Predisposing factors for adolescent dysmenorrhea in public high school students in Surakarta, Central Java, Indonesia

Background Dysmenorrhea or menstrual pain is a menstrual symptom that often occurs in almost all women of reproductive age, especially in adolescents. Dysmenorrhea itself is the most commonly complained-of symptom of endometriosis in adolescents. There are many factors that influence the incidence of adolescent dysmenorrhea. This study aimed to analyze factors predisposing adolescents to dysmenorrhea.

This cross-sectional study involved 211 first-grade students at Sekolah Menengah Atas Negeri (SMA N) 1 Surakarta, selected through total sampling based on inclusion and exclusion criteria. Dysmenorrhea incidence was the dependent variable, with independent variables including menarche age, body mass index (BMI), menstrual regularity, menstrual cycle length, menstrual duration, family history of dysmenorrhea, breastfeeding history, and cigarette exposure. Data were analyzed with SPSS version 25.0, using Chi-Square for bivariate and logistic regression for multivariate analysis.

The prevalence of dysmenorrhea among adolescents was 89.1%. A significant association was found between a family history of dysmenorrhea and dysmenorrhea incidence in adolescents (OR = 5.26; 95% CI = 1.92–14.45; p = 0.001). Prolonged menstrual cycles were also significantly associated with dysmenorrhea (OR = 3.15; 95% CI = 1.13– 8.80; p = 0.029).

Family history of dysmenorrhea and prolonged menstrual cycles significantly increase the likelihood of dysmenorrhea in adolescents. These factors should be considered in managing adolescent dysmenorrhea, which can impact daily activities and quality of life.

Adolescent, Dysmenorrhea, Predisposition factor, Prevalence, Symptom Predisposing factors for adolescent dysmenorrhea in public high school students in Surakarta, Central Java, Indonesia Uki Retno Budihastuti1*, Abdurahman Laqif1, Eriana Melinawati1, Darto1, Asih Anggraeni2, Agung Sari Wijayanti1 and Atthahira Amalia Hafiizha1 Page 2 of 8 Budihastuti et al. Middle East Fertility Society Journal (2025) 30:65

Dysmenorrhea or menstrual pain is a menstrual symp - tom that affects the majority of women of reproductive age, particularly adolescents [ 1]. Among adolescents, dysmenorrhea significantly interferes with daily activi - ties, including school attendance and academic perfor - mance. It is a leading cause of short-term absenteeism and decreased classroom participation, which collec - tively reduce effective learning outcomes such as concen- tration, comprehension, and memory retention during lessons [ 2, 3]. Dysmenorrhea is characterized by recur - rent cramping pain in the lower abdomen that occurs before or during menstruation and may be accompanied by nausea, fatigue, headache, and mood changes [ 4]. It is generally classified into two types, primary and second - ary dysmenorrhea. Primary dysmenorrhea occurs when there is menstrual pain without any abnormalities in the pelvis. Meanwhile, secondary dysmenorrhea leads to menstrual pain with the presence of pelvic abnormalities or other known medical conditions [5]. According to the World Health Organization (WHO), adolescents are in the second phase of life and includes indiciduals aged 10–19 years [ 6]. The global prevalence of dysmenorrhoea is estimated to range between 43% and 93% among women of reproductive age [ 7]. A meta- analysis involving over 20,000 young women from 38 countries reported an average prevalence of 71.1%, with particularly high rates among adolescents and university students [ 4]. Several risk factors have been identified, including early menarche, prolonged menstrual dura - tion, heavy flow, family history, smoking, lack of physical activity, stress, and low body mass index (BMI) [ 8, 9]. In addition, psychosocial and environmental determinants such as job-related stress, limited menstrual education, and sociocultural stigma also contribute to the wide vari - ation in prevalence and severity of dysmenorrhea across populations [10]. Differences in the causes and associated factors of dysmenorrhea are evident across countries and demo - graphic groups. Studies among working women in Egypt revealed strong associations with workplace stress, early menarche, and family history, whereas research among adolescents in China found that poor stress-coping abil - ity significantly increased the likelihood of dysmenorrhea [8, 11]. In contrast, studies from Pakistan and Saudi Ara - bia demonstrated that BMI and lifestyle factors were the most significant predictors among medical students [ 7, 9]. In Indonesia, dysmenorrhea remains a significant reproductive health concern among young women. Research conducted among medical students and adoles- cents in Central Java and Surakarta reported prevalence rates ranging from 79% to 91%, with significant associa - tions found for family history, BMI, and menstrual cycle length [7, 12]. Although the prevalence of dysmenorrhea in adolescents is relatively high, there are still many ado - lescents who do not receive professional treatment [13]. Apart from that, something that needs to be evaluated in adolescents with dysmenorrhoea is identifying factors that increase the risk of dysmenorrhoea. Previous studies have identified several factors that influence the occur - rence of dysmenorrhoea, both primary and secondary, such as early age at menarche, excessive menstrual blood volume, family history, smoking, alcohol consumption, obesity, and other social factors [ 13, 14]. However, con - flicting study results often emerge between studies. This study was conducted at SMA N 1 Surakarta, one of the leading public schools in Central Java, representing adolescents from diverse socioeconomic and academic backgrounds. Surakarta has also been reported to have a high prevalence of dysmenorrhoea among female ado - lescents, reaching 89.8% among those aged 15–17 years [15]. This high prevalence reflects the importance of con- ducting school-based research in this region to identify modifiable risk factors that could inform early interven - tion and menstrual health education programs. Thus, this study aimed to determine the factors influencing dys - menorrhoea among adolescents in SMA N 1 Surakarta, with the expectation that the findings can be applied in school-based health promotion and early preventive efforts for adolescent dysmenorrhea.

Study design This study employed an analytical observational approach with a cross-sectional design to identify factors associ - ated with adolescent dysmenorrhea. This research was conducted at Sekolah Menengah Atas Negeri (SMA N) 1 Surakarta, Central Java, Indonesia. This school, founded in 1943, is one of the leading high schools in Surakarta, Indonesia. Population and sample The population in this study consisted of all female stu - dents at SMA N 1 Surakarta, Indonesia, with a total of 222 individuals. This population was chosen because ado- lescents in this age group are more likely to experience menstrual problems such as dysmenorrhea, which can interfere with daily activities and school performance. All eligible students were invited to participate in the study using a total sampling technique. The minimum number of participants required was determined using the Slovin formula with a 5% margin of error, which resulted in a minimum of 141 respondents. This for - mula was selected because the total population size was known, while the population variance was unavailable. It is commonly used in descriptive cross-sectional research to obtain a representative sample when working with a Page 3 of 8 Budihastuti et al. Middle East Fertility Society Journal (2025) 30:65 finite population. To increase accuracy and minimize bias due to possible non-responses, all 222 students who met the inclusion criteria were recruited. Participants included female students aged 10 to 18 years who had experienced menarche and agreed to par - ticipate voluntarily. Students with chronic or acute medi- cal conditions that might affect menstrual patterns, such as endocrine disorders, pelvic inflammatory disease, or systemic illness, were not included. All returned questionnaires were checked for com - pleteness and consistency. Any incomplete or unclear responses were removed during the data cleaning process to ensure the accuracy of the final dataset. Study instrument Primary data were obtained through self-administered questionnaires covering demographic information (age, BMI, age at menarche, smoking exposure, and family history) and menstrual characteristics related to dys - menorrhea. The instrument consisted of two main parts. The first part contained 35 items assessing demographic data, menstrual history (regularity, cycle length, duration of menstruation), menstrual pain (location, intensity on a 1–10 scale, duration, and impact on daily activities), family history of dysmenorrhea, and smoking expo - sure. The second part included questions on psychoso - cial background, adapted from the International Child Abuse Screening Tool for Children (ICAST-C), to iden - tify environmental and emotional stress factors poten - tially related to menstrual pain. Dysmenorrhea status was measured using the Verbal Multidimensional Scoring System (VMSS), which classifies pain as mild, moderate, or severe according to its impact on daily activities and the need for medication. Respondents reporting men - strual pain of any intensity were categorized as having dysmenorrhea. Content validity of the modified ques - tionnaire was reviewed by six obstetrics-gynecology spe - cialists and one public-health expert, yielding a Content Validity Index (CVI) of 0.91. A pilot test involving twenty students demonstrated good reliability with a Cronbach’s alpha of 0.87. Statistical analysis The data were then subjected to univariate, bivariate, and multivariate analysis. Bivariate analysis uses the chi- squared statistical test, with a p-value < 0.05 considered significant. Then, the odds ratio (OR) is calculated, where the OR value and confidence interval (CI) are used to assess the significance of the relationship. Variables with p < 0.25 in the bivariate analysis (Table  2) were included in the multivariate logistic regression model to identify independent predictors of dysmenorrhea. Data were ana- lyzed using the SPSS 25 edition software (SPSS Inc. Chi - cago, IL, USA). Variable and measurement Dependent variable Dysmenorrhea The dependent variable in this study was dysmenor - rhea, defined as menstrual pain experienced during menstruation. Respondents were classified as having dysmenorrhea if they reported pain occurring before or during menstruation. The variable was categorized dichotomously into: Yes: respondents who experienced menstrual pain, No: respondents who did not experience menstrual pain. This variable was measured through a structured ques - tionnaire using self-reported data from participants. Independent variables Age Age was recorded as a continuous variable based on the respondent’s age at the time of data collection. Partici - pants were grouped into categories (15, 16, 17, and 18 years). Body Mass Index (BMI) BMI is an anthropometric measurement carried out by dividing the value of body weight (kg) by the square of body height (m 2). In this study, the numerical scale was converted into ordinal categories. The underweight cat - egory is if the BMI is 24.9. In this study, the BMI variable was divided into dichotomous categories, namely normal BMI (18.5–24.9) and abnor - mal ( 24.9). Age at Menarche Menarche was defined as the age when a girl experienced her first menstrual period. Early menarche was identified when menstruation occurred before the age of 12 years [16]. The variable was divided into two categories: <12 years and ≥ 12 years. Menstrual Regularity Menstrual regularity was determined based on partici - pants’ self-reported menstrual cycle patterns during the last six months. Regular: cycles occurring at consistent intervals (21–35 days). Irregular: cycles varying by more than seven days from month to month. Menstrual cycle length The menstrual cycle is between the first day of a period and the day before the next period begins. The menstrual Page 4 of 8 Budihastuti et al. Middle East Fertility Society Journal (2025) 30:65 cycle lasts around 28 days but can vary between 21 and 35 days. This study divided variables into categorical vari- ables: menstrual cycles ≤ 27 days and > 27 days. Duration of Menstruation Normal menstrual duration is approximately 3–7 days. This study divided variables into categorical variables: menstrual duration ≤ 7 days and > 7 days. Family History of Dysmenorrhea A family history of dysmenorrhea was defined as the presence of similar menstrual pain among first-degree female relatives, specifically the participant’s mother or sister [ 17]. The variable was categorized as no (if there was none) and yes (if there was a family history). History of Smoking Exposure The low level of active smoking and the increase in pas - sive smoking among children make this study take variables regarding cigarette exposure in adolescents (second-hand smoke) [ 18]. Exposure to second-hand smoke was evaluated with one question with two answer options: “yes” and “no” . Ethical consideration This study obtained ethical approval from the Health Research Ethics Committee of Dr. Moewardi Gen - eral Hospital (Number 994/IV/HREC/2024). Written informed consent was obtained from all participants and their parents/guardians. Participants were informed about the study’s objectives, anonymity was ensured, and participation was voluntary. All collected data were kept confidential and used solely for research purposes.

A total of 211 respondents from 222 target populations met the inclusion and exclusion criteria in this study. The prevalence of dysmenorrhoea among female stu - dents at SMA N 1 Surakarta was 89.10% (188 out of 211 respondents). Respondents in this study were mostly 16 years old. Half of the research respondents had a nor - mal-weight BMI, with 68.20% of respondents experienc - ing menstruation at the age of more than 12 years. 119 respondents admitted experiencing a menstrual cycle of > 27 days, and 59.20% experienced a regular cycle. 63.50% of respondents admitted to having a duration of ≤ 7 days. More than half of the respondents (62.10%) had a history of close family, such as a mother or sister, experiencing dysmenorrhea. The characteristics of the research sub - jects can be seen in Table 1. Based on bivariate analysis in this study, it was found that there was a significant relationship between fam - ily history and the incidence of dysmenorrhoea. A fam - ily history of dysmenorrhoea in mothers and sisters has a 4.09 times higher risk of experiencing dysmenorrhoea in adolescents (OR = 4.09; 95% CI = 1.59–10.53; p = 0.002). This study found that factors such as BMI, menarche age, menstrual regularity, menstrual cycle, duration of men - struation, and history of smoking exposure did not have a significant relationship with the incidence of adolescent dysmenorrhea. The results of the bivariate analysis can be seen in Table 2. The results of the multivariate analysis (Table  3) showed that adolescents with a positive family history of dysmenorrhoea had a significantly higher likelihood of experiencing dysmenorrhoea compared with those without such a history (OR = 5.26; 95% CI: 1.92–14.45; p = 0.001). Moreover, the menstrual cycle was also sig - nificantly associated with dysmenorrhea, where ado - lescents with a menstrual cycle length of < 27 days had a 3.15 times higher risk of experiencing dysmenorrhea compared with those with a normal cycle length ≥ 27 days (95% CI = 1.13–8.80; p = 0.029). Table 1 Baseline characteristics of participants in SMAN 1 Surakarta based on risk factors Characteristics n = 211 (%) Dysmenorrhea Yes No n % n % Age (year) 15.67 ± 0.53 15 74 (35.10) 60 81.10 14 18.90 16 133 (63.00) 125 94.00 8 6.00 17 3 (1.40) 3 100.00 0 0.00 18 1 (0.50) 1 100.00 0 0.00 BMI 20.23 ± 3.70 Abnormal ( 24.9) 96 (45.50) 84 87.50 12 12.50 Normoweight (18.5–24.9) 115 (54.50) 105 91.30 10 8.70 Menarche Age (year) < 12 67 (31.80) 61 91.00 6 9.00 ≥ 12 144 (68.20) 128 88.90 16 11.10 Menstrual Regularity Reguler 125 (59.20) 114 91.20 11 8.80 Irreguler 86 (40.80) 75 87.20 11 12.80 Menstrual cycle (day) ≤ 27 92 (43.60) 86 93.5 6 6.50 > 27 119 (56.40) 103 86.6 16 13.40 Duration of Menstruation (days) ≤ 7 134 (63.50) 119 88.8 15 11.20 > 7 77 (36.50) 70 90.9 7 9.10 Family History of Dysmenorrhea Yes 131 (62.10) 124 94.70 7 5.30 No 80 (37.90) 65 81.30 15 18.80 History of Smoking Exposure Yes 104 (49.30) 95 91.30 9 8.70 No 107 (50.70) 94 87.90 13 12.10 BMI Body mass index Page 5 of 8 Budihastuti et al. Middle East Fertility Society Journal (2025) 30:65

This study found that the prevalence of dysmenorrhoea in teenagers at SMA N 1 Surakarta was relatively high. This is in line with other research conducted in various countries, such as studies in France, where the prevalence of dysmenorrhoea in adolescents was 92.9% [ 19], Sweden 89% [ 20], and Ghana 68.1% [ 19]. A meta-analysis study conducted by Wang et al. revealed that the prevalence of dysmenorrhoea, especially primary dysmenorrhoea, in students throughout the world in 2022 was 66.1%, and this prevalence was higher than in previous years [ 14]. This indicates that dysmenorrhoea is a gynecological health issue that often occurs in women of reproductive age, both teenagers and young adults, and needs more attention. Other studies involving students, such as those in Turkey, were 83.3% [20], Lebanon had a prevalence of 80.9% [21], Zimbabwe had 75,9% [ 22], Spain 74.8% [ 23], Ethiopia 51.5% [ 24] and China 41.7% [ 25]. The varia - tion in prevalence in several studies in various countries is possible due to differences in the demographics of research respondents, the age criteria of respondents used in a study, and socioeconomic factors. Family history of dysmenorrhoea for both mother and sister had a significant relationship in this study (OR = 5.26; 95% CI: 1.92–14.45; p = 0.001). This aligns with previous research where family history was a risk factor for dysmenorrhoea, with odds ratios varying from 1.68 to 3.29 [21, 22, 24, 25]. This is possible due to the role of genetics [ 26], wherein studies of both primary and sec - ondary dysmenorrhoea populations, chromosome 1p13.2 was identified as being close to the nerve growth factor locus, which is associated with the severity of pain and can increase the body’s sensitivity to pain [ 27]. Apart from that, the behavior of the family, especially the mother, can also influence the perception of pain because children learn behavior from their mother when suffer - ing from dysmenorrhea [ 21]. Thus, early education and counseling interventions targeting both adolescents and Table 2 Results of bivariate analysis of factors associated with adolescent dysmenorrhoea Independent Variables Dysmenorrhoea OR (CI 95%) p-value Yes No N % n % BMI (kg/m2) Abnormal ( 24.9) 84 87.50 12 10.00 1.50 (0.62–3.64) 0.368 Normoweight (18.5–24.9) 105 91.30 10 8.70 Menarche Age (year) < 12 61 91.00 6 9.00 0.79 (0.29–2.11) 0.633 ≥ 12 128 88.90 16 11.10 Menstrual Regularity Reguler 114 91.20 11 8.80 0.66 (0.27–1.59) 0.351 Irreguler 75 87.20 11 12.80 Menstrual cycle (day) ≤ 27 86 93.50 6 6.50 0.45 (0.17–1.20) 0.103 > 27 103 86.60 16 13.40 Duration of Menstruation (days) ≤ 7 119 88.80 15 11.20 1.26 (0.49–3.24) 0.630 > 7 70 90.90 7 9.10 Family History of Dysmenorrhea Yes 124 94.70 7 5.30 4.09 (1.59–10.53) 0.002* No 65 81.30 15 18.80 History of Smoking Exposure Yes 95 91.30 9 8.70 0.69 (0.28–1.68) 0.406 No 94 87.90 13 12.10 Based on chi-square test; *, significantly associated at p-value < 0.05, BMI: body mass index Table 3 Results of multivariate logistic regression analysis of predisposing factors for adolescent dysmenorrhoea Independent Variable OR CI 95% p Lower Limit Upper Limit Menstrual Cycle (< 27 days)a 3.15 1.13 8.80 0.029* Family History of Dysmenorrhea (Yes)b 5.26 1.92 14.45 0.001* Constant 13.15 - - 0.000 n observation = 211 Nagelkerke R2 = 13.7% −2 Log likelihood = 126.53 *Significant at p-value < 0.05 aReference category: menstrual cycle ≥27 days (normal) bReference category: no family history of dysmenorrhea Page 6 of 8 Budihastuti et al. Middle East Fertility Society Journal (2025) 30:65 their mothers are essential to reduce dysmenorrhoea severity and improve pain management strategies. One of the characteristics of menstruation is the men - strual cycle, which appears to have a significant relation - ship with dysmenorrhoea in adolescents. In this study, a menstrual cycle of >27 days had a 3.15 times higher risk of dysmenorrhoea in adolescents. This is in line with pre- vious research where menstrual cycles of more than 29 days were more likely to experience dysmenorrhoea than those 35 days is a risk factor for primary dysmenorrhoea in adolescents [28]. The American College of Obstetricians and Gynecolo - gists (ACOG) and several studies have identified that abnormal menstrual cycles are more common in ado - lescents. This is caused by the immaturity of the HPO axis pathway at puberty, even though adolescents have experienced menarche [ 29]. Puberty begins with the first release of gonadotropin-releasing hormone (GnRH) from the hypothalamus, which induces the production of follicle-stimulating hormone (FSH) and luteinizing hor - mone (LH) from the anterior pituitary. During puberty, the feedback mechanism and response of the ovarian fol - licles to hormonal stimulation are still not sensitive, caus- ing the luteal phase of the ovarian cycle to become longer and ovulation to fail. The presence of anovulatory cycles causes abnormally long menstrual cycles in adolescents [30– 32]. Women who experience abnormal menstrual cycle length usually experience anovulation and low progester- one secretion. Decreased progesterone secretion causes excessive activation of the cyclooxygenase (COX) and lipooxygenase (LOX) pathways. This causes excessive production of prostaglandins, prostacyclins, A2 throm - boxane, and leukotrienes, increasing the intensity of dys - menorrhea [33, 34]. Apart from the menstrual cycle, other menstrual characteristics such as menstrual regularity, menstrual duration, and age at menarche were also examined in this study. Different from previous studies, menstrual regularity and age at menarche do not have a significant relationship with the incidence of dysmenorrhoea in ado- lescents. Several previous studies have shown that men - strual irregularity has a significant relationship with the occurrence of dysmenorrhoea [ 19], as well as the age of menarche [20, 22]. A study conducted on 4606 Chinese students found that age at menarche < 12 years and irreg- ular menstrual cycles increased the risk of dysmenor - rhoea by 1.16 and 1.22 times [ 25]. A possible underlying reason is the fact that girls experiencing early menarche have longer exposure to uterine prostaglandins, result - ing in a higher prevalence of dysmenorrhea [ 35]. One of the reasons why the results in this study are different from other studies may be due to the small number of teenagers experiencing menarche who are under 12 years old. Our findings are equivalent to the results observed by Acheampogn et al., who found no difference in the age of menarche between adolescents with dysmenor - rhea and non-dysmenorrhea [19]. Further research with a larger and more diverse adolescent population is needed to clarify these relationships. Another study also said that irregular menstrual cycles increase by up to 2.34 times. This is possible due to excessive prostaglandin production in the endome - trium, which causes increased uterine contractions and arterial vasoconstriction, resulting in ischemic pain [ 24]. Although the analysis did not find any significance, ado - lescents with irregular cycles in this study were 59.2%, which may indicate that there are still many adolescents in this study whose HPO axis is still immature. In this study, we also did not find a significant relation - ship between menstrual duration and the occurrence of dysmenorrhoea in adolescents ( p = 0.630). The relation - ship between menstrual duration and dysmenorrhoea remains contradictory. Several studies say that menstrual duration is a risk factor for dysmenorrhea, where men - strual duration ≥ 7 days has a 1.6 times higher chance of experiencing dysmenorrhea ( p 5 days had 1.9 times the risk of developing dysmen- orrhoea [ 35]. However, a recent study in 2019 in Ghana concluded that there was no significant relationship between menstrual duration and dysmenorrhea ( p >0.01) [19]. This study was strengthened by another study in 2021, which also stated that there was no significant relationship between menstrual duration and dysmenor - rhoea (p = 0.56) [21]. Different study results regarding behavioral risk factors associated with dysmenorrhoea were found. Although some studies did not find a relationship between unhealthy lifestyle behaviors such as smoking, low BMI (25), some studies reported a strong positive correlation [ 20, 21, 25]. Based on previ - ous literature, women with a low BMI (thin) or obesity have a high risk of dysmenorrhoea [ 37]. Thin and obese adolescents are also known to have a higher degree of dysmenorrhea pain compared to groups of normal- weight and overweight adolescents [ 38]. However, a sys - tematic review and meta-analysis study in 2022 argued that only the underweight group had an increased risk of dysmenorrhoea. In contrast, no significant relation - ship was found for the overweight and obese groups [39]. Our study found that there was no significant cor - relation between abnormal BMI and the incidence of dys- menorrhoea, as well as the history of smoking exposure, respectively, p = 0.368 and p = 0.406. Previous evidence has stated that there is a significant relationship between women who smoke actively and dysmenorrhoea [ 40, Page 7 of 8 Budihastuti et al. Middle East Fertility Society Journal (2025) 30:65 41]. However, there is still little literature that discusses women who are exposed to cigarette smoke/passive smoke. One study found that women who smoke pas - sively increased their risk of dysmenorrhoea 1.32 times [42]. This study has provided a comprehensive overview of the predisposing factors for dysmenorrhea in adoles - cents, covering various aspects, starting from menstrual characteristics to lifestyle. However, researchers are aware of the limitations of the research. First, the sample taken has the potential not to represent all teenagers in the Surakarta City area because this research was only conducted at one center for upper secondary education (SMA). Second, the cross-sectional design precludes causal inference and is susceptible to recall bias in self- reported menstrual characteristics and lifestyle factors. Third, several potentially relevant covariates were not measured, and the content validity index of the newly developed questionnaire was not formally calculated. Therefore, long-term, multi-center studies with more standardized risk factor measurements are needed for future research to estimate the true impact and generate robust evidence.

The prevalence of dysmenorrhoea among adolescents at SMA N 1 Surakarta was 89.1%. A shorter menstrual cycle and a positive family history of dysmenorrhea were sig - nificantly associated with dysmenorrhea among adoles - cents. These factors should be taken into account when assessing adolescents who present with menstrual pain. Considering that dysmenorrhea can interfere with school activities and reduce quality of life, health-care providers and school-based health services may consider routine assessment of menstrual pain and provision of appropri - ate management and education on menstrual health.

The author would like to thank SMA N 1 Surakarta for permitting research and Universitas Sebelas Maret for its financial support through the Penelitian Hibah Grup Riset (Hgr-UNS) B research scheme. Authors’ contributions URB: Conceptualization, Methodology, Supervision, Funding Acquisition, Writing – Original Draft, Review & Editing. AL: Data Curation, Formal Analysis, Funding Acquisition, Review & Editing. EM: Investigation, Project Administration, Validation, Funding Acquisition. D: Software, Data Collection, Funding Acquisition. AA: Visualization, Literature Review, Funding Acquisition, Review & Editing. ASW: Resources, Ethics Approval, Project Administration. AAH: Questionnaire Distribution, Statistical Analysis, Writing – Original Draft. Funding This research received grant funding from Universitas Sebelas Maret through the Penelitian Hibah Grup Riset (Hgr-UNS) B research scheme with contract number 194.2/UN27.22/PT.01.03/2024. Data availability The datasets studied are available from the corresponding author upon reasonable request. Declarations Ethics approval and consent to participate This research has received ethical approval from the ethics committee of Dr. Moewardi General Hospital with number 994/IV/HREC/2024. Written informed consent was obtained from all participants and their parents/guardians. Consent for publication All participants provided written informed consent to publish anonymized data in this manuscript. Competing interests The authors declare no competing interests. Received: 9 July 2025 / Accepted: 28 November 2025

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