https://orcid.org/0000-0001-6640-0558
Abstract
The Global school-based student health survey (GSHS) was developed by the World Health Organization (WHO) and Centers for Disease Control (CDC) in affiliation with other organizations to obtain data on young people’s health behaviour and protective factors related to the leading causes of morbidity and mortality among children and young adults. This report discusses results from the first Global school-based student health survey carried out in Bahrain which assesses and measures students’ behavioural risk and protective factors with the aim of promoting health among schoolchildren. The GSHS includes students aged 13–17 and employed a two-stage sample design involving a school and class level. We sampled 64 schools, including 320 classes from grades 7–11. The ten core questionnaire modules address the leading causes of morbidity and mortality among children and adults worldwide. The overall response rate was 89%, 3,685 (51.1%) were males. 5,843 (84.5%) were between the ages of 13 to 17. Almost 40% were overweight, and 18.2% of the students were obese. Overall, 1,452 (23%) of the students were not physically active, with a higher representation of the female students; 774 (53%). About 27% have smoked cigarettes, 70.7% of whom are males, and 3.1% of students reported using drugs, 76% of them are males. 616 (19%) of students had food from fast-food restaurants for five or more days of the week. 24% never or rarely consumed breakfast, while 47% consumed fruits less than once per day, of whom 53% are female. The survey showed alarming rates of obesity, overweight and unhealthy food practices among school students. The lifestyle behaviours identified in this study will inform community-based intervention to help the country develop priorities, establish programs and advocate for resources for school health programs.
1. Introduction
The World Health Organization (WHO) and the Centres for Disease Control and Prevention (CDC), in affiliation with UNESCO, UNICEF, and UNAIDS developed the Global school-based student health survey (GSHS; WHO and CDC, Citation2013). The GSHS is a relatively low-cost school-based survey that uses a self-administered questionnaire to obtain data on young people’s health behaviour and protective factors related to the leading causes of morbidity and mortality among children and adults worldwide. The GSHS is a collaborative surveillance project designed to assess behavioural risk factors and protective factors among students ages 13 to 17 in 10 key areas (WHO and CDC, Citation2013).
In Bahrain, the Ministry of Education and Ministry of Health established the National School Health Program in 2003 with similar objectives (MOH and MOE, Citation2003). The National School Health Program ensured health education, prevention, and promotion of a healthy lifestyle in early childhood and adolescent development through community and school-based health services (MOH and MOE, Citation2003). It also highlighted the importance of collaboration between the Bahraini society, health professionals, private sector agencies, students, teachers, families, and support groups. This supportive environment improves the students’ health habits and increases their health services utilization. Consequently, this allows both the Ministry of Health and the Ministry of Education to provide information and resources to students and their families to promote healthy physical, intellectual, emotional, and social development (MOH and MOE, Citation2003).
The GSHS survey aids countries in identifying any deficits in the schooling system and mending them with new youth health programs and policies. The GSHS survey also advocates youth health promotion by developing priorities, establishing programs, and advocating for resources and measures that encourage healthy behaviour and lifestyle choices. Further, it allows international agencies, countries, and others to compare across countries regarding the prevalence of health behaviours and protective factors (Maldives-GSHS-Report, Citation2009).
More than 70 countries completed the GSHS (Maldives-GSHS-Report, Citation2009). This paper will discuss the results of the Global school-based student health survey conducted in Bahrain by the Ministry of Health in collaboration with WHO, CDC, and the Ministry of Education from 2015 to 2016. It is the first national school health survey to explore the health behaviour and protective factors in the Kingdom of Bahrain among school students aged 13–17.
Two previous studies generated from the GSHS survey in Bahrain were published discussing tobacco use and mental health (Pengpid & Peltzer, Citation2020a, Citation2020b). Results indicated that among boys the prevalence of current cigarette smoking was 30.2% attending public schools and 7.3% in private schools, and 5.9% in girls attending public schools and 3.2% in private schools (Pengpid & Peltzer, Citation2020a). The prevalence of psychological distress was 20.4% among female students and 12.6% among male students. The rate was higher in female students and associated with low peer and parental support, tobacco use, and environmental stressors (Pengpid & Peltzer, Citation2020b). Other health behavioral risk factors have not yet been discussed to date. Therefore, we conducted this study to report other risk factors such as dietary behaviours, drug use, hygiene, physical activity, sexual behaviours, and tobacco use.Between the ages of 13–17 or the period of adolescence, students become more independent and have increased access to different food choices. In this period, students also increase social interactions with other students and start to follow new eating habits and physical activity patterns (Haji, Citation2016; MOH and MOE, Citation2003; WHO and CDC, Citation2013). Dietary habits are established in the mid-teens and are closely associated with future lifestyle choices. Since school years are also a time of enormous growth, students are at an essential stage in developing lifelong skills that will enable them to make good decisions about lifestyle, learning, relationships, and self-sufficiency.
There are several health impacts of obesity and unhealthy lifestyles among adolescents in Bahrain, hence understanding the sociodemographic and behavioural contributors to obesity through means such as this survey is imperative.
1.1. Purpose
This report discusses results from the first Global school-based student health survey carried out in Bahrain which measures students’ behavioural risk and protective factors with the aim of promoting health among school children.
1.2. Methods
The GSHS is a school-based survey conducted primarily among students aged 13–17. Through a standardized scientific sampling selection process, standard school-based methodologies, core questionnaire modules, core-expanded questions, and country-specific questions, the GSHS was created as a self-administered questionnaire that the students can complete during one regular class period (Haji, Citation2016).
1.3. Design and sampling
This is a descriptive cross-sectional study in which we employed a two-stage cluster sample design and was done on two levels: School and class levels.
School Level—All schools that included grades 7–11 were added to the sample. Schools were selected systematically with probability proportional to enrolment in grades 7–11 using a random start. This resulted in the sampling of 64 schools.
Class Level—The sampling frame included all classes in each selected school. All students in the sampled classrooms were eligible to participate in the GSHS. Therefore, 320 classes were included. A total of 8,672 students in grades 7–11 were approached, and 7,143 completed the questionnaires. After data editing, seven thousand one hundred forty-one students were included, with 3,685 male and 3,884 female students.
1.4. Core questionnaire modules & core-expanded questions
GSHS created a self-administered questionnaire involving three components: Core Modules, Core Expanded questions, and Country Specific questions. The questions are translated into the appropriate language of instruction for the students and pilot tested for comprehension. All questions share common characteristics to enhance the flow of the survey and understanding by the student.
The ten core modules address the leading causes of morbidity and mortality among children and adults worldwide: dietary behaviours, drug use, hygiene, mental health, physical activity, protective factors, sexual behaviours, tobacco use, violence, and unintentional injury.
The Total Number of Questions is 67, with 47 questions from the core questionnaire modules and 20 from the core-expanded and country-specific questions (supplementary file). Students self-reported their responses to each question on a computer scannable answer sheet.
1.5. Data analysis
All data processing (scanning, cleaning, editing, and weighting) was conducted at the US Centers for Disease Control. The weighing factors associated with each questionnaire are provided in this link:https://extranet.who.int/ncdsmicrodata/index.php/catalog/654.
We used descriptive statistics (frequencies and percentages) to describe the sociodemographic characteristics of survey respondents. The Stata software program that took into consideration the complex sample design (strata, cluster, and weights) was used to compute prevalence estimates and 95% confidence intervals of the risk factors in the 10 core modules (dietary behaviours, drug use, hygiene, physical activity, tobacco use) with their sex distribution.
1.6. Results
Sixty-four sampled schools participated, and 7,143 (89%) of the 8,068 sampled students completed questionnaires. Seven thousand one hundred forty-one questionnaires were usable after data editing.
1.7. Demographics
2. Response rate
The school response rate was 100%, the student response rate was 89%, and the overall response rate was 89%. Of the students who responded, 3,685 (51.1%) were males and 3,449 (48.9%) were females. 5,843 (84.5%) were between the ages of 13 to 17 years old, and 90 (1.8%) were 18 years old or older. 1,504 (24.1%) were 16 or 17 years old, and 1,204 (13.8%) were 12 years old or younger.1,572 (21.9%) students were in Grade 7, 1,618 (21.2%) grade 8, 1,530 (20.3%) grade 9, 1,276 (20.3%) grade 10, and 1,139 (16.3%) grade 11.
2.1. Weight and dietary behavior
There were 5.0% underweight students, 39.6% overweight students, and 18.2% obese students. Table shows that 135 (2.5%) of the students went to bed hungry because there was not enough food in their homes, whereas 3,220 (43.5%) of the students never went hungry. Overall, 3,039 (40%) of the students always had breakfast. 589 (9%) of the students never had breakfast, 243 (41%) were males, and 345 (59%) were females. Table shows that 2,525 (43%) of the students ate fruits less than once daily; 1,178 (47%) were males. As for vegetable intake, the survey showed that 2,025 (34%) of the students ate vegetables less than one time per day, 47% of whom are males. 3,090 (43%) of the students drank carbonated drinks less than once daily. About 63.1% of participants consumed milk once per day or less.
Table 1. Dietary behaviours among students
Table 2. Frequency of food consumption in a day
The survey showed that 616 (19%) of the students had food from fast-food restaurants for five or more days of the week. 2,107 (27%) of the students had fast food once during the seven days while 1,841 (25%) did not have fast food in the past seven days.
The survey showed that 9% of the students took diet pills, powders, or liquids without a doctor’s advice to lose or maintain their weight, while 91% did not. 89% of the males did not consume weight maintenance or weight loss products while 11% did. 92% of the females did not consume weight maintenance or weight loss products while 8% did. The results showed that 49% of the students attended classes where they were taught the benefits of healthy eating.
2.2. Hygiene
The results showed that 193 (4%) of the students in the past 30 days did not clean or brush their teeth at all. Male students represent a higher percentage of 154/193 (80%) compared to female students of 39/193 (20%). 2,968 (36%) brushed their teeth twice a day, and 1,752 (23%) of the students brushed them once daily. More than half of the samples washed their hands before eating, and 78% washed their hands after using the toilet. The results also showed that 8.4% of students never or rarely washed their hands before eating. Also, 4.3% of students never or rarely used soap when washing their hands.
2.3. Physical activity
Overall, 1,452 (23%) of the students were not physically active at all during the past seven days with, a higher representation from the female students 774 (53%) compared to male students 678 (47%). The majority, 73% (5,511), did not walk or ride a bicycle to or from school in the past seven days. One-third of the class (36%) attended physical education classes twice a week.
2.4. Sleep
Overall, 1443 (20%) of the students had an average of eight hours of sleep during a school night, and 1805 (26%) of students had five or fewer hours of sleep during a school night
2.5. Tobacco
In this survey, 1,480 students (27%) smoked cigarettes, 70.7% were males, and 26.4% were females. Of the students who smoke, 1,416 (25.8%) started before the age of 15. Also, 998 students (16.9%) used any tobacco product other than cigarettes such as Sheesha, Medwakh, chewing tobacco, or electronic cigarettes on one or more days during the past 30 days, with higher representation from the male students (69.3%). Table . Overall, 4,308 (65.2%) students reported that people smoked in their presence one or more days during the past seven days.
Table 3. Use of tobacco among students
2.6. Drug use
In this study, 205 (3.1%) students used drugs, 76.1%; were males, and 23.9% were females. Of the students who tried drugs, 2.6% were 13 years old or younger. 128 (2.1%) students have used marijuana, with a higher proportion of male students (85.2%). 1.6% of students have tried using amphetamines or methamphetamines, 1,632 (30.3%) students used solvents or inhalants (glue -sniffing or stop), with a higher percentage of females (54.9%) in comparison to male students (45.1%). 988 (14.6%) students tried using anabolic steroids during the past six months, with a higher percentage of male students (59.3%) compared to female students (40.7%) Table .
Table 4. Drug use among students
2.7. HIV-related knowledge
Overall, 4,723 (67.4%) students have heard of HIV infection or AIDS almost equally in males (50.3%) and females (49.6%). In addition, 3,041 (45.6%) students recall learning about HIV or AIDS in any class. The results also showed that 20% of students have ever talked to their parents or guardians about HIV or AIDS. Male students (47.6%) are less than female students (52.2%) to discuss HIV or AIDS with their parents or guardians.
2.8. Discussion
This study presents findings from the 2015–2016 Bahrain Global School-based Student health survey (BHR_2016_GSHS; Haji, Citation2016). The survey results have identified the prevalence of health issues (drugs, tobacco, dietary behaviour, etc.) associated with our adolescent-age children (WHO, Citation2016). GSHS is the first comprehensive national survey on health behaviors and protective factors among students in grades 7–11. The results show the prevalence of behavioral risk factors and protective factors in 10 areas encompassing physical and mental health and lifestyle choices. Critical health issues, including drugs, tobacco, and dietary behavior, were discussed.
Male students are clearly plagued by more problems than female students particularly in relation to drugs, smoking and hygiene domains, which aligns with findings from other countries (Fikry & Al-Matroushi, Citation2005; Maldives-GSHS-Report, Citation2009). Whereas females seem to surpass male in physical inactivity and unhealthy food practices such as skipping breakfast meal.
This study yielded an alarming prevalence of overweight among adolescents reaching up to 40%. This is comparable to recent reports from Bahrain demonstrating rates of overweight of 29.3% among adolescent males and 32% among females (AlAbdulKader et al., Citation2020; Taher et al., Citation2019). The differences in reported rates of overweight could be attributed to sampling methods (our study is population based whereas other studies were conducted on a defined population of primary care attendees). Several causative factors are contributing to this high rate of overweight such as lifestyle changes with reduced physical activity and increased indoor sedentary activities (AlAbdulKader et al., Citation2020). Most students in Bahrain displayed good personal hygiene with female predominance which could partially be attributed to the oral hygiene outreach school programs, preschool dental screening and school curriculum emphasizing personal hygiene.
The results from Bahrain portrayed that only 29.2% of students were physically active for at least 60 minutes per day on five or more days. Although this number is low, it is higher than what had been reported in the UAE (19.5%; Fikry & Al-Matroushi, Citation2005). The importance of encouraging students to increase their physical activity at home and school is essential in improving their cardiovascular, metabolic, and bone health (Al-Hazzaa et al., Citation2011).
The survey showed a high percentage of students in Bahrain (around one-third) who adopted unhealthy eating (fewer fruits and vegetables and more fast food and carbonated drinks). A recent study conducted in Saudi Arabia in adolescents aged 10–19 reported a significant positive correlation between sugar-sweetened beverage consumption and poor dietary habits (Al-Hazzaa et al., Citation2011). In the UAE, 25% of the students drank carbonated soft drinks twice or more daily; 18% of the students ate at a fast-food restaurant three or more times in the past seven days (Fikry & Al-Matroushi, Citation2005). In England, however, 36% of young people reported consuming carbonated sugary drinks at least 2–4 times a week (Brooks et al.,). Therefore, teaching adolescents significant healthy habits, such as healthy eating and physical exercise in school, is essential for helping adolescents embrace a healthier lifestyle. Some Arabian Gulf countries including Bahrain have taken some steps to reduce the consumption of carbonated drink for example, a unified tax on sugar-sweetened beverages has been introduced in 2017 (AlAbdulKader et al., Citation2020).
The results showed a lifetime drug use prevalence of 3% compared to 5% in Maldives and UAE using a similar survey (Fikry & Al-Matroushi, Citation2005; Maldives-GSHS-Report, Citation2009). The percentage of those who smoked cigarettes one or more times during the past 30 days was 15% which is higher than that reported in UAE (9%) and Maldives (10%; Fikry & Al-Matroushi, Citation2005; Maldives-GSHS-Report, Citation2009). Consistent with other studies, drugs and smoking rates were significantly higher among males than females, the majority starting at 13 years old or younger when they first tried drugs. The results showed that 25.8% of the students smoked cigarettes before the age of 15. In a recent study published in 2018, the prevalence of men and women aged 15 and over who smoke in Bahrain was 25.10% Bahrain Smoking Rate (Citation2007–2021). More than half of the students (65.2%) were around people who smoked in their presence one or more days during the seven days. Exposure to second-hand smoking can cause various problems among young adults, including lower respiratory infections such as pneumonia and bronchitis (Secondhand Smoke (SHS, Citation2021)). Studies also showed that asthmatic young adults are more likely to suffer from severe and frequent asthma attacks when exposed to second-hand smoking (Secondhand Smoke (SHS, Citation2021)).
In this survey, the most used drug among students was solvents or inhalants (30.3%). Studies showed that most students are unaware of the consequences the solvents or inhalants can have on their bodies. Therefore, it continues to be a significant problem among students worldwide (Al-Hazzaa et al., Citation2011). Raising awareness among the youth is essential to prevent substantial consequences affecting the student’s morbidity and mortality (Kurtzman et al., Citation2001).
The results relayed that 67% of the students in Bahrain heard of HIV infection or the disease called AIDS, which was close to the percentage reported in the Maldives 71% (Maldives-GSHS-Report, Citation2009). However, the ratio is low compared to the results found in the UAE which was 90.0% (Fikry & Al-Matroushi, Citation2005). Furthermore, only 37.2% of the students were taught how to avoid HIV or AIDS. These results indicate that sexual health and prevention programs are essential to raise awareness among adolescents
2.9. Translation to health education practice
The lifestyle behaviours identified in this study can inform community-based intervention to help the country develop priorities, establish programs and advocate for resources for school health programs, policies, and youth health. These efforts may help Bahrain reduce the morbidities and mortalities associated with unhealthy lifestyles and behaviours.
2.10. Conclusion
The survey showed alarming rates of obesity, overweight and unhealthy food practices among school students. The lifestyle behaviours identified in this study will inform community-based intervention to help the country develop priorities, establish programs and advocate for resources for school health programs.
Collaborative work is fundamental with The National School Health Program to ensure adequate health education, prevention, and promotion of healthy lifestyle choices among students of all ages.
Disclaimer
The user of the data acknowledges that the original collector of the data, the authorized distributor of the data, and the relevant funding agency bear no responsibility for use of the data or interpretations, or inferences based upon such uses.
Supplemental Material
Download PDF (134.7 KB)Acknowledgements
We would like to thank Ministry of education for their collaboration and assistance in completing this survey. This paper uses data from the Global School-Based Student Health Survey (GSHS). GSHS is supported by the World Health Organization and the US Centers for Disease Control and Prevention.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Data availability statement
GSHS data release and publication policies and procedures are based on the following guiding principles:
GSHS data are owned by the official country-level agency (ex. Ministry of Health) conducting or sponsoring the survey.
Public health and scientific advancement are best served by an open and timely exchange of data and data analyses.
The privacy of participating schools and students must be protected.
Data quality must be maintained. https://extranet.who.int/ncdsmicrodata/index.php/catalog/654
Supplementary material
Supplemental data for this article can be accessed online at https://doi.org/10.1080/27707571.2022.2120576
Additional information
Funding
References
- AlAbdulKader, A. M. Khaled T., & Goutham R. (2020). Obesity and cardiovascular risk in the Arab Gulf States. Current Cardiovascular Risk 14, 14(7), 7. Accessed on September 10th 2021. https://doi.org/10.1007/s12170-020-00642-8
- Al-Hazzaa, H. M., Abahussain, N. A., Al-Sobayel, H. I., Qahwaji, D. M., & Musaiger, A. O. Physical activity, sedentary behaviors and dietary habits among Saudi adolescents relative to age, gender and region. The International Journal of Behavioral Nutrition and Physical Activity. 8(140), 140. 21 Dec. 2011. https://doi.org/10.1186/1479-5868-8-140. Accessed on June17th 2022
- Bahrain Smoking Rate 20072021 [Internet]. Macrotrends.net. Available from: https://www.macrotrends.net/countries/BHR/bahrain/smoking-rate-statistics. Accessed on August 20th 2021
- Brooks, F., Ellen K., Kayleigh C., Josefine M., & Neil S. (2020). HBSC England national report: Findings from the 2018 HBSC study for England. University of Hertfordshire. http://hbscengland.org/wp-content/uploads/2020/01/HBSC-England-National-Report-2020.pdf. Accessed on August 20th 2021.
- Fikry, M., & Al-Matroushi, M. A. (2005). United Arab Emirates Global Schoolbased Student Health Survey GSHS country report. UAE. WHO. https://www.who.int/ncds/surveillance/gshs/2005_United_Arab_Emirates_GSHS_Country_Report.pdf. Accessed on August 24th 2021.
- Haji, E. (2016). World health organization and the centers for disease control and prevention. Bahrain Global School-based Student Health Survey (GSHS), BHR_2016_GSHS_v01. WHO. http://ghdx.healthdata.org/record/bahrain-global-school-based-student-health-survey-2016. Accessed on August 24th 2021
- Kurtzman, T. L., Otsuka, K. N., & Wahl, R. A. (2001, March). Inhalant abuse by adolescents. The Journal of Adolescent Health: Official Publication of the Society for Adolescent Medicine, 28 (3), 170–10. PMID: 11226839. Accessed on August 15th 2021 https://doi.org/10.1016/s1054-139x(00)00159-2
- Maldives-GSHS-Report (2009). Global school - based student health survey, Maldives 2009. Available from https://www.moe.gov.mv/assets/upload/2009_Maldives_GSHS_report.pdf. Accessed on Sept 5th 2020.
- MOH and MOE (2003). Bahrain national school health program. Available from: https://www.moh.gov.bh/Services/SchoolHealth?lang=en. Sept 5th 2020
- Pengpid, S., & Peltzer, K. (2020a). Tobacco use among male and female adolescents in public and private schools in bahrain. Gender & Behaviour Internet]. [cited 21 June 2022];18(2):15764–15768. Available from https://www.ajol.info/index.php/gab/article/view/198203
- Pengpid, S., & Peltzer, K. (2020b). Psychological distress in a national sample of male and female adolescents from public and private schools in bahrain. Gender & Behaviour Internet]. [cited 21 June 2022];18(2):15795–15802. Available from https://www.ajol.info/index.php/gab/article/view/198207
- Secondhand Smoke (SHS) Facts [Internet]. Centers for Disease Control and Prevention. 2021. Availablefrom:https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/. Accessed on August 20th 2021
- Taher, Amina T., Leena A. S., & Ahmed A. J. (2019). Prevalence of overweight and obesity amongst Bahraini adolescents aged 12-15 years attending primary care health centers. Journal of the Bahrain Medical Society, 31(1), 37–43. https://www.bhmedsoc.com/jbms/view-article.php?Article_Unique_Id=JBMS133
- Wang, Q. Underweight, overweight, and tobacco use among adolescents aged 12–15 years: Evidence from 23 low-income and middle-income countries. Tobacco Induced Diseases. 19(37), 1–12. 12 May. 2021. https://doi.org/10.18332/tid/133932. Accessed on June17th 2022
- WHO (2016). Global school-based student health survey, Bahrain fact sheet 2016. https://www.cdc.gov/gshs/countries/eastmediter/bahrain.htm. Accessed on August 24th 2021
- WHO and CDC (2013). “Global school-based student health survey.” Available from https://www.cdc.gov/gshs/pdf/GSHSOVerview.pdf. Sept 5th 2020