyst for interventions and resource allocation.

This statement shows that external funding priorities often dictate data collection and not local needs. It is important to find a way to allow for donor priorities to align with local priorities. The other challenges described were who should pay for the data to be collected and what type of infrastructure would be needed to collect the data. Many of the stakeholders feel that the government should be in charge of taking the lead in owning the list of indicators and providing the information for said indicators. Exploring partnerships between government, international organisations and local stakeholders could be a way to address these challenges.

13 Discussion

Stakeholders identified 22 out of 50 GAMA adolescent health indicators as relevant and feasible. Seventeen indicators were considered relevant but not feasible with certain changes and can be feasible to collect in the country, and 11 were considered not relevant and not feasible, as they are very hard to collect in the West Bank. Still, the 17 indicators are considered relevant but not feasible. No indicator received a rating of higher than 4.5 in feasibility. Many of the included indicators had scores of 3.5 for feasibility. The unfeasible indicators came from the categorisation of sexual and reproductive health, violence and injury, and mental health.

Cultural and social norms were one of the main reasons some indicators were not feasible to collect in the West Bank. This is expected to be a problem in other countries in the Eastern Mediterranean Region. Sex before marriage is not socially acceptable to discuss. In a recent study in Saudi Arabia, women acknowledged their marriage status when discussing sexual and reproductive health topics [26]. Another study in Iran showed that university students initiated sexual intercourse after marriage. Still, a percentage did not have the information needed to perform safe sexual behaviours [27]. Girls also often know nothing about menstruation before it starts [28].

The Palestinian Educational System is currently working on incorporating sexual education, mental health, gender roles, and gender equity and equality into the educational curriculum. There is no sexual education programme in the current system. Furthermore, two studies have been done on the perception of sexual education and knowledge of university students in different geographical regions in the Occupied Palestinian Territory. Results showed that university students have insufficient knowledge of SRH rights, as well as limited awareness of the transmission of sexually transmitted infections and HIV/AIDS [29, 30]. A potential reason for the disparity in SRH knowledge was noted between students who attended private schools in the occupied Palestinian territory, where co-educational settings and some sexual education might be provided [29, 30]. The lack of open discussion about SRH allows the formation of misconceptions, leaving adolescents and young adults without the tools to make informed decisions about their health.

Globally, comprehensive sexual education has been shown to improve SRH knowledge, reduce risky behaviours and promote gender equity. Knowledge of menstruation and puberty is also a part of comprehensive sexual education [31]. Yet, in culturally conservative settings like Palestine, introducing it into the curriculum requires a tactical approach. Community resistance, driven by fears that discussing sexual health may encourage premarital sexual activity, presents a significant barrier. There is a belief amongst parents and teachers that if sexual and reproductive health is discussed, sexual behaviours are more likely to increase. Studies have shown that comprehensive sexual education has not affected the desire for youth or adolescents to perform sexual behaviours. The educational curriculum has led to safer sexual behaviours but not increased sexual behaviours [32].

Some of the main programmes run in the country are mental health, violence and injuries, sexual and reproductive health and WASH. If it is not acceptable and a priority for these areas to be measured, then how are we measuring the success of our programmes? The main issues found in the mental health indicators were the wording of the indicator itself and the ability to collect the indicators. The ability to collect mental health indicators is a worldwide concern. Mental health data availability is scarce, particularly in low- and middle-income countries, as over 100 countries were found to have no data, and Palestine is no exception [33]. The wording was found to be a problem because the focus of mental health in humanitarian settings is on post-traumatic stress disorders and depression, as this can be misleading and subjective in disasters and armed conflict [34]. These indicators risk excluding other significant mental health challenges, such as anxiety, adjustment disorders or substance use. Also, the cultural differences in how distress is expressed emphasise the need for culturally adapted indicators. There is a need for the measurement of other mental health disorders or problems. This need was recognised with the formation of the MMAP initiative (Measurement of Mental Health among Adolescents at the Population Level). The initiative hopes to address the different mental health indicators in various situations [35]. By collaborating with MMAP, stakeholders in Palestine could refine mental health indicators to ensure cultural appropriateness, feasibility and representativeness.

Sexual violence and injuries were seen as unfeasible due to the stigma involved. Many times, sexual abuse of female children and adolescents goes unreported for fear of hurting the family reputation and future marriage prospects [36]. This is also a problem in the region. In a systematic review done on the key forms of violence against adolescents in the Arab region, it was found that the available data were insufficient in giving a clear picture of the prevalence of violence in the region. Many times, the sample sizes were small, showing that there were areas of violence where more research was needed [37]. Another review of child sexual abuse in Arab countries showed the under-researched area as well. Many of the included studies showed cultural adaptation to questions to refrain from using sexual terms when describing sexual abuse. When the adaptations were not done, response rates were found to be lower than when adaptations were considered [38]. To address the stigma around sensitive health topics, implementing culturally adapted programmes and anonymous reporting systems may help provide an environment where adolescents feel safer sharing their experiences. Studies from similar humanitarian settings suggest that engaging community leaders and educators can help normalise discussions around mental health and sexual health, reducing stigma over time [39].

Stakeholders were open to adapting the relevant and feasible indicators, although many challenges were addressed. A comprehensive understanding of how data collection was operationalised, considering challenges and highlighting the significance of various factors like political will, leadership roles, costs, and responsibilities in this process, is needed. One of the main challenges faced in humanitarian crises is the collaboration of agencies and validation of data collection [40].

14 Conclusion and Recommendations

Stakeholders agreed that 22 of the 50 adolescent health indicators were relevant and feasible to be collected in the West Bank. This does not mean that these should be the only indicators that should be measured and collected. The real challenge lies in the 17 indicators that were found to be relevant but not feasible. A way to overcome cultural norms would be to offer culturally sensitive, comprehensive sexual education. Comprehensive sexual education would be essential to be added to school curricula [41]. With an increase in the use of the internet and the vast variety of material available, comprehensive sexual education in schools allows teachers and counsellors to share correct and trusted information instead of adolescents looking for it themselves [42]. Cultural sensitivities should be considered, starting with awareness of gatekeepers such as religious leaders, teachers, counsellors and parents. The community's involvement will allow for change and acceptance of discussing sexual and reproductive health, allowing for the feasibility of these indicators to be collected [43]. It would also be important to change the wording of the mental health indicators to reflect humanitarian setting needs, as well as move away from the stigma involved with sexual abuse and suicidal thoughts by providing anonymous ways of reporting and speaking with professionals when needed. Implementing school-based mental health programmes as well as antibullying programmes is the most efficient way to encourage the discussion of mental health in any country [44]. It is also important to find the resources to invest in the measurement of some of these indicators, as measuring will save resources in the future [45].

These steps serve as a foundation for actionable change, ensuring that findings are effectively translated into meaningful improvements in adolescent health in the West Bank.

15 Contribution to the Field Statement

This study makes a significant contribution to the field of adolescent health in the Eastern Mediterranean region, particularly in humanitarian settings. It addresses the critical issue of overlooking adolescents' health needs during crises by identifying 22 relevant and feasible indicators to monitor their health in the West Bank. Work will be needed to help collect the 17 indicators deemed as relevant but not feasible. With limited data available on adolescent health in such contexts, this study fills an essential gap and advocates for evidence-based programmes and policies. By engaging diverse stakeholders and advocating for culturally sensitive, comprehensive sexual education and mental health programmes, the study aims to overcome cultural and social barriers that hinder data collection on sensitive topics. The establishment of a national list of adolescent health indicators serves as a milestone for standardising data collection, guiding health programme planning and fostering accountability. Overall, this study's findings will significantly improve understanding, interventions and prioritisation of adolescent health in the region, potentially influencing similar contexts worldwide.

Author Contributions

Aisha Shalash: conceptualisation, writing – original draft, methodology, writing – review and editing, data curation. Niveen Abu Rmeileh: supervision, funding acquisition, writing – review and editing, conceptualisation. Dervla Kelly: conceptualisation, writing – review and editing, supervision. Khalifa Elmusharaf: conceptualisation, data curation, writing – review and editing, supervision.

Ethics Statement

The Institute of Community and Public Health, Birzeit University's ethical committee review board, has approved this study. Each participant was informed that their participation was voluntary and that, at any stage, they could withdraw their participation. They were also informed that their answers were not identifiable and that their participation would remain anonymous. No animal studies are presented in this manuscript. No potentially identifiable human images or data are presented in this study.

Conflicts of Interest

The authors declare no conflicts of interest.