Introduction
Miklah Health Assessment Tool is a comprehensive multi-dimensional self-assessment tool for youth and adolescents’ health. In this brief article, we explain how we designed this tool following many years of practice, experience, scholarly review of prominent and globally recognized tools, and guidance from others.
What is the problem? Why the tool?
In this modern age, young people are increasingly becoming victims of both communicable and non-communicable diseases, sometimes at rates far higher than the old or even children below 15 years. As such, self-assessment tools empower youth and adolescents to screen themselves in time and seek or get referred to appropriate health support sytems before it is too late! MHAT is the first and the most important part of this whole vision.
Adolescent and youth health challenges are increasingly complex, interconnected, and context-specific. Mental health distress, sexual and reproductive health vulnerabilities, climate-related stressors, and nutrition and lifestyle transitions do not occur in isolation. Instead, they interact dynamically, shaping young people’s physical, psychological, and social well-being.
Despite this reality, most assessment tools remain siloed—focusing on a single health dimension while overlooking broader determinants and protective factors. The Miklah Health Assessment Tool (MHAT) was therefore developed as a multi-dimensional, rights-based, and systems-informed framework designed to capture the holistic health status of adolescents and youth in a structured, measurable, and scalable manner.
MHAT was designed to be:
- Scientifically grounded
- Contextually adaptable (especially for African and low-resource settings)
- Youth-friendly and rights-affirming
- Programmatically actionable
- Suitable for schools, community programs, health facilities, and research validation
Conceptual Foundation
The development of MHAT followed a structured methodological process. See below:
1. Benchmarking Global Standards
MHAT drew from internationally validated frameworks and tools across domains. This ensured that MHAT aligns with global best practices while remaining adaptable to local realities.
– Sexual-reproductive health section: The section asks about a person’s sexual and reproductive health, knowledge, behaviors, relationships, and access to health services. These questions explore topics such as contraception and STI awareness, decision-making regarding sexual activity, experiences of consent or coercion, and the availability of services that support reproductive health. This section was developed with guidance from internationally recognized tools and frameworks for adolescent and youth sexual and reproductive health, including theDemographic and Health Surveys (DHS) youth modules, the Global School-based Student Health Survey (GSHS), the Youth Risk Behavior Survey (YRBS), developed by the Centers for Disease Control and Prevention (read more about this tool here), WHO adolescent sexual and reproductive health questionnaires, and UNICEF and UNFPA youth SRH survey tools. The purpose is to better understand experiences, knowledge, and access to services, not to judge personal choices.
– Nutrition and Physical Activity. This section explores the usual eating habits and physical activity patterns. These questions explore the types of foods a participant commonly consumes, their access to adequate and nutritious meals, their level of physical activity (including work, transport, and recreation), and the amount of time they spend sitting or being inactive. The items were developed with guidance from internationally recognized public health assessment tools, including the World Health Organization Global Physical Activity Questionnaire (GPAQ), theWHO STEPwise Approach to NCD Risk Surveillance (STEPS), the Food and Agriculture Organization dietary diversity frameworks (see here and here), and the World Health Organization / Centers for Disease Control and Prevention Global School-based Student Health Survey (GSHS).
– Climate-Health Section. The section asks about a person’s experiences, feelings, and responses related to climate change and environmental conditions. These questions explore how environmental changes such as heat, flooding, drought, or pollution may have affected your health and daily life, as well as your thoughts, concerns, coping capacity, and engagement in environmental action. This section was developed with guidance from internationally recognized climate and health assessment frameworks, including the Climate Anxiety Scale (CAS), the Hogg Eco-Anxiety Scale (HEAS), climate perception surveys from the Yale Program on Climate Change Communication, and vulnerability and adaptation frameworks developed by the World Health Organization and UNICEF.
Mental health section. This section asks about the emotional well-being, thoughts, and daily functioning over the recent past. These questions explore mood, anxiety, stress, concentration, energy, coping ability, and overall psychological well-being. This assessment was developed with guidance from internationally validated transdiagnostic and well-being instruments, including the DSM-5 Level 1 Cross-Cutting Symptom Measure of the American Psychiatric Association (see all the versions of the tool here), the Depression Anxiety Stress Scales (DASS-21), the WHO-5 Well-Being Index, the General Health Questionnaire (GHQ-12), the Patient Health Questionnaire (PHQ-9), and the mental health Gap Action Programme(mhGAP) framework of the World Health Organization. The purpose is not to provide a diagnosis, but to better understand a person’s current mental and emotional state so that appropriate support or guidance can be identified if needed. There are no right or wrong answers.
2. Systems-Based Health Perspective
Rather than treating health as fragmented components, MHAT was built on a systems health model, recognizing four interlinked domains that shape youth outcomes.
- Psychological health
- Sexual and reproductive agency
- Environmental and climate exposure
- Lifestyle and nutrition behaviors
These domains interact bidirectionally. For example:
- Climate anxiety can increase depressive symptoms.
- Poor nutrition can impair concentration and mood.
- SRHR vulnerabilities can heighten emotional distress.
- Economic stress may affect both mental health and sexual decision-making.
MHAT therefore measures health not only as absence of disease, but as presence of resilience, agency, and adaptive capacity.
The Four Core Sections of the Comprehensive MHAT
As highlighted above, MHAT is structured into four major assessment sections, each composed of validated and synthesized subdomains.
SECTION I: Sexual-Reproductive Health and Rights (SRHR)
Based on the synthesis of global tools (see above) and empirical research on adolescent SRH, we initially identified ten candidate domains believed to collectively represent the comprehensive spectrum of SRH determinants and outcomes:
- Knowledge & Awareness
- Attitudes, Beliefs & Self-Perception
- Behaviors & Practices
- Access to Information & Services
- Rights, Protection & Policy Awareness
- Relationships, Communication & Emotional Well-being
- Safety & Risk Environment
- Financial & Economic Empowerment
- Past SRHR History & Experiences
- Future Aspirations & Empowerment
These domains reflect both proximal determinants (e.g., knowledge, attitudes, behaviors) and structural or contextual factors (e.g., access barriers, economic empowerment, policy awareness) known to influence SRH outcomes among adolescents and youth. These were later condensed into 6 major domains as shown below:
- Knowledge, Awareness & Rights Literacy
- Puberty and pregnancy understanding
- Contraception knowledge
- STI/HIV awareness
- Legal protections and consent
- Attitudes, Beliefs & Self-Perception
- Body image
- Gender equality beliefs
- Stigma reduction
- Personal agency
- Behaviors, Practices & Personal SRHR History
- Protective behaviors
- Testing history
- Coercion or exploitation screening
- Health-seeking behavior
- Access, Digital Exposure & Service Experience
- Youth-friendly services
- Confidentiality
- Digital safety
- Financial barriers
- Relationships, Communication & Emotional Readiness
- Consent negotiation
- Peer pressure resistance
- Relationship health
- Economic Empowerment & Future Aspirations
- Financial literacy
- Career goals
- Reproductive life planning
SECTION II: Mental Health & Psychosocial Well-being
This section captures both distress and protective factors using a refined 5-domain model. The five domains were a refined list frome the first 10 domains that we had produced based on the tools we benchmarked. The original ten domains were as follows:
The First 10 Mental Health Domains
- Emotional Well-Being
Focus: Positive affect, life satisfaction, sense of purpose, enjoyment of daily life. - Depressive Symptoms
Focus: Persistent sadness, hopelessness, loss of interest, low motivation. - Anxiety & Excessive Worry
Focus: Nervousness, restlessness, fear, panic symptoms, uncontrollable worry. - Stress & Pressure Handling
Focus: Feeling overwhelmed, irritability, difficulty coping with responsibilities. - Cognitive Functioning & Concentration
Focus: Attention, memory, clarity of thought, decision-making ability. - Sleep, Energy & Physical–Mental Interface
Focus: Sleep quality, fatigue, somatic symptoms linked to psychological distress. - Social Connection & Support
Focus: Belonging, peer/family support, loneliness, social withdrawal. - Coping Skills & Resilience
Focus: Adaptability, emotional regulation, problem-solving, recovery after setbacks. - Risk Behaviors & Emotional Regulation
Focus: Impulsivity, substance use, anger control, risky coping behaviors. - Safety, Self-Harm & Existential Distress
Focus: Hopelessness, suicidal thoughts, self-harm ideation, perceived life worth.
These are later condensed into the five domains that later guide the assessment tool as follows:
- Emotional Distress
- Depression
- Anxiety
- Stress
- Functioning & Mind–Body Health
- Concentration
- Sleep
- Energy
- Somatic symptoms
- Positive Mental Health & Resilience
- Hope
- Purpose
- Emotional regulation
- Problem-solving
- Social Connectedness & Support
- Belonging
- Family and peer support
- Loneliness
- Risk & Safety Indicators
- Substance use
- Impulsivity
- Self-harm ideation
- Suicidal risk
SECTION III: Climate-Health & Environmental Well-being
Recognizing growing climate-related stress among youth, this section focused on climate and health. It considered four domains as guided by the cited global tools and literature.
Domain 1: Climate-Linked Emotional and Psychological Distress
Domain 2: Environmental Exposure and Climate-Related Health Impacts
Domain 3: Climate Resilience and Adaptive Capacity
Domain 4: Climate Agency, Engagement, and Sustainable Practices
SECTION IV: Nutrition & Physical Activity
This section assesses lifestyle determinants that strongly influence both mental and physical outcomes. Originally, we constructed 6 domains from the benchmarked tools as follows:
🟢 Domain 1: Dietary Quality & Diversity
(Fruit and vegetable intake; whole grains; protein sources; ultra-processed food intake; sugary drinks; fast food frequency)
🟢 Domain 2: Food Security & Access
(Skipped meals due to lack of food; financial constraints; access to nutritious food; affordability and availability of healthy options — especially relevant in LMIC contexts)
🟢 Domain 3: Eating Behaviors & Patterns
(Meal regularity; emotional eating; night eating; body image-driven restriction; eating habits linked to mental health)
🔵 Domain 4: Physical Activity Level
(Frequency — days per week; duration — minutes per session; intensity — moderate or vigorous activity)
🔵 Domain 5: Sedentary Behavior
(Sitting time; screen time; occupational or school-related inactivity)
🔵 Domain 6: Functional Fitness & Energy
(Perceived stamina; fatigue levels; physical limitations in daily activities)
These are later summed up into two major domains to guide our questionnaire:
Domain 1: Nutrition quality and food security
Domain 2: Physical activity and sedentary life
The tool supports:
- Individual screening
- School-level health profiling
- Community baseline studies
- Program monitoring and evaluation
- Policy development
- Research validation studies
3. Scoring and Grading of Health Status
Scoring within the assessment is based on a standardized 5-point Likert scale (1–5), where responses are first aligned so that higher values consistently represent better health status. For negatively worded or risk-oriented items, reverse scoring is applied to ensure directional consistency across all questions.
Item scores are summed within each domain, converted into percentage scores using normalized minimum and maximum possible values, and then aggregated to generate section-level scores (SRHR, Nutrition & Physical Activity, Mental Health, and Climate-Health), as well as an overall health score.
Health status is categorized using an improved percentage grading framework (customized Bloom’s cut-off point): 0–29% indicates Poor/High Concern (or critical risk), 30–59% Lower Moderate/At Risk, 60–79% Upper Moderate/Stable but vulnerable, and 80–100% Good/Healthy or flourishing.
Importantly, sentinel trigger items (e.g., severe risk indicators) override percentage-based grading and prompt immediate risk flags and referral recommendations where necessary, ensuring that critical health concerns are not masked by aggregate scores. We understand that the concept of sentinel triggers or events might not be familiar. As such, below is more about it:
Sentinel indicator or sentinel event item: In health assessment and quality monitoring, a sentinel trigger (often referred to as a sentinel indicator or sentinel event item) is a specific survey or assessment item that signals a critical failure, regardless of the overall score. While most assessments use aggregate scoring (where a high total score can mask individual poor results), a sentinel trigger acts as a “red flag” that demands immediate, independent investigation because the specific risk it represents is too high to be averaged out. Read more about this here and here.
Conclusion
The Miklah Health Assessment Tool (MHAT) represents a shift from fragmented health screening toward a comprehensive, youth-centered, systems-integrated health assessment framework. By combining mental health, SRHR, climate-health, and lifestyle domains within one structured instrument, MHAT provides a multidimensional understanding of adolescent and youth well-being.
Its development reflects methodological rigor, contextual sensitivity, and a commitment to rights-based health measurement—positioning it as a scalable and policy-relevant innovation for youth health systems strengthening.