LITHUANIAN UNIVERSITY OF HEALTH SCIENCES
MEDICAL ACADEMY FACULTY OF PUBLIC HEALTH
DEPARTMENT OF PREVENTIVE MEDICINE
Usman Nasir
HEALTH BEHAVIOUR OF SCHOOL-AGED CHILDREN IN
PAKISTAN: A COMPARATIVE STUDY
Master thesis
Scientific supervisor:
Professor Linas Šumskas MD, DPH, PhD
Kaunas, 2013
SUMMARY
Health behavior of school aged children in Pakistan: a comparative study
Usman Nasir
Academic supervisor Prof. Dr. Linas Šumskas
Lithuanian University of Health sciences, Faculty of Public Health, Department of Preventive
Medicine. Kaunas; 2013. 54 pages.
Aim. To observe and evaluate the health behaviour in school aged children and to get key
insights into the health related behaviours of young people.
Objectives. To analize and evaluate health behaviours among boys and girls in Pakistan. To
analize and evaluate health-risk behaviors among boys and girls in Pakistan.To compare
health behaviours of adolescents in Pakistan and Lithuania.
Methods. Health Behavior in School aged Children (HBSC) questionnaire was used in this
study. Questionnaire survey was carried out in 2 schools of Pakistan. One school was private
and one school was public. The were 300 participants and majority of them were 14 and 15
years old. Health behavior was measured with questions concerning adolescent’s nutritional
habits (breakfast, fresh fruit and vegetable, sweets, fast food and soft drinks with sugar
consumption), health-risk behavior (cigarette use, injuries) and physical activity. Statistical
data was analyzed using the statistic package SPSS 15.0 for Windows.
Results. Two thirds (78.5%) of respondents thought they are in good health and just 4%
claimed having excellent health. Study results showed, that 41% of school students exercise
2-3 times a week and 7.3% less than once a month. It was estimated that more than half of
Pakistan adolescents eat breakfast every day on weekdays, but on weekends less than one
third have breakfast at home. One third of respondents stated, that eat fresh vegetable and
20.1% of then eat fresh fruit every day. Unhealthy diet products such as sweets, soft-drinks
with sugar, fast food adolescents consumed (from 0% till 24.6%) every day or 4-6 times a
week. Significant differences were found among gender and soft-drinks with sugar and fast
food consumption – girls consumed unhealthy diet products less frequent than boys. The
results showed that 12.1% of adolescents reported smoking once a week. Statically significant
differences were found among respondent gender and injuries. Girls were injured more often
than boys in the past 12 month. Teenagers in Pakistan thought they are in excellent health less
frequent than teenagers in Lithuania. Study result showed that statistically significant
differences were found between breakfast consumption on weekends, nutritional habits,
smoking of adolescents in Pakistan and Lithuania.
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Conclusions. Adolescents in general experience good health in Pakistan. Physical activity of
the majority adolescents did not meet the global WHO recommendations for school-aged
children. Fresh vegetables were more popular than fresh fruits among adolescents. Boys and
girls consumed fresh fruits and vegetables equally often. Majority of adolescent’s unhealthy
diet products consumed rarely. Unhealthy diet products were more popular between boys than
girls in Pakistan. Adolescents in Lithuania experience excellent health more often than
teenagers in Pakistan. Health behavior of adolescents were different in Pakistan and
Lithuania.
Keywords. Health behavior, adolescents, nutritional habits, health risk behavior.
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LIST OF ABBREVIATIONS
CDC – Centers for Disease Control and Prevention
WHO – World health organization
SES – socio-economic status
HBSC – Health Behavior in School age Children
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CONTENTS
INTRODUCTION ...................................................................................................................... 6
1. THE AIM AND OBJECTIVES ............................................................................................. 8
2. LITERATURE REVIEW ....................................................................................................... 9
2.1 Defining adolescence ....................................................................................................... 9
2.2 Health-related behavior in adolescence.......................................................................... 10
2.3 Perception of self and health-related behavior ............................................................... 11
2.4 Health-related behaviors and other intrapersonal and interpersonal factors .................. 13
2.5 Socioeconomic background of adolescent health-related behaviors .............................. 13
2.6 Socioeconomic differences in self-esteem of adolescents influenced by personality,
mental health and social support .......................................................................................... 14
2.7 Self-efficacy, affectivity and smoking behavior in school aged children in adolescence
.............................................................................................................................................. 17
2.8 Socioeconomic status and physical activity among school aged children (adolescents)19
3. MATERIAL AND METHODS ........................................................................................... 20
3.1 Survey plan and sampling. ............................................................................................. 20
3.2 Statistical analysis. ......................................................................................................... 21
4. RESULTS AND DISCUSSION .......................................................................................... 22
4.1 Health behavior among boys and girls in Pakistan ........................................................ 22
4.1.1 Physical activity of adolescents in Pakistan ............................................................ 22
4.1.2 Nutritional habits of adolescents in Pakistan .......................................................... 23
4.2 Health-risk behavior of adolescents in Pakistan ............................................................ 25
4.3 Correlation between health behaviour of school students in Pakistan and Lithuanian .. 29
CONCLUSIONS ...................................................................................................................... 34
PRACTICAL RECOMMENDATION .................................................................................... 35
REFERENCES ......................................................................................................................... 36
ANNEX .................................................................................................................................... 45
Physical activity ....................................................................................................................... 50
Family....................................................................................................................................... 53
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INTRODUCTION
Health behavior is one of the most important determinant of health. Health
Behavior s – any activity undertaken by an individual, regardless of actual or perceived health
status, for the purpose of promoting, protecting or maintaining health, whether or not such
behavior is objectively effective towards that end. Research into children’s health and health
behavior and the factors that influence them is essential for the development of effective
health education and health promotion policy, programmers and practice targeted at young
people. It is important that young people’s health is considered in its broadest sense, as
encompassing physical, social and emotional wellbeing; and that, in accordance with the
WHO perspective, health is viewed as a resource for everyday living, not just the absence of
disease. (WHO, 1948).
Thus, research into children’s health needs to consider the positive aspects of
health, as well as risk factors for future illness and disease. Many behaviors’ that comprise
young people’s lifestyles may directly or indirectly impinge on their health in the short or
long term; consequently, a wide range of behavioral variables should be measured. Positive or
health promoting behavior needs to be studied, as well as health-damaging or risk behavior.
Certain behavior is initiated in the adolescent years, while some patterns of
behavior, such as eating patterns, become established in earlier childhood. Taking a social as
opposed to a purely biomedical research perspective means studying the social, environmental
and psychological influences or determinants of child and adolescent health and health
behavior. Thus family, school and peer settings and relationships need to be explored, as does
the socioeconomic environment in which young people grow up, if we are to understand fully
the patterns of health and health behavior found in the adolescent population (Penedo &
Dahn, 2005; Parfi tt & Eston, 2005).
The focus area of this thesis work was Health, Eating habits, Tobacco use and
physical activity.
Adolescence is defined as the period from the onset of puberty to the termination of
physical growth and attainment of final adult height and characteristics that occurs during the
second decade of life. It is characterized by rapid physical growth, significant physical and
psychological changes, and evolving personal relationships. Adolescence and the great and
rapid changes associated with it may have major effects on the health of individuals, and,
conversely, variations in health may significantly affect the transitions of adolescence. (Lam,
Stewart, & Ho, 2001).
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Thus, data on how young people move through adolescence, and factors that influence
the success of and difficulty with this transition should include measures and indicators of
health. International comparisons of the rates and variations of transitions through
adolescence and the interactions of adolescence with health offer rich opportunities to confirm
fundamental biological and developmental processes while examining the effects of
contextual and cultural processes. Perceptions of health, self-confidence and satisfaction with
life reflect the level of stress and anxiety that young people experience. The frequency of
morning tiredness may offer important guidance for policy on schools’ hours of operation.
Medication use for certain symptoms may reflect the prevalence of causes of these symptoms,
and attitudes towards and availability of medication, or both. In most instances, these data
cannot determine the cause of health events experienced by young people, but international
comparisons can describe similarities between countries, and highlight issues to be addressed
and questions to be answered.
Numerous health behaviors’ and attitudes in adolescence and adulthood are begun in
the family setting during childhood. Lifestyle-related habits in hygiene, nutrition and physical
activity, as well as communication skills and social competences, are an essential part of
familial education. (Hallal, Victora, Azevedo & Wells, 2006).
Deficits in these areas are among the main reasons for health impairments in later life.
The family is therefore a decisive factor in young people’s health that needs investigation.
In adolescence the educational role of the family decreases. In search of individual
adult identity, young people tend to orient themselves towards peer groups. In most cases
this also means orientation towards adolescent subcultures. Risk behavior, such as alcohol
and tobacco consumption, is part of social interaction within these peer groups. While
experimentation with such behavior can be considered a regular developmental task, group
pressure may cause their maintenance, which impairs health.
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1. THE AIM AND OBJECTIVES
The aim
To observe and evaluate the health behaviour in school aged children and to get key insights
into the health related behaviours of young people.
The objectives
1. To analize and evaluate health behaviours among boys and girls in Pakistan.
2. To analize and evaluate health-risk behaviors among boys and girls in Pakistan.
3. To compare health behaviours of adolescents in Pakistan and Lithuania.
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2. LITERATURE REVIEW
2.1 Defining adolescence
Adolescent population and health of adolescents is a very special issue and is focus of
attention globally for various reasons. The world today is home to the largest generation of
10–19 year olds in our history and number over one billion and their population is
continuously increasing.
The demands on young people are new and unprecedented; their parents could not
have predicted many of the pressures they face. How we help adolescents meet these demands
and equip them with the kind of education, skills, and outlook they will need in a changing
environment will depend on how well we understand their world. (Bandura, 1995)
The first step toward deepening our understanding is to clarify the concept of
adolescence. There is no universal method for doing so, and in Pakistan policies and programs
affecting young people are bound to be affected by a lack of consistency. “Adolescents” and
its cognates are variously defined. The lines between childhood, adolescence, and adulthood
may differ by culture and region. The CDC uses the terms “adolescents and young adults” for
those aged 10 to 24, inclusive, usually broken into 3 age groups (ages 10–14, 15–19, and 20–
24).
The population aged 15–24 in Pakistan was estimated to be approximately 27 million in 2000,
and it is expected to continue to increase, reaching 44.6 million in 2020. This is an increase of
39 percent in just 20 years. This age group accounts for almost one quarter of the population
in Pakistan and the peak number of youth will be reached in the year 2035.
Basic data on education, employment, and reproductive health among
adolescents shows that they are not receiving the adequate schooling and capability building
to equip them for the future. It also follows from the Mensch et al. characterization of
adolescence that the period of transition to adulthood must equip young people with the
education, skills, decision-making power, and information to function as responsible adults in
society (De Vries & Mudde, 1998).
Adolescents are a unique population with specific health concerns and needs.
Adolescence is the peak age of onset for serious mental illness like depression and psychosis.
Over load of stress from physical, emotional, social and sexual change makes adolescents
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overloaded with stress which can result in anxiety, withdrawal, aggression, poor coping skills
and actual physical illness. (Curry & Youngblade, 2006; Colder & Stice, 1998)
The adolescent period is characterized by its rapid physical and psychological
changes in the individual, together with increasing demands from and influence of peers,
school and wider society. It is well documented that behaviors developed during this period
influence health in adulthood. Several health compromising behaviors (e.g. smoking, alcohol)
as well as health enhancing behaviors’ (e.g. physical exercise) is adopted in adolescence and
they often persist into adulthood (Van Nieuwenhuijzen et al., 2009; Lam, Stewart, & Ho,
2001; Jessor, 1991). The World Health Organization estimates that 70% of premature deaths
among adults are due to behavior (smoking, illicit drug use, reckless driving) initiated during
adolescence. Therefore, helping adolescents establish healthy lifestyles and avoid developing
health risk behaviors is crucial and should be started before these behaviors are firmly
established.
2.2 Health-related behavior in adolescence
Health-related behaviors have traditionally been defined as behaviors
undertaken by individuals that affect their health (Kasl & Cobb, 1966). These behaviors can
be further distinguished between health compromising behaviors (e.g. smoking, alcohol
consumption, can abuse, and unprotected sex), which have an undesired effect from a public
health perspective on health, and health-enhancing behaviors (e.g. physical activity, healthy
eating), which have a desired effect on health from a public health perspective. Patterns of
health-compromising behaviors and their initiation and progression in adolescence are
generally considered to be predictive of later involvement in such behaviors and exposure to
their harmful consequences (Tucker, Ellickson, Orlando, Martino, & Klein, 2005). Healthy
lifestyle patterns that include health-enhancing behaviors can be also traced back to childhood
and adolescence (Hallal, Victora, Azevedo, Wells, 2006).
Previous research (Van Nieuwenhuijzen et al., 2009; Lam, Stewart, & Ho, 2001;
Jessor, 1991) shows that the mentioned behaviors cluster together and therefore might have
similar patterns of determinants. Empirical evidence supports the existence of organized
patterns in adolescent health-related behaviors with several domains of influence (Petraitis,
Flay, Miller, 1995; Jessor, 1991), which are described in more details in Table 1.1.Based on
these models it is possible to distinguish the following domains of influence: genetics (e.g. a
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family history of addiction), intrapersonal factors (e.g. low self-esteem), interpersonal factors
(e.g. family and/or peer support) and sociocultural (e.g. socioeconomic status) factors.
Understanding factors related to health-related behaviors is essential for
developing effective and successful strategies that contribute to health promotion not only in
adolescence (present health) but also in adulthood.
2.3 Perception of self and health-related behavior
Adolescence, as the period of transition from childhood to adulthood, is a
critical time for the development of lifelong perceptions, beliefs, values and practices. This
period is related to making that transition and to coping with several challenges. Adolescents
struggle with the developmental tasks of establishing an identity, accepting changes in
physical characteristics, learning skills for a healthy lifestyle and separating from family
(Susman, Dorn & Schiefelbein, 2003; Burt, 2002). Adolescents’ family, peers, neighborhood
environment, school and other associations can help them complete these tasks or can pose
significant barriers that many youths will not be able to overcome on their own. During
adolescence, youths continue with developing their perception of the self and face the task of
establishing a satisfying self-identity (Burt, 2002; Anderson & Olnhausen,1999).
Self-esteem is an evaluative and affective aspect of the self. It is also considered
as equivalent to self-regard, self-estimation and self-worth (Harter, 1999). It refers to a
person’s global appraisal of his/her positive or negative value (Markus & Nurius, 1986). Selfesteem has well-known consequences not only for current physical and mental health and
healthrelated behaviors, but also for future health and health-related behaviors during
adulthood (Mann et al, 2004).
Positive self-esteem is a basic element of mental health, but it also contributes to
better health through its role as a buffer against negative influences. Conversely, negative
self-esteem can play a critical role in the development of several internalizing (depression,
anxiety) and externalizing (violence, substance use) problems (Mann et al., 2004). Selfesteem is closely connected with self-efficacy and plays an important role in what are
currently the most frequently used cognitive models of health-related behavior, such as the
Theory of Planned Behavior (TPB) (Ajzen, 1991), the Attitude-Social influence-self-Efficacy
(ASE) model (De Vries & Mudde, 1998), the Theory of Triadic Influence (TTI) (Flay &
Petraitis, 1994) and the Precede-Proceed model (Green & Kreuter, 1999). Based on the
review by Mann et al. (2004), self-effi cacy in behavioral domains, according to the TPB,
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influences self-esteem or the evaluation of self-worth. At the same time, according to other
models such as the ASE or TTI, self-esteem could be considered as a distal factor influencing
self-efficacy in specific behavioral domains.
Self-esteem has been repeatedly associated with health compromising and
health-enhancing behaviors in past research. Recent studies have confirmed the connection
between higher self-esteem and regular physical activity (White, Kendrick & Yardley, 2009;
Penedo & Dahn, 2005; Parfi tt & Eston, 2005). Evidence about the association between
smoking or cannabis use and self-esteem is more contradictory but still suggests a connection
between higher self-esteem and lower engagement in smoking and cannabis use (Kokkevi,
Richardson, Florescu, Kuzman, & Stergar, 2007; Wild, Flisher, Bhana, & Lombard, 2004;
Carvajal, Wiatrek, Evans, Knee, & Nash, 2000).
Self-efficacy, defined as beliefs in one’s capabilities to organize and execute the
courses of action required to manage prospective situations (Bandura, 1995), has a central
role in socio-cognitive theories, e.g. Ajzen’s (1988) theory of planned behavior or Bandura’s
(1986) social cognitive/learning theory. People’s beliefs in their own efficacy influence the
choices they make, their aspirations, how much effort they mobilize in given behaviors and
how long they persevere in the face of difficulties (Bandura, 1991). Behavior-specific selfefficacy is therefore generally considered as an important determinant of the practice of
health-related behaviors. Specific beliefs about self-efficacy are considered to have the most
immediate and direct association with health-related behaviors like regular smoking, cannabis
use and physical activity. Low perceived self-efficacy has been repeatedly connected with a
higher prevalence of smoking behavior (Engels, Hale, Noom, & De Vries, 2005; Kim, 2004;
Engels, Knibbe, de Vries & Drop, 1998) and a lower prevalence of physical activity (White,
Kendrick & Yardley, 2009; Annesi, 2006).
Self-competence and self-liking were defined by Tafarodi & Swann (1995) as
constructs emerging from global self-esteem. Self-competence is defined as the evaluative
experience of oneself as an intentional being with efficacy and power. Self-liking, on the
other hand, is defined as the evaluative experience of oneself as a good or bad person
according to internalized criteria for worth. These two dimensions could also be extracted
from the Rosenberg Self-esteem Scale, as has been confirmed in other studies (Schmitt &
Allik, 2005; Tafarodi & Milne, 2002). There is a lack of studies exploring self-liking and selfcompetence in association with health-related behaviors. However, both mentioned aspects of
self are closely related to the concept of self-esteem and it can be assumed that they are
associated with health-related behaviors in a similar way (Tafarodi & Swann, 1995).
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2.4 Health-related behaviors and other intrapersonal and interpersonal factors
Based on the comprehensive social-psychological framework for explaining
health-related behaviors proposed by Petriatis, Flay, & Miller (1995) and Jessor (1991), other
intra- and interpersonal factors can be expected to contribute to the association between the
perception of self and health-related behaviors. From the intrapersonal domain, factors like
personality, affectivity, mental health and resilience have been associated with health related
behaviors in previous research (Markey et al., 2006; Curry & Youngblade, 2006; Windle &
Windle, 2001; Gordon Rouse, Ingersoll, & Orr, 1998). From the interpersonal domain, family
and peers factors are the most studied determinants of health-related behaviors (Tomcikova et
al., 2009; Mistry et al., 2009; Peters et al., 2009). To be able to fully explore health-related
behaviors and their determinants, it is important to look for the expected contribution of
factors from different domains.
2.5 Socioeconomic background of adolescent health-related behaviors
Socioeconomic background is probably an important cause of adolescents’
health-related behaviors, but evidence on its role is not yet conclusive. There are some
differences regarding type of health-related behaviors and some country differences as well.
Different types of health-related behaviors do not associate similarly with socioeconomic
status, and differences in the association between socioeconomic status and health-related
behaviors were also found across countries (Richter et al., 2009; Currie et al., 2008).
Regarding smoking, some studies found that socioeconomic differences in adolescent
smoking are not present or not as pronounced as in adult smoking (Richter et al., 2009;
Tuinstra et al., 1998), while other studies revealed consistent socioeconomic differences
regarding this type of health-related behavior (Piko & Keresztes, 2008; Salonna et al., 2008;
Goodman & Huang, 2002; Madarasova Geckova et al., 2005).
Consistent socioeconomic differences can be found in health-enhancing
behaviors like physical activity or consumption of fruits and vegetables. Higher
socioeconomic status was associated with more frequent physical activity and a higher
frequency of fruits and vegetables consumption (Richter et al., 2009; Vereecken, Maes & De
Bacquer, 2004). Geckova (2002) provided several explanations for these contradictory
findings: (a) differences in the socio-cultural context; (b) differences in the measurements of
13
socio-economic status; (c) differences in the measurements of health-related behaviors and (d)
differences in the samples. Differences in the socio-cultural context are very likely to occur
and influence the findings. Therefore, they need to be taken into account in the process of
explaining the results. In addition, differences in measurements of health-related behaviors
might be more pronounced than differences in measurements of socioeconomic status since
there is more variety in the questionnaires used for measuring various types of health-related
behavior. A fifth explanation for these discrepancies could be the period of life in which these
behaviors are established. For instance, health-enhancing behaviors like physical activity are
usually established in childhood when parental influence is much stronger than in adolescence
(Richter et al., 2009). Therefore, socioeconomic status defined by the educational level of
parents might be associated more strongly with such health-enhancing behaviors. In contrast,
health-endangering behaviors like smoking are established more intensively in adolescence
when the influence of parents is less pronounced and the influence from peers is growing.
This might explain the less consistent findings about the connection between the
socioeconomic status of parents and health-endangering behaviors like smoking in this period
of life. These inconsistent findings also support the assumption made by Petraitis, Flay, &
Miller (1995) that health-related behaviors in adolescence need to be explored with regard to
factors from different domains of influence (intrapersonal, interpersonal and socio-cultural)
which might contribute to the connection between socioeconomic status and health-related
behaviors and which were not fully explored in the above mentioned studies.
2.6 Socioeconomic differences in self-esteem of adolescents influenced by personality,
mental health and social support
Socioeconomic position has a clear impact on developing self-esteem, especially
during the important stage of adolescence. At this period of life, the self-esteem of young
people undergoes important changes, influenced not only by the already-mentioned
socioeconomic status, but also by variety of other intrapersonal, interpersonal and
sociocultural determinants (Finkenauer, Engels, Meeus & Oosterwegel, 2002). Adolescence,
the period of transition from childhood to adulthood, is a critical time for the development of
lifelong perceptions, beliefs, values and practices. An adolescent struggles with the
developmental tasks of establishing an identity, accepting changes in physical characteristics,
learning skills for a healthy lifestyle and separating from family (Susman, Dron &
Schiefelbein, 2003).
14
Therefore, before entering adulthood, it is important for the adolescent to
develop high self-esteem and the ability to care for the self (Anderson & Olnhausen, 1999).
Self-esteem has well-known consequences not only on current physical and mental health and
health-related behavior, but also on future health and health-related behavior during adulthood
(Mann, Hosman, Schaalma & de Vries, 2004).
Self-esteem also plays an important role in what are currently the most
frequently used cognitive models of health behavior, such as the Theory of Planned Behavior
(TPB) (Ajzen, 1991), the Attitude-Social influence-self-Efficacy (ASE) model (De Vries &
Mudde, 1998), the Theory of Triadic Infl uence (TTI) (Flay & Petraitis, 1994) and the
Precede-Proceed model (Green & Kreuter, 1999). Based on the review by Mann et al. (2004),
self-efficacy in behavioral domains, according to the TPB, influences self-esteem or the
evaluation of self-worth. At the same time, according to other models such as the ASE or TTI,
self-esteem could be considered as a distal factor influencing self-efficacy in specific
behavioral domains. In addition, to be able to change the consequences of self-esteem on
future health and health-related behavior, it is important to be aware of possible correlates and
associations of low or high self-esteem which are crucial during the developmental stage of
adolescence. According to Harter (1999), the development and maintenance of self-esteem in
childhood and adolescence is influenced by two important factors: perceived competence in
areas of importance and the experience of social support. Considering other factors, correlates
of self-esteem can be divided into several essential domains: (a) gender, (b) socioeconomic
factors, (c) personality factors and mental health, and (d) factors from family, friends and
significant others. It is also necessary to mention that in the past, researchers only investigated
levels of explicit self-esteem.
However, in recent decades other aspects of self-esteem have been discovered
and explored, such as implicit self-esteem, contingent self-esteem and self-esteem stability
(Crocker, Luhtanen, Cooper & Bouvrette, 2003; Kernis et al., 1993). Gender has been
reported to have an influence on developing selfesteem during adolescence. Boys are more
likely to have high self-esteem at this stage of life than girls (McMullin & Cairney, 2004;
Robins et al., 2002; Kling, Hyde, Showers & Buswell, 1999). Gender differences have also
been reported in age-related changes. Self-esteem among boys tends to increase, while selfesteem among girls tends to decrease a little during early adolescence (Birndorf, Ryan,
Auinger & Aten, 2005; Robins et al., 2002). Previous studies also show socioeconomic status
to be significantly related to self-esteem. In general, those with higher socioeconomic status
report higher self-esteem than those with lower socioeconomic status (Rhodes, Roffman,
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Reddy & Fredriksen, 2004; Francis & Jones, 1996). Among socioeconomic factors, family
income seems to be most related to self-esteem among adolescents (Birndorf et al., 2005).
Mental health has been reported to be associated with selfesteem in the past.
Several studies (Miyamoto et al., 2001; Bolognini, Plancherel, Bettschart, & Halfon, 1996;
Rosenberg, Schooler, Schoenbach & Rosenberg, 1995; Brown & Mankowski, 1993) have
been conducted in this field, and associations have been found between self-esteem and
depression and between self-esteem and anxiety. Self-esteem has been also reported to be
related to eating disorders (Stice, Presnell & Spangler, 2002) and aggression (Donnellan et al.,
2005; Baumeister, Smart & Boden, 1996). However, the relationship between self-esteem and
aggression is currently being debated by researchers. Some authors argue that low selfesteem
is related to aggression (Donnellan et al., 2005), whereas others indicate that high self-esteem
is linked to aggression (Baumeister, Smart & Boden, 1996). Surprisingly, less attention has
been paid to the connection between personality dimensions and self-esteem itself, though it
could be hypothesized that consistent personality traits might influence the way people
perceive and evaluate themselves (Robins et al., 2001).
Family, peers and significant others play a major role in the development of an
adolescent’s self-esteem. The family in particular, as the primary environment at this period
of life, provides an important background for developing and creating the initial sense of
oneself. Previous studies have found a positive relationship between supporting family
relationships and self-esteem (Birndorf et al., 2005; Sweeting & West, 1995; Barrera &
garrison-Jones, 1992). On the other hand, a lack of support or a dysfunctional family
environment has been described as a contributor to maladjustment, behavioral problems and
drug abuse (Wentzel, 1994; McKay, Murphy, Rivinus & Maisto, 1991). In addition, support
from peer groups and signifi can’t others, like teachers, could positively or negatively infl
uence the development of one’s self-esteem.
The question remains regarding how social support from family, friends and
significant others contribute along with other self-esteem factors (e.g. personality, mental
health) to the association between socioeconomic status and self-esteem. Factors such as
gender, socioeconomic status, personality and mental health and support from family and
other relationships are all suggested as important influences in the field of the developing selfesteem during the adolescence, ultimately affecting outcomes in the area of mental health and
health behavior. Understanding the associations between self-esteem and its correlates could
bring new ideas to the role of self-esteem in the framework of health promotion among young
people. Socioeconomic status is less strongly associated with self-esteem in comparison to
16
personality dimensions and mental health constructs, which are very similar and strongly
associated. Social support from family, friends and significant others could be seen again as
conceptually more distinct in relation to self-esteem.
Therefore, based on the theoretical and empirical findings, the main aim of this
study is to assess whether personality, mental health and social support contribute to the
relationship between socioeconomic status and self-esteem. We will explore these variables
and their associations with self-esteem. We assume that (a) socioeconomic status, personality,
mental health and social support will be significantly associated with self-esteem; (b)
socioeconomic status will be less strongly related to self-esteem in the model, and the
explanatory power will decrease after adding personality dimensions, mental health and social
support subscales; and (c) personality dimensions and mental health subscales, as similar
constructs, will be strongly related to self-esteem and have a greater explanatory power.
2.7 Self-efficacy, affectivity and smoking behavior in school aged children in adolescence
Smoking is the most common form of substance use, and its harmful impact on
health is well known. Tobacco use among young people leads to short-term health problems,
including reduced lung function, increased asthmatic problems, coughing, wheezing and
shortness of breath, and reduced physical fitness. It also leads to greater susceptibility to and
severity of respiratory illness (Currie et al., 2004). Similarly, cannabis is also widely used and
is most frequently used by adolescents as their first illicit drug (Kingery, 1999). Recently,
young people have reported using more drugs and starting to do so at an earlier age (Currie et
al., 2004). Patterns of substance use, initiation and progression in adolescence are generally
considered to be predictive of later involvement with substance use and exposure to its harmful
consequences (Tucker, Ellickson, Orlando, Martino, & Klein, 2005).
Understanding the factors associated with substance use in adolescents is
therefore essential in the field of prevention and health promotion. Evidence on healthcompromising behavior demonstrates the continued high prevalence of cigarette smoking by
young people (Baska, 2009; Currie et al., 2008; 2004; 2000). Initiation and progression in this
stage of life are also generally considered to be predictive of later involvement and exposure to
smoking’s harmful consequences (Tucker, Ellickson, Orlando, Martino, & Klein, 2005).
Moreover, smoking behavior has been shown to cluster with other types of healthcompromising behavior as part of a problem behavior syndrome (Lam, Stewart, & Ho, 2001).
17
Research on the determinants implies a connection between perceived selfefficacy and health-compromising behavior. This, for instance, holds true for regular smoking,
drunkenness and substance use (Engels, Hale, Noom, & De Vries, 2005; Petraitis, Flay, Miller,
Torpy, & Greiner, 1998). Self-efficacy, defined as beliefs in one’s capabilities to organize and
execute the courses of action required to manage prospective situations (Bandura, 1995), has a
central role in socio-cognitive theories, e.g. Ajzen’s (1988) theory of planned behavior or
Bandura’s (1986) social cognitive/ learning theory. Specific beliefs about self-efficacy are
considered in these theories as the most immediate and direct association with regular
smoking, drunkenness and substance use. Low perceived self-efficacy has been repeatedly
connected with a higher prevalence of smoking behavior (Engels, Hale, Noom, & De Vries,
2005; Kim, 2004; Engels, Knibbe, de Vries & Drop, 1998).
However, those studies mostly focused on behavior-specifi c self-efficacy. It
could be expected that these two aspects of self-efficacy play different roles in connection with
smoking behavior. General self-efficacy is assumed to be a protective factor. On the other
hand, self-efficacy as a construct similar to social competence might play a role as a risk factor.
Evidence regarding social self-efficacy and social competence suggests this assumption
(Veselska et al., 2009; Simons-Morton & Haynie, 2003; Carvajal, Wiatrek, Evans, Knee, &
Nash, 2000). Additionally, Simons et al. (1988), in their multistage social learning model, went
one step further toward the explored role of self-efficacy and included emotional distress
(negative affectivity) as a determinant of health-compromising behavior. Lately, more attention
has been given to the way self-efficacy interacts with affectivity and how these variables
contribute to the association between self-efficacy and health compromising behavior (Curry &
Youngblade, 2006; Engels, Hale, Noom, & De Vries, 2005). Research on the associations
between affectivity (especially negative affectivity) and health-compromising behavior has
confirmed the influence of negative affect as a risk factor (Curry & Youngblade, 2006; Colder
& Stice, 1998). Evidence suggests that high levels of negative affect (e.g. depression, anxiety,
anger) and underdeveloped affect regulation might lead to the smoking behavior (Chang &
Chiang, 2009; Windle & Windle, 2001). Also, based on previous research, we assume that
negative affect influences other variables, e.g. the association of self-efficacy with smoking
behavior.
18
2.8 Socioeconomic status and physical activity among school aged children (adolescents)
Regular physical activity is a part of a lifestyle which leads to physical health
benefits such as reduced risks of coronary heart disease, diabetes and obesity but also to mental
health benefits like reduced risks of depression, anxiety and mood disorders (Penedo & Dahn,
2005). Healthy lifestyle patterns that include regular physical activity can be traced back to
childhood and adolescence. Those stages of development are crucial for adopting healthy
lifestyles that have consequences for current and future physical and mental health (Hallal,
Victora, Azevedo & Wells, 2006). Despite the well-known health benefits of regular exercise,
recent international studies (Currie et al., 2008; 2004; 2000) show a lack of sufficient physical
activity among adolescents, indicating a potentially serious public health problem (Hallal,
Victora, Azevedo & Wells, 2006).
It is therefore important to identify possible determinants for the specific target
groups. Social inequalities have been found in the physical activity of adolescents, adolescents
with low-educated or low-income parents being less physically active (Currie et al., 2008;
Mota, Ribeiro & Santos, 2009; Richter et al., 2009; Piko & Keresztes, 2008). One explanation
for this is that parents with a higher education level may help students develop more positive
attitudes towards health and health-related behaviors, and a high family income may support
the engagement in certain sports having high costs.
Moreover, intrapersonal factors may contribute to social inequalities in physical
activity and influence the connection between the socioeconomic status of youths and their
engagement in physical activity. Several studies (Veselska et al., 2009; Birndorf, Ryan,
Auinger & Aten, 2005; Rhodes, Roffman, Reddy & Fredricksen, 2005) have shown that
adolescents from higher socioeconomic groups report higher self-esteem. In turn, self-esteem
has been shown to be significantly associated with physical activity (Penedo & Dahn, 2005;
Parfi tt & Eston, 2005).
19
3. MATERIAL AND METHODS
3.1 Survey plan and sampling. The survey was conducted in April 2013 in 2 different types
(one private and one public) of schools in Pakistan. Class was chosen as a sampling unit. The
data was collected from 9th grade primary school students. The participants were 300 (200
boys and 100 girls). 100 boys and 50 girls were from public school and 100 boys and 50 girls
were from private school. Majority of respondents were 14 and 15 years old and just 3% of
participant were 16 years old (Fig. 1). More than 90% of participants lived in urban areas
(cities, towns) and 5.5% in countryside (Fig. 2).
Figure 1. Distribution of 14-16 year old adolescent by gender
Health Behavior in School aged Children (HBSC) questionnaire was used in this
study. HBSC, a WHO collaborative cross-national study, collects data on 11-, 13- and 15year-old boys’ and girls’ health and well-being, social environments and health behaviors
every four years. This study used questions regarding health behaviors of adolescents. Health
behavior was measured with questions concerning adolescent’s nutritional habits (breakfast,
fresh fruit and vegetable, sweets, fast food and soft drinks with sugar consumption), healthrisk behavior (cigarette use, injuries) and physical activity.
Adolescents were asked to fill in the questionnaire in school classroom during
ordinary school hours. Written informed consent was obtained from the students after
explaining the study objectives. The students were free to withdraw at any time without
20
giving any reason. Strict confidentiality was maintained throughout the process of data
collection, entry and analysis. All efforts were made in this study to fulfill the ethical
considerations in accordance with the ‘Ethical principles for medical research involving
human subjects’ of Helsinki Declaration. The response rate was 100 percent.
5; 5%
26,7%
68.3%
Figure 2. Distribution of adolescent place of residence
3.2 Statistical analysis. Statistical data analyze was performed by using SPSS/15.0 for social
sciences for data accumulation and analysis. Data were analyzed by descriptive statistics with
frequency distribution, cross-tub calculation, and correlation by mean values. Correlations
were considered to be statistical significant when the p-value were < 0.05.
21
4. RESULTS AND DISCUSSION
4.1 Health behavior among boys and girls in Pakistan
4.1.1 Physical activity of adolescents in Pakistan
Physical activity is an important lifestyle factor that is associated with a wide range of
health benefits (Andersen LB et.al. 2011). Participation in regular physical activity in
childhood and adolescence has also been reported to positively influence physical activity
levels in adulthood (Tammelin T et.al. 2003).
Study results showed, that 41% of school students exercise 2-3 times a week and 7.3%
less than once a month. No significant differences were observed between gender and student
physical activity. From questionnaire were also analyzed data of adolescent’s time spend
being physically active. It was established that 11% of boys and girls spend 4-6 hours a week
being physically active (Table 1). Which means, that small part of adolescents meet the global
recommendations for school-aged children physical activity (participate in at least 60 minutes,
and up to several hours, of at least moderate physical activity on a daily basis) (WHO, 2010).
Table 1. Correlation between gender and exercise hour a week
Exercise hour a week
None
1/2 hours
1 hours
2-3 hours
4-6 hours
χ2 = 2,466; df = 4; p> 0,05
Boys
Girls
Total
%(n)
%(n)
%(n)
1,5 (3)
0
1 (3)
12,5 (25)
16 (16)
13,7 (41)
38 (76)
40 (40)
38,7 (116)
37 (74)
33 (33)
35,7 (107)
11 (22)
11 (11)
11 (33)
22
4.1.2 Nutritional habits of adolescents in Pakistan
Children and adolescents nutritional habits play a key role in health behavior.
Epidemiological research claims that youth breakfast consumption is very important part of
young people future health (Affenito SG et al., 2007, Haug E et al., 2009). Regular breakfast
consumption is associated with higher intakes of micronutrients, a better diet that includes
fruit and vegetables and less frequent use of soft drinks (Timlin MT et al., 2008). Despite the
potential importance of breakfast consumption, the prevalence rates of breakfast skipping
among children and adolescents have increased in the past few decades (Deshmukh-Taskar
PR et al., 2010).
The study result showed that more than half (53.8%) of Pakistan adolescents eat
breakfast every day on weekdays, but on weekends less than one third (28.1%) have breakfast
at home. It was estimated, that significant differences were found between breakfast
consumption on weekends and gender – girls eat breakfast less frequent then boys (Table 2).
It should be noted, that 14% of despondences reported, never eat breakfast on weekends.
A recently published WHO/HBSC international report confirmed these study findings,
determining that girls eat breakfast less frequent than boys (Currie C et al., 2012).
Table 2. Correlation between gender and breakfast consumption on weekdays and
weekends
Breakfast consumption
Boys
Girls
Total
on weekdays
%(n)
%(n)
%(n)
Every day
57,9 (110)
46 (46)
53,8 (156)
Less than every day
42,1 (80)
54 (54)
46,2 (134)
0
0
0
Breakfast consumption
Boys
Girls
Total
on weekends
%(n)
%(n)
%(n)
Every day
32,2 (64)
20 (20)
28,1 (84)
Less than every day
53,3 (106)
67 (67)
57,9 (173)
Never
14,6 (29)
13 (13)
14 (42)
Never
χ2 = 3.729; df = 1; p> 0,05
χ2 = 5,790; df = 2; p< 0,05
23
Fresh fruit and vegetable consumption is very important determinant regarding healthy
lifestyle. Longitudinal studies suggest that fruit and vegetable consumption tracks into
adulthood which points at the importance of establishing healthy eating behavior among
children and adolescent (Kelder SH et al., 1994, Te Velde SJ et al., 2007).
One third (32.6%) of respondents stated, that eat fresh vegetable and 20.1% of then eat
fresh fruit every day. This suggests that, fresh vegetables are more popular than fruits among
adolescents. It was determined that no significant differences were found among gender and
fresh fruit, vegetable consumption (Table 3). Other studies in Europe confirm opposite
results, that vegetable intake was in general lower than fruit intake and boys consumed less
fruit and vegetables than girls did (Yngve A et al., 2005).
Table 3. Correlation between gender and fresh fruit, vegetable consumption
Fresh fruits consumption
Boys
Girls
Total
%(n)
%(n)
%(n)
Every day and 4-6 times a week
18,6 (37)
23 (23)
20,1 (60)
1-3 times a week and never
81,4 (162)
77 (77)
79,9 (239)
Boys
Girls
Total
%(n)
%(n)
%(n)
Every day and 4-6 times a week
34,8 (69)
28 (28)
32,6 (97)
1-3 times a week and never
65,2 (129)
72 (72)
67,4 (201)
χ2 = 1,235; df = 1; p> 0,05
Fresh vegetables consumption
χ2 = 0,558; df = 1; p> 0,05
Unhealthy diet products such as sweets, soft-drinks with sugar, fast food adolescents
consumed (from 0% till 24.6%) every day or 4-6 times a week. It was determined that
significant differences were found among gender and soft-drinks with sugar and fast food
consumption – girls consumed unhealthy diet products less frequent than boys. No significant
differences were found among gender and sweets consumption (Table 4).
Other studies confirmed that consumption of sugar-sweetened beverages, including
soft drinks, has risen across the globe, accompanied by an increase in the prevalence of
overweight and obesity (Currie C et al., 2012).
24
Table 4. Correlation between gender and unhealthy diet products consumption
Sweets consumption
Boys
Girls
Total
%(n)
%(n)
%(n)
3,5 (7)
0
2,3 (7)
96,5 (192)
100 (100)
97,7 (292)
Soft- drinks with sugar
Boys
Girls
Total
consumption
%(n)
%(n)
%(n)
Every day and 4-6 times a week
24,6* (49)
9 (9)
19,4 (58)
1-3 times a week and never
75,4 (150)
91 (91)
80,6 (241)
Boys
Girls
Total
%(n)
%(n)
%(n)
Every day and 4-6 times a week
7* (14)
0
4,7 (14)
1-3 times a week and never
93 (185)
100 (100)
95,3 (285)
Every day and 4-6 times a week
1-3 times a week and never
χ2 = 6,348; df = 1; p> 0,05
χ2 = 3,765; df = 1; p< 0,05
Fast food consumption
χ2 = 1,758; df = 1; p< 0,05
In summary every second 9 th grade student has breakfast every day in Pakistan. Fresh
vegetables are more popular than fruits among adolescents. Unhealthy diet products such as
sweets, soft-drinks with sugar, fast food are more popular between boys than girls.
4.2 Health-risk behavior of adolescents in Pakistan
It is clear from research worldwide that many children and adolescents experience
behavior disorders. Substance use, alcohol consumption, smoking, fighting, injuries and
suicide attempt were all found to be prominent health risk behaviors among the young (Chen
C-Y et al., 2006, Faeh D et al., 2006).
Tobacco use is one of the major preventable causes of death in the world. The WHO
attributes some 4 million deaths a year tobacco use, a figure which is expected to rise to
8.4million deaths a year by 2020 (WHO, 2008).
The results showed that 12.1% of adolescents reported smoking once a week. The
percentage rate of respondents, who smoked daily, were small – 2% (Fig. 3). It was estimated,
that significant differences were found between smoking and gender – girls smoke cigarette
25
less frequent then boys (Fig. 4). This finding confirms what has been reported in countries –
USA (Anderson C et al., 2009), Portugal (J. Precioso et al., 2012) in which males were more
current cigarette smokers than females.
Figure 3. Frequencies of adolescents cigarette use
Picture 4. Correlation between gender and cigarette use
*p<0.05 – z test, compared boys and girls
26
Being in good physical and emotional health enables young people to deal with the
challenges of growing and eases their transition to adulthood. Self-rated health is a subjective
indicator of general health. Young people’s appraisal of their health is thought to be shaped
by their overall sense of functioning, including physical and non-physical health dimensions
and is associated with a broad range of health indicators: medical, psychological, social and
health behaviors (Currie C et al., 2012).,
Analyzing data of adolescents self- rated health were found, that two thirds
(78.5%) of respondents thought there are in good health and just 4% claimed having excellent
health (Fig. 5).
Figure 5. Frequencies of adolescents self - rated health
Analyzing relationship between adolescent’s self-rated health and smoking were
found statistically significant differences. It was determined that smokers more frequent
thought there are in poor health compared to non-smokers (Fig. 6).
27
Figure 6. Correlation between students self-rated health and smoking
*p<0.05 – z test, compared non-smokers and smokers
Unintentional injury is an important health priority in almost all countries. The
frequency, severity of injuries makes injury prevention a key public health goal for improving
young people’s health (Currie C et al., 2012).
Very interesting findings appeared analyzing injuries rates among adolescents in the
past 12 month. It was determined that significant differences were found among respondent
gender and injuries. Girls were injured more often than boys in the past 12 month (Fig. 7).
Figure 7. Correlation between gender and adolescent’s injuries in the past 12 month
*p<0.05 – z test, compared boys and girls
28
In summary two thirds of teenagers thought there are in good health. Majority of
adolescents don’t smoke. Boys smoke cigarettes more often than girls. Statistically significant
differences were found between adolescents self-rated health and smoking.
4.3 Correlation between health behaviour of school students in Pakistan and Lithuanian
Pakistan and Lithuania are completely different countries in many aspects:
demografic, economic, religiuos, health and others. Pakistan represent health behavoir of
adolescents in Asia region, while Lithuania represent health behavoir of adolescents in
Europian region. Because of such as significant differences is very interesting to analyze and
evaluate the differences between the countries. To make this data analysis, adolescents filled
the same HBSC questionnaire in Pakistan and Lithuania.
It was estimated, that significant differences were found between adolescents selfrated health in Pakistan and Lithuania. Teenagers in Pakistan thought there are in excellent
health less frequent than teenagers in Lithuania. The same 17% of adolescents in Pakistan and
Lithuania thought there are in poor health (Table 5).
Table 5. Correlation between adolescents self-rated health in Pakistan and Lithuania
Pakistan
Lithuanian
%(n)
%(n)
4 (12)
28,2 (504)
Good
78,6 (234)
54,5 (975)
Poor
17,4 (52)
17,4 (310)
Adolescents self-rated health
Excellent
100 (298)
Total %(n)
100 (2087)
χ2 = 91,2; df = 3; p< 0,05
Study result showed that statistically significant differences were found between
breakfast consumption on weekends in Pakistan and Lithuania. On weekends, adolescents in
Lithuania eat breakfast every day more frequent than children in Pakistan (Table 6). The
obtained results lead to the conclusion that adolescents in Lithuanian are more supervised by
their parents than in Pakistan.
29
Table 6. Correlation between breakfast consumption of adolescents on weekends in
Pakistan and Lithuania
Breakfast consumption on
Pakistan
Lithuania
weekends
%(n)
%(n)
Every day
28,1 (84)
74,9 (1530)
Less than every day
57,9 (173)
15,2 (311)
14 (42)
9,9 (203)
100 (298)
100 (2044)
Never
Total %(n)
χ2 = 529,8; df = 2; p< 0,05
Fresh fruits and vegetables consumption reflects not only nutritional habits of
adolescents, but also indicates family’s health literacy rates. In this survey were established
that adolescents in Lithuanian eat more fresh fruits and vegetables than teenagers in Pakistan
(Table 7).
Table 7. Correlation between fresh fruit and vegetable consumption of adolescents in
Pakistan and Lithuania
Fresh fruits consumption
Pakistan
Lithuania
%(n)
%(n)
Every day and 4-6 times a week
20,1 (60)
38,8 (689)
1-3 times a week and never
79,9 (239)
61,2 (1086)
Total %(n)
100 (299)
100 (1775)
Pakistan
Lithuania
%(n)
%(n)
Every day and 4-6 times a week
32,6 (97)
43 (765)
1-3 times a week and never
67,4 (201)
57 (1013
Total %(n)
100 (298)
100 (1778)
χ2 = 39,9; df = 1; p< 0,05
Fresh vegetables consumption
χ2 = 11,53; df = 1; p<0,05
The consumption of unhealthy diet products were different between the countries also.
It was determined that significant differences were found among Pakistan and Lithuania
30
teenager’s sweets, soft-drinks with sugar consumption. Adolescents in Lithuania consume
sweets more frequent than school children in Pakistan (Fig. 8), opposite findings were
determined in soft-drinks with sugar consumption – adolescents in Lithuania consume softdrinks with sugar less frequent than teenagers in Pakistan (Fig. 9).
Fi
gure 8. Correlation between sweets consumption of adolescents in Pakistan and
Lithuania
*p<0.05 – z test compared adolescents in Pakistan and Lithuania
Fast foods are very popular with adolescents, who are at a stage in life in which they
experience increased autonomy, both in terms of availability of meals outside the home and
discretionary income (Johnson F et al., 2002).
31
Figure 9. Correlation between soft-drinks with sugar consumption of adolescents in
Pakistan and Lithuania
*p<0.05 – z test compared adolescents in Pakistan and Lithuania
Frequent consumption of fast food has adverse effects on nutrition because of
excessive content of energy and fat and low nutritional value (Sebastian RS et al., 2009).
Study results showed that significant differences were found between fast food
consumption of adolescents in Pakistan and Lithuania. Adolescents in Lithuania consume fast
food more frequent than school children in Pakistan (Fig. 10). The obtained results lead to the
conclusion that adolescents in Lithuanian may have greater accessibility to fast food
restaurant than teenagers in Pakistan.
32
Figure 10. Correlation between fast food consumption of adolescents in Pakistan and
Lithuania
*p<0.05 – z test compared adolescents in Pakistan and Lithuania
Analyzing relationship between adolescent’s smoking in Pakistan and Lithuania
were found statistically significant differences. It was determined that frequency of smoking
every day was significantly higher in Lithuania than in Pakistan (Fig. 11).
Figure 11. Correlation between adolescent’s use of cigarette in Pakistan and Lithuania
*p<0.05 – z test compared adolescents in Pakistan and Lithuania
33
CONCLUSIONS
1.
Adolescents in general thought they are good health in Pakistan. Physical activity of the
majority of adolescents did not meet the global WHO recommendations for schoolaged children. No statistically significant differences were found between the gender
and physical activity. Every second 9th grade student had breakfast every day in
Pakistan. Fresh vegetables were more popular than fresh fruits among adolescents.
Boys and girls consumed fresh fruits and vegetables equally often.
2.
Majority of adolescent’s unhealthy diet products such as sweets, soft-drinks with sugar,
fast food consumed rarely (1-3 times a week or never). Unhealthy diet products were
more popular between boys than girls in Pakistan.
3.
The percentage rate of teenagers, who smoked daily, were small, girls smoke cigarette
less frequent then boys. Adolescents smoking were related to self-rated poor health.
4. Adolescents in Lithuania experience excellent health more often than teenagers in
Pakistan. Health behaviors of adolescents were different in Pakistan and Lithuania –
teenagers in Lithuania consumed fresh fruit and vegetables more frequent than school
students in Pakistan. On another hand, lower consumption of sweets, soft-drinks with
sugar and fast food was established in Pakistan. Frequency of school students smoking
every day was significantly higher in Lithuania than in Pakistan.
34
PRACTICAL RECOMMENDATION
1. Monitoring. Health behavior of adolescents is one of the most important determinants
of health. Behaviors established during childhood and youth can continue into
adulthood, affecting issues such as mental health, the development of health
complaints, tobacco use, diet, physical activity level. This is why monitoring health
behavior of school age children’s should be applied in school on the routine base.
2. Health educations. The lessons of health behavior education should be implemented
into the teaching curriculum, because appropriate health knowledge and skills is
essential component of children and youth future health and quality of life.
3. Community. Young people's feelings of safety in out-of-home settings, having a
place in their community and perceiving the wider adult community as supportive,
appears to have an important protective function in preventing the most harmful forms
of health-related risk behaviors. For this reason, health promotion programs, initiatives
should be carried out in local communities.
35
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44
ANNEX
Annex 1. QUESTIONNAIRE FOR SCHOOL AGED CHILDREN REGARDING HEALTH
BEHAVIOUR (BASED on HBSC QUESTIONNAIRE). HEALTH BEHAVIOUR IN
SCHOOL – AGED CHILDREN IN PAKISTAN.
1.
2.
Date: 2013 ............. month ...... day
Are you: a boy or a girl?
Please tick adequate box with cross (X).
1 Boy
2 Girl
3.
Which grade are you in?
1 The fifth
2 The seventh
3 The ninth
4.
What’s your year of birth?
199
199
199
199
199
199
199
199
199
200
1
2
3
4
5
6
7
8
9
0










5.
July
Which month were you born?
January
February
January
April
May
June
1
2
3
4
5
6
August
September October
Novembe December
r
6
8
9
10
11
12
45
6.
Where do you live in?
1 City
2 Town
3 Village
4 Country
7.
What is your nationality?
1 Pakistani
2 Lithuanian
3 Polish
4 Other
8.
What language do you generally use at home?
1 Urdu
2 English
3 Lithuanian
4 Other
9.
How much is your weight? (without clothes) If you don't
remember go to the next question.
My weight is ........................................ kilo
10.
What is your height? If you don't remember go to the next
question.
My height is................................... centimeters
Eating habits
46
11.
How many days a week do you meanly have breakfast (more than
a cup of tea, fruit juice and so on)? Please tick one box for
weekdays and one box for weekend
A.
1
Weekdays
I
never
B. SSaturday and Sunday
have
during weekdays
2
One day
breakfast
1 I never have breakfast during
weekend
2 I usually have breakfast on only
one day of the weekend
3
Two days
4
Three days
(Saturday OR Sunday)
3 I usually have breakfast on both
weekend days
5
Four days
6
Five days
(Saturday AND Sunday)
12. Some children go to school or to bed hungry because there is not
enough food at home. How often does this happen to you?
1
Always
2
Often
3
Sometimes
4
Never
47
13. How often do you drink or eat something foods? Please tick one box
for each line
1
2
3
4
5
6
7
Every
day,
Less
than
Neve once
r
week
2-4
5-6
Every
more
days
days
day,
than
a
a
once
once a
week
week
week
a day
day
Once
a a
1. Fruits







2. Vegetables







3. Sweets,







4. Cakes, biscuits, 



















foods






chocolate
cookies
5. Coke and other
soft drinks
6. Chips
7. Fast
(hamburgers,
hotdogs,
doughnut, and so
on)
48
Health
14. What would you describe your health?
1
Excellent
2
Good
3
Satisfactory
4
Poor
15. Has the doctor ever told you that you have bronchial asthma?
1 Yes
2 No
3 I don’t know
16. In the last 12 months, has your chest sounded wheezy during or
after physical activity?
1 Yes
2 No
3 I don’t know
17. In the last 12 months, have you had a dry cough at night, apart
from a cough associated with a cold or a chest infection?
1 Yes
2 No
3 I don’t know
49
18. Has the doctor ever told you that you have allergic skin rash?
1 Yes
2 No
3 I don’t know
19. Do you think your body is?
1
Very thin
2
Thin
3
Normal
4
Slightly too fat (burly)
5
Fat
Physical activity
20. Over the past 7 days, on how many days were you physically
active for a total of at least 60 minutes per day? Please tick one
box.
None
1
2
3
4
5
6
7
Days
Life satisfaction
21. In general, how do you feel about your life at the moment?
1
Very happy
2
Enough happy
3
Unhappy
4
Quite unhappy
50
Behaviour;
22. Have you ever smoked (at least one cigarette)?
1 Yes
2 No
23. How often do you smoke at present?
1 Every day
2 At least once a week, but not every day
3 Less than once a week
4 I don't smoke
24. How often do you drink anything alcoholic beverage, such as
beer, wine, spirits or other, at present? Try count up even those
times when you drink only a small amount (less than a glass
but more than an one gulp). Please tick one box for each line.
1
2
3
4
Every
Every
day
week
month Rarely
5
Every
Never
1.
Beer





2.
Wine





3.
Champagne





4.
Liqueur





5.
Vodka or other 








strong beverages
6.
Soft
alcoholic 
beverages (Mix,
Fizz,
cocktails
with alcohol)
51
25. Have you ever had so much alcoholic beverage that you were
dizzy?
1 Never
2 Yes, once
3 Yes, 2 – 3 times
4 Yes, 4 – 10 times
5 Yes, more than 10 times
26.
How many times in the last 30 days you have done?
Please tick one box for each line.
1
2
3
4
5
6
7
40
times
Neve 1-2
r
6-9
10-19 20-39 or
times times times times times more







alcoholic 






from 






1. Smoked
2. Drunk
3-5
beverages
3. Felt
dizzy
alcohol
52
Have you ever smoked cannabis („grass“, marihuana, hashish?
27.
Please tick one box for each line.
1
2
3
4
5
6
7
40
times
Neve 1-2
r
the
last
6-9
10-19 20-39 or
times times times times times more







12 













1. In your life
2. In
3-5
months
3. In the last 30 days
Family
28. Which of the following descriptions best describes your current
family situation?
1
I live with BOTH parents
I live NOT WITH BOTH parents, because:
2
3
My parents are divorced
Already years, as one of their living and
working in another location
4
One of them is dead
5
One of them I'm not seeing a whole
6 I live in a foster home or children's home
53
29. If your parents are divorced, how often do you communicate with
the other parent?
1
Often
2
Sometimes
3
Rarely
4
Never
30. Is it easy for you to talk to the following persons about things that
are very important for you and worry you?
Please tick one box for each line.
1
2
3
4
5
Don't
Very
Very
have or
Diffic
difficu see this
easy
Easy
ult
lt
person
1.
With father





2.
With stepfather





3.
With mother





4.
With stepmother





With elder brother (- 




5.
s)
6.
With elder sister (-s)





7.
With best friend





8.
With same-sex friend 




opposite-sex 




9.
With
friend
54