|Year : 2015 | Volume
| Issue : 2 | Page : 203-208
A study on health risk behavior of mid-adolescent school students in a rural and an urban area of West Bengal, India
Nivedita Das1, Dipankar Chattopadhyay1, Sajib Chakraborty2, Aparajita Dasgupta3, Fasihul Akbar1
1 Department of Community Medicine, College of Medicine and Sagore Dutta Hospital, Kamarhati, Kolkata, India
2 Department of Anatomy, College of Medicine and Sagore Dutta Hospital, Kamarhati, Kolkata, West Bengal, India
3 Department of Preventive and Social Medicine, All India Institute of Hygiene and Public Health, Kolkata, West Bengal, India
|Date of Web Publication||16-Dec-2015|
35/3, Kankrapara Lane, Howrah - 711 104, West Bengal
Source of Support: None, Conflict of Interest: None
Background and Objective: High-risk behaviors can have adverse effects on health of adolescents. It is essential to identify risks so that modification can be initiated before any damage. The present study was conducted among adolescents to study their risk behaviors. Materials and Methods: This cross-sectional descriptive study based on the concept of Global School-based Student Health Survey was conducted by interviewing adolescents of one urban and one rural randomly selected school. For quick overall assessment of their risk behaviors, a predesigned three-point scoring system was followed. Data were analyzed using Epi Info version 3.5.1. Results: The study of six domains of important risk behaviors among 788 school-going adolescents (rural: 436 [55.3%], urban: 352 [44.7%]), (male: 406 [51.5%], female: 382 [48.5%]) revealed that occurrence of dietary high-risk behavior was more in urban students (11.4%) than rural students (1.8%). Regarding violence, occurrence of high-risk behavior was also higher among urban students (18.8% vs. 6%). The number of mentally disturbed girls is more than boys. Conclusion: The mean risk scores in all domains, except personal hygiene, are either in 'Moderate' or 'high' risk grade. It is of great concern that rural and urban, male and female adolescents are at risk though their vulnerability varies.
Keywords: Adolescent, behavior, health risk, protective factor
|How to cite this article:|
Das N, Chattopadhyay D, Chakraborty S, Dasgupta A, Akbar F. A study on health risk behavior of mid-adolescent school students in a rural and an urban area of West Bengal, India. Arch Med Health Sci 2015;3:203-8
|How to cite this URL:|
Das N, Chattopadhyay D, Chakraborty S, Dasgupta A, Akbar F. A study on health risk behavior of mid-adolescent school students in a rural and an urban area of West Bengal, India. Arch Med Health Sci [serial online] 2015 [cited 2019 Jun 25];3:203-8. Available from: http://www.amhsjournal.org/text.asp?2015/3/2/203/171906
| Introduction|| |
Adolescence, the second decade of life, is a period of transition between childhood and adulthood. It is a period of identity crisis and experimentation, a time of physiological and psychological changes of puberty. Teen-agers' peer pressure is believed to play a significant role in the onset of lifestyle risk behaviors. 
High-risk behaviors are those that can have adverse effects on health and well-being. This includes behaviors that cause immediate physical injury (e.g., fighting), as well as behaviors with cumulative negative effects (e.g., lack of physical activity, harmful peer relationships). Causes of high-risk behaviors include inadequate information and skill, poor access to education and health services, unsupportive social environment and exploitation.
Some risk factors are determined by the behavior established in adolescence. Preventing the development of such behaviors is easier than reversing them in adulthood. There lies the need of initiating behavioral changes at the earliest. Health education to school children in their formative age is the most effective method for protection and promotion of their health since they are likely to be receptive to changes in ideas and agreeable to modification of their habits. 
Most importantly, risky behaviors such as smoking, consuming high fat diets, alcohol, sedentary lifestyle and engaging in unprotected sex can result in disease outcomes such as cancer, obesity, hypertension and other cardiovascular diseases, type 2 diabetes and HIV infection; which are among the leading causes of death in both developed and developing countries. Other risks like depression, suicidal ideation and violence may also be associated.
School is the place where adolescents spend considerable time of the day by learning, performing activities and experimenting new things along with their peers. Good support from fellow students may enhance subjective well-being at school and reduce stress. On the other hand, experiences of being bullied or excluded from the activities might have an adverse effect. 
The students can serve as means of promoting health of fellow children, their families, and community members. There is a growing recognition that the health and psychosocial well-being of children are of fundamental value and that the school settings can provide a strategic means of improving children health, self-esteem, life skills and behaviors.
In 2001, WHO in collaboration with UNAIDS, UNESCO and UNICEF and with technical assistance from the US center for disease control and prevention (CDC), initiated the global school-based health surveillance system (GSH).  One component of GSH is the Global School-based Student Health Survey (GSHS) to periodically monitor the occurrence of important health risk behaviors and protective factors among students.
Thus, the present school-based cross-sectional descriptive study based on the concept of GSHS was conducted among the students (Class VII to IX) in West Bengal to study the distribution of low, moderate and high health risk behaviors among rural and urban, male and female adolescent students and to assess statistical significance of difference in high-risk behaviors between various categories.
Health risk behavior involves actions and related attributes and perceptions that contribute to people's propensity to engage in, or avoid, activities that have been deemed by experts as hazardous or dangerous to their health. This study to identify health risk behaviors of mid-adolescent school students in our situation is an attempt to assist young people to avoid them.
| Materials and Methods|| |
This observational descriptive and cross-sectional study was conducted from January 2010 to April 2010. Purposive Sampling Method was followed in selecting study areas, that is, a rural block (Singur, Hooghly District) and an urban area (Chetla, Kolkata) of West Bengal. Considering limited resources it was decided to restrict the study in four (20%) of twenty-two co-education high schools in the study areas. Thus, two schools each from the rural and the urban clusters were randomly selected. All students of Class VII to IX after obtaining written informed consent from the parents/guardians were included in the study. Permission from appropriate administrative authorities including institutional ethical committee was also sought and obtained.
Tools used in the present study were the modified "2007 INDIA (CBSE) GSHS" health survey questionnaire,  for school students aged 13-15 years. The questionnaire included 35 multiple choice questions including 8 questions on respondent demography and 27 questions on dietary behaviors, personal hygiene, physical activity, mental health, protective factors and violence and unintentional injury. For this survey, the questionnaire was translated in Bengali, the local language, maintaining the semantic equivalence and validated by three experts of the All India Institute of Hygiene and Public Health, Kolkata. The India-specific GSHS (CBSE) questionnaire was pretested with students of similar ages. The final questionnaire was modified accordingly before it was administered in selected schools.
GSHS survey questionnaire has given a working definition of physical activity. Physical activity is any activity that increases heart rate of the individual and makes someone get out of breath for some time. It may be sports, playing with friends, or cycling to school. Some examples of physical activity are running, fast walking, dancing or playing football.
Adolescents who live in a home and school environment which encourages self-expression within structure and boundaries and provides meaningful relationships with parents, teachers and peer groups, who have positive attitudes toward school are less likely to initiate sexual activity early, less likely to use substances, and less likely to experience depression and suicidal ideation. The questions in 'Protective factor' section measure school attendance, perceived social support at school, parental regulation and monitoring as well as parental bonding and connection.
On each day of survey the self-administered standard questionnaire was distributed to the students of class VII, VIII, IX to answer over a period of 45 min following an introductory session explaining the purpose and how to fill up the questionnaire. Complete anonymity was ensured to encourage the students to express their true opinions.
Responses were recorded on five-point scale. For quick overall assessment of the health risk behaviors of the students from rural and urban settings, a predesigned three-point scoring system, validated by three experts of the All India Institute of Hygiene and Public Health, Kolkata, was followed in this study. The responses were grouped in three categories as follows:
Group I: Never and Rarely.
Group II: Sometimes.
Group III: Most of the time and always.
Depending on the most desirable to least desirable behavior or practice, the Group I, II and III are allotted either 2-1-0 or 0-1-2 score in order. Score 2 is given for the most desirable response, and 0 is for the least desirable response for each question. Cumulative score on each topic was calculated for each and every student. Total obtainable score for each topic was sub-divided into three groups:
Thus, for each topic, each student obtained a grade from A to C, that is, indicating low-risk to high-risk behavior. The number of students obtaining different risk grades for various domains was computed.
- (Maximum desirable score range) indicating low-risk behavior.
- (Intermediate score range) indicating moderate risk behavior.
- (Minimum desirable score range) indicating high-risk behavior.
Data collected were entered in Microsoft Office Excel 2007 and analyzed using statistical software Epi Info version 3.5.1 developed by Centers for Disease Control and Prevention. The frequency was calculated in percentages. Z-test or Chi-square test was used to assess statistical significance of the difference between various categories. Level of significance was fixed in this study at P < 0.05.
| Results|| |
The present cross-sectional study covered six domains of the important health risk behaviors among 788 school-going adolescents (rural: 436 [55.3%], urban: 352 [44.7%]), (male: 406 [51.5%], female: 382 [48.5%]) of Class VII to IX. These included health risk dietary behaviors, ill-maintained personal hygiene, inadequate physical activity, instability in mental health, lack of optimum protective factors and behaviors that may result in injuries and violence.
In each of the six domains, the scoring pattern was studied to assess the distribution of low, moderate and high-risk behaviors among rural and urban, male and female adolescent students. For each key area, rate of high-risk behavior was compared between rural and urban groups of study population and Z-test is performed to determine the significance of the difference in [Table 1].
|Table 1: Comparison between rural and urban students based on their health risk behavior and practice grades (n = 788)|
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For dietary issue, occurrence of high-risk behavior was more in urban students (11.4%) than their rural counterpart (1.8%).
In the domains of personal hygiene practice and physical activity, rural students had higher risk behavior pattern.
Regarding the violence and unintentional injury issue, overall occurrence of high-risk behavior was higher among urban students (18.8%) than students from the rural background (6%).
Since higher the score obtained less is the health risk, rural students had significantly less risk taking behavior or practices than their urban counterparts in respect of diet and violence. On the other hand, urban study group had significantly less health risk behaviors regarding personal hygiene, physical activity and protective factor issues than the rural group.
In [Table 2], comparison has been made between rural and urban study groups according to the mean score obtained by them in each of the domain under study. Here, Z-test is used for comparing between two sample means of rural and urban groups.
|Table 2: Comparison between rural and urban students based on mean health risk behaviour and practice score (n = 788)|
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In all domains other than mental health issues, significant statistical differences exist between the mean scores obtained by rural and urban students.
Since higher the score obtained less is the health risk, rural students had less risk taking behavior or practices than their urban counterparts in respect of diet, physical activity, mental health and injury issues. On the other hand, urban study group had less health risk behaviors regarding personal hygiene and protective factor issues than the rural group.
Distribution of various health risk behaviors or practices were tested for a significant difference between boys and girl students. Chi-square test was employed to determine statistical significance of the difference of proportions. Significantly different risk behaviors or practices are presented in [Table 3].
|Table 3: Gender-wise distribution of the students according to selected health risk behaviour or practices (n =788)|
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More boys did not eat vegetables twice a day in most days during past 14 days, had fast-food and carbonated drinks once or more per day on most of the days. They skipped bathing more frequently. Boys engaged more in physical fights got injured more frequently and was abused verbally or physically by teachers on more occasions.
But the number of girls who felt disturbed most of the time during past 12 months due to comments by their peers, family members or teachers is more than their boy counterparts.
Regarding mental health this study revealed that 8.1% students felt lonely most of the time and 9.6% students had worries disturbing their sleep. About 26.4% adolescents felt so sad or hopeless that they stopped their usual activities once or more during the past 12 months preceding the survey. About 35.8% students felt disturbed due to comments from their peers, family members or teachers during the past 12 months. About 19.5% students reported that they had seriously considered attempting suicide during past 12 months. About 17.2% adolescents stated that they had no close friend.
In the present study, 35% students missed classes or school without guardian's permission on one or more occasions in the past 1-month. About 52.8% students have reported that most of the students in their school were helpful most of the time during the past 30 days preceding the survey. About 16.5% students stated that their parents enquired whether their homework was done. About 15.7% of the study population had parent or guardian who understood their problems and worries and 20.6% students stated that their parents or guardians were not usually aware of what they were doing in their leisure.
| Discussion|| |
The World Health Organization has defined "adolescents" as persons in the 10-19 years age group.  During adolescence, teenagers start to make individual choices and develop personal lifestyles. Many of these lifestyle choices are related to risk behaviors resulting in disease outcomes.  It is also easier to inculcate healthy behavior at a young age rather than to modify behaviors at later ages or after the onset of the disease. 
In the present study among 12-17 years school going adolescents 60% students (rural: [65.1%], urban: [52.8%]) usually did not eat vegetables at least 2 times daily. Though fruits and vegetables are grown in the rural areas, the paradox is possibly due to lack of awareness or poorer economic condition of rural students. The availability of fruits and vegetables can be augmented by kitchen gardens for family consumption.
The intake of fast-foods and carbonated drinks were less prevalent among students in the present study in comparison to studies at Chandigarh  and New Delhi.  It is evident in the present study that the urban students had roadside fast foods more frequently than their rural counterpart (20.4% vs. 10%). The rural adolescents perhaps have less access to them; their pocket money may also be less. Male students also had more fast foods than female students, possibly due to more time spent outside home and more peer pressure.
In a study at Indori village, Pune  1.3% boys and 4.5% girls had poor hygiene. In this study, 18.5% study population did not brush their teeth every day. This may be due to lack of awareness regarding oral hygiene.
About half (51.2%) (rural: [61.5%], urban: [38.6%]) and 43.9% (rural: [60.5%], urban: [23.3%]) of the study subjects rarely washed their hands with soap before meals and after using toilets respectively. It might be that more rural people use indigenous materials after toilet. Also, poorer people cannot afford soaps for hand washing.
Unlike the previous cases, only 6.9% of rural students in contrast to 15.3% of urban students did not take bath daily. This may be due to less availability of water in urban areas.
The Chandigarh study  stated that 40.7% boys and 23.9% girls claimed to be physically active. The respective figures stated by Singh et al.  are 81.7% and 77.8%. This variation may be due to different methodologies adopted in different studies. In this study, 58.1% students were not physically active for at least 60 min/day in most of the days during the past 14 days. This may be a result of scarcity of playground, burden of homework and private tuition as well as attraction of other entertainments after school hours.
Most students (82.9%) spent three or more hours per day watching television, listening music or gossiping with friends in a typical week day. It is alarming that most adolescents prefer to lead sedentary lifestyle.
Only a quarter (29.7%) of the adolescents (rural: [42.2%], urban: [14.2%]) usually slept more than 9 h at night. It is most likely that the life of rural adolescents is more relaxed; whereas the urban adolescents had more exposure to attractions outside.
Nair et al.  found 3% prevalence of depression among school-going adolescents. Deb et al.  found that 20.1% boys and 17.9% girls were suffering from anxiety in Kolkata. Sharma et al.  reported that 15.8% students thought of committing suicide, while 5.1% had actually attempted suicide during last 12 months. The results regarding mental health obtained in the present study could not be compared with other studies because data in the present study were obtained only through self-administered questionnaire.
In the present study, 43.8% of study population had a physical fight once or more during past 12 months. This may be due to intense competitive atmosphere and lack of the supportive environment. About 45.4% students sustained injuries including accidental injury requiring medical attention once or more during past 12 months. About 64.5% of these students reported that their injury occurred while they were playing. About 29% amongst them reported that their injury was due to other accidents. Sharma et al.  found that one in every two boys reported being involved in a physical fight, and 17.8% received injury serious enough to require medical attention. Unintentional injuries are a major cause of death and disability among young children. 
In our study, 20.4% students were bullied by their peers once or more during past 12 months. About 36.5% students reported being physically or verbally abused by teachers during that period. Victims of bullying have increased stress and a reduced ability to concentrate and are at increased risk for substance abuse, aggressive behavior, and suicide attempts. 
This study gives a glimpse of baseline information of high-risk behavior of mid-adolescent school students in selected rural and urban areas of West Bengal. The areas of concern are excessive consumption of fast food and carbonated drink, lack of physical activity, verbal and physical abuse by peers, family members or teachers and depression and suicidal ideation.
The mean risk scores of both rural and urban adolescent boys and girls in the domains of dietary behavior, physical activity, mental health issues, protective factors, violence and unintentional injury are either in the 'moderate' or 'high' risk grade.
An integrated action strategy involving various stakeholders (decision makers, community leaders including teachers, parents and adolescents) should be undertaken for prevention and control of health risk behaviors among adolescents. Focused formal and informal life skill education through school and other social institutions and mass media may be tried to reduce health risk behaviors of adolescents in rural and urban areas.
| Acknowledgment|| |
The authors sincerely acknowledge the support of Prof. Madhumita Dobe Head, Department of Health Education, All India Institute of Hygiene and Public Health, Kolkata at every stage of the study.
| References|| |
Selvan MS, Kurpad AV. Primary prevention: Why focus on children & young adolescents? Indian J Med Res 2004;120:511-8.
Kulkarni V, Pratinidhi A, Garad SG. Study of knowledge of school children in a health education programme. Indian J Community Med 1997;3:129-33.
Gore SL, Aseltine RH Jr. Stress, coping resources, and gender: An ecology of protective processes in adolescence. Am J Community Psychol 1995;23:301-27.
World Health Organization. The Global school-based student health survey (GSHS). Available from: http://www.who.int/chp/gshs/en
. [Last accessed on 2011 Nov 31].
Singh AK, Maheshwari A, Sharma N, Anand K. Lifestyle associated risk factors in adolescents. Indian J Pediatr 2006;73:901-6.
Majumder R, Ganguli SK, Raje S. A study of adolescents in rural area. Health and Population - Perspectives and Issues. Vol. 24. New Delhi: NIHFW; 2001. p. 198-205.
Nair MK, Paul MK, John R. Prevalence of depression among adolescents. Indian J Pediatr 2004;71:523-4.
Deb S, Chatterjee P, Walsh KM. Anxiety among high school students in India: Comparison across gender, school type, social strata and perceptions of quality time with parents. Aust J Educ Develop Psychol 2010;10:18-31.
Sharma R, Grover VL, Chaturvedi S. Suicidal behavior amongst adolescent students in south Delhi. Indian J Psychiatry 2008;50:30-3.
Sharma R, Grover VL, Chaturvedi S. Risk behaviors related to inter-personal violence among school and college-going adolescents in South Delhi. Indian J Community Med 2008;33:85-8.
[Table 1], [Table 2], [Table 3]