Report on Bhutan Global School-Based Student Health Survey 2016

Transcription

1 Report on Bhutan Global School-Based Student Health Survey 2016 Ministry of Health Royal Government of Bhutan 2017

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3 Report on Bhutan Global School-Based Student Health Survey 2016 Comprehensive School Health Programme Health Promotion Division, Department of Public Health, Ministry of Health, Royal Government of Bhutan and World Health Organization Regional Office for South-East Asia, New Delhi, India 2017 Ministry of Health Royal Government of Bhutan 2017

4 This survey and report have been made possible by the joint efforts of the United States Centers for Disease Control and Prevention (CDC), the World Health Organization Regional Office for South-East Asia (WHO- SEARO) and the Ministry of Health, Royal Government of Bhutan. Online repositories for Bhutan GSHS can be found at: Suggested citation: World Health Organization, Regional Office for South-East Asia and Comprehensive School Health Programme, Health Promotion Division, Department of Public Health, Thimphu, Ministry of Health, Royal Government of Bhutan. Report on Bhutan Global School-based Student Health Survey (GSHS) 2016.New Delhi: WHO-SEARO, ISBN: World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.. Suggested citation. World Health Organization, Regional Office for South-East Asia and Comprehensive School Health Programme, Health Promotion Division, Department of Public Health, Thimphu, Ministry of Health, Royal Government of Bhutan. Report on Bhutan Global School-based Student Health Survey (GSHS) 2016.New Delhi: WHO-SEARO, Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at Sales, rights and licensing. To purchase WHO publications, see To submit requests for commercial use and queries on rights and licensing, see Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover photo credit: Mr Sangay Thinley

5 Acknowledgements The Ministry of Health, Royal Government of Bhutan, expresses its sincere and profound gratitude to all individuals and organizations that contributed immensely towards the conduct of Bhutan s First Global School-Based Student Health Survey (GSHS) in Many individuals and organizations were involved in the planning of, pretesting for and conduct of the survey, as well as in the analysis of the data and writing of the report for the Bhutan GSHS. We would like to thank Ms Leanne Riley (WHO headquarters, Geneva); Dr Laura Kann, Yoshimi Yamakawa, Tim McManus, Connie Lim and Denise Bradford from the CDC, Atlanta; Dr Thaksaphon Thamarangsi, Dr Manju Rani, Dr Gampo Dorji, Mr Naveen Agarwal and Dr Rizwan SA from the WHO-SEARO; and Dr Ornella Lincetto, Dr Rui Paulo De Jesus and Mr Tshering Dhendup from WHO Country for Bhutan for their valuable technical support and constant guidance. We would also like to express our gratitude to the Ministry of Education, particularly to Ms Karma Dechen from the School Health and Nutrition Division, for all her hard work which contributed to the smooth and successful conduct of the fieldwork in the schools. We would like to make a special mention of the Steering Committee members, survey administrators, and writers (from the WHO-SEARO and Country Programmes) of the Bhutan GSHS report. Their enormous contributions at various stages of the survey are highly appreciated. iii Lastly, we would like to sincerely thank the principals, teachers, school health coordinators, class captains and health captains of the 50 sampled schools for their support during the stage of data collection. Last but not the least, we are extremely thankful to all the students and parents for their participation in this survey, the first of its kind in Bhutan.

6 Contents Acknowledgements List of tables Abbreviations Foreword by Health Secretary, Royal Government of Bhutan Foreword by the WHO Regional Director for South-East Asia iii vi vii ix xi Executive summary 1 1. Introduction Objectives 5 2. Methods Sampling of schools Questionnaire and its administration Data management and analysis 8 iv 3. Results Diet and physical activity Nutritional status and dietary behaviour Physical activity Tobacco, betel nut, alcohol and substance abuse Use of tobacco and betel nut Use of alcohol Use of drugs Mental health Suicidal behaviour Loneliness Missing classes and school experience Engagement of parents/guardians 23

7 3.4 Violence and injury Physical violence Sexual violence Bullying in schools Injuries HIV/AIDS Sexual behaviours Awareness of and attitude to HIV infection/ AIDS Personal hygiene Oral hygiene Hand-washing behaviours Discussion Nutritional status Dietary behaviours and physical activity Tobacco, alcohol and substance use Mental health 38 v 4.5 Violence and injuries Sexual behaviours and HIV/AIDS awareness Hygiene Limitations Recommendations 44 References 46 Annexes 1. Bhutan GSHS 2016 questionnaire Bhutan GSHS 2016 key findings factsheet Bhutan GSHS 2016 detailed tabulations for all indicators (available online at 4. Bhutan GSHS 2016 List of steering committee members Bhutan GSHS 2016 List of survey administrators 75

8 List of tables vi Table 1: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Demographic characteristics of the respondent population, GSHS Bhutan, Nutritional status and dietary behaviours among students of years of age in GSHS Bhutan, Patterns of physical activity among students of years of age in GSHS Bhutan, Patterns of tobacco use among students of years of age in GSHS Bhutan, Patterns of alcohol use among students of years of age in GSHS Bhutan, Patterns of drug use among students of years of age in GSHS Bhutan, Mental health of students of years of age in GSHS Bhutan, Level of parental engagement with students of years of age in GSHS Bhutan, Violence and injuries among students of years of age in GSHS Bhutan, Table 10: Sexual behaviours and knowledge of HIV/AIDS among students of years of age in GSHS Bhutan, Table 11: Oral hygiene and oral health among students of years of age in GSHS Bhutan,

9 Abbreviations BMI CDC FGDs GSHS GYTS HIV/AIDS MoE MoH NCD OCR PE PTSD RGoB SD SEARO SHS STDs STH UNAIDS UNDP UNESCO UNICEF WHO body mass index Centers for Disease Control and Prevention, Atlanta, United States focus group discussions Global School-based Student Health Survey Global Youth Tobacco Survey Human immunodeficiency virus/acquired immune deficiency syndrome Ministry of Education Ministry of Health noncommunicable disease optical character recognition physical education post-traumatic stress disorder Royal Government of Bhutan standard deviation WHO Regional Office for South-East Asia secondhand smoke sexually transmitted diseases soil-transmitted helminths Joint United Nations Programme on HIV/AIDS United Nations Development Programme United Nations Educational, Social and Cultural Organization United Nations Children s Fund World Health Organization vii

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11 ix

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13 Foreword by the WHO Regional Director for South-East Asia Adolescents constitute an important social and demographic group in the WHO South-East Asia Region, accounting for almost one fifth or 18.8% (362.2 million individuals) of the total regional population. Of this group, year-olds account for 181 million or nearly one tenth (9.4%) of the total regional population. Adolescent health is not only important in its own right, but is also an important predictor of the overall adult disease burden in the future. Given the importance of understanding health risk behaviours among adolescents, WHO is actively supporting the implementation of integrated adolescent risk factor surveys in all Member States of the Region as part of the Global School-based Student Health Survey (GSHS) Initiative. The purpose of an integrated adolescent risk factor survey such as the GSHS is to generate comprehensive and nationally representative data on major health risk factors among adolescents, ranging from nutritional status and dietary habits to mental health issues, to violence and unintentional injuries and risky sexual behaviours. Using the school as the venue for selecting and interviewing students results in substantial cost savings compared with household surveys, and provides greater privacy for students. If implemented regularly (every 3 5 years), these surveys will provide valuable data not only for tracking the health of adolescents but also for predicting the overall future disease burden, with almost 35% of the global burden of disease having its roots in adolescence. xi I congratulate the Ministry of Health and Ministry of Education of the Royal Government of Bhutan for completing the first GSHS survey in the country. While the survey revealed certain encouraging findings such as a high level of personal hygiene practices and high levels of HIV/AIDS awareness, it also revealed unacceptable levels of tobacco and alcohol use, high levels of mental health issues, poor dietary habits and low levels of physical activity. However, it is heartening to note that Royal Government of Bhutan has already acknowledged these issues and has already started appropriate policy and programmatic actions to address them. The survey findings suggest that action is required at the national and school levels to ensure the physical, mental and social well-being of adolescents and youth. I

14 sincerely hope that the Ministry of Health and Ministry of Education will institutionalize adolescent risk factor surveillance as part of their overall health information system, and will conduct this survey every 3 5 years to enable monitoring of these risk factors over time, and also undertake evaluation of the policies and programmes put in place to control these risk factors. Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region xii

15 Executive summary The first Global School-Based Student Health Survey (GSHS 2016) in Bhutan was conducted among school children of the age of years attending classes 7 11 to assess the trends in the prevalence of key health behaviours and protective factors. A two-stage cluster sampling method was used to select a nationally representative sample of 50 schools and 7990 students. Of these, all 50 schools participated and 7578 (7576 usable data) students participated, giving an overall response rate of 95%. The students anonymously self-administered an 84-item questionnaire, covering demographics (age, gender); nutritional status; dietary habits and physical activity; violence and unintentional injuries; mental health; tobacco, alcohol and substance use; sexual behaviours; knowledge of HIV/AIDS; and habits related to personal hygiene. Of the 7576 students who completed the questionnaire, 87 did not report their gender, and of the remaining 7489, 48.1% were male and 51.9% female. Of the total respondents, 4.8% were 12 years old or younger and 18.8% were 18 years old or older. The main report presents findings mainly for the age group of years (n=5809, 2515 male and 3255 female students, 39 did not report gender). The key findings of the survey were as follows. 1. Nutritional status: The prevalence of undernutrition was 2.1% and 3.1% of students reported going hungry most of the time or always because of the lack of food in their homes or boarding school. However, over-nutrition seems to be emerging, with 11.4% being overweight and 2% obese according to the BMI classification Risky dietary behaviour and limited physical activity: About 40% of the students reported drinking carbonated soft drinks one or more times a day. In addition, only 32.1% reported eating fruits two or more times a day and 42% reported eating vegetables three or more times a day. About 32.2% of the students reported eating fast food on 4 or more days during the 7 days preceding the survey. Only 23.5% reported being physically active for at least 60 minutes per day on 5 or more days during the 7 days preceding the survey and 30% spent 3 or more hours per day doing sedentary activities. 3. Tobacco and betel nut use: The prevalence of tobacco use (any tobacco product smokeless or smoking) was estimated at 29.4%, with the prevalence of cigarette smoking being 24.7% as defined by using a tobacco product or smoking tobacco product on 1 or more days in the last 30 days 9.4% of students were frequent smokers, smoking cigarettes 6 or more days in the

16 past 30 days. The rate of exposure to second-hand smoke, as measured by people smoking in their presence on one or more day in the last seven days, was high at 49.7%. In addition, 36.8% of student reported use of some form of tobacco by their parents or guardians. Though 55.2% of the respondents had tried to smoke tobacco before the age of 14 years, it was encouraging to note that 83% had tried to quit in the year preceding the survey. The reported rate of betel nut use was very high, with almost two-thirds of the students (65.8%) reporting that they consumed either of the two categories of betelnut products: Rajnigandha, Dildar, Wiz and others (58%), and doma khamtog (betel product) (49%) on one of more days in the last 30 days. 4. Alcohol and substance use: Almost one-quarter (24.2%) of students reported that they currently consumed alcohol defined as having had at least one drink of alcohol (which does not include a few sips for religious purposes) on at least 1 day during the 30 days before the survey. In addition, about one in 10 (12%) students said they currently used marijuana (one of more days in the past 30 days) and 7.2% reported current using drugs like N10, RP, SP or dendrite Mental health: About 11% of students reported having attempted suicide one or more times during the 12 months before the survey, while nearly half (43.3%) felt that their parents or guardians understood their problems and worries most of the time or always. 6. Violence and injuries: About 39% of the students reported having been physically assaulted at least once in the past year and about a quarter (26.5%) reported having been bullied on one or more days during the 30 days before the survey. 7. Sexual behaviour and awareness of HIV/AIDS: About 15% of students had ever had sexual intercourse, with just 59% of these reporting that they had used a condom during the last sexual intercourse. It is worrisome that among those who had ever had sexual intercourse, nearly half (49.3%) reported that their first sexual intercourse was before the age of 14 years. The students awareness of HIV/AIDS was high, with 86.3% reporting that they had ever heard about HIV/AIDS. 8. Personal hygiene: A small percentage of students (4.2%) said they never or rarely washed their hands after using the toilet or latrine, while 3.7% reported never or rarely washing their hands before eating. About one-third (33.6%) reported having no access to clean drinking water in school.

17 Some of the findings of the survey were encouraging. For example, a high proportion of students followed healthy practices related to personal hygiene and the level of knowledge of HIV/AIDS was high. However, some areas need urgent such as reducing the tobacco, alcohol and drug use, increasing parental engagement, creating a better environment at school with control of bullying and inter-personal violence and encouraging physical activity. However, Bhutan s school-going adolescents require focused interventions for reducing the risk factors for noncommunicable diseases (NCDs) and mental health issues. Programmatic measures must be developed to implement the holistic policies adopted so as to intervene early, since these behaviours may extend into adult life, fueling an NCD epidemic and mental health problem. There is a need for intensification of actions both at the upstream policy level as well as the downstream programmatic level that is, the community and school levels, to ensure the physical, mental and social well-being of adolescents and the youth. Any laxity in taking measures for this age group and during this time period could represent a missed opportunity to improve the health of the overall population. 3

18 1. Introduction Adolescence (persons aged years old) is a critical transition period in a human being s life, as it is during this time that the foundations for health and well-being are established. The rapid biological and psychosocial changes taking place during this period give rise to new health needs and risks, thereby making this age group especially vulnerable. The health status of an adult is mostly an outcome of the health behaviours initiated at a younger age. Several behavioural risk factors, such as an unhealthy diet, the lack of physical activity, poor personal hygiene and sanitation, drug abuse, and tobacco and alcohol consumption, deserve special attention. Many of these risk factors (use of tobacco, physical inactivity, harmful use of alcohol, unhealthy diet) have their origin in adolescence and lead to full-blown noncommunicable diseases in adulthood, and finally, contribute to premature mortality. The prevention or control of these risk factors later during life becomes extremely difficult because over time, they become an integral part of a person s lifestyle. Therefore, the primary prevention of risk factors among children and adolescents is of critical importance. 4 Bhutan is a small landlocked country, located between the two most populous countries in the world India and China with a total land area of 38,394 square kilometres. A peaceful mountainous kingdom in the Himalayas, Bhutan has a total population of 768,577 (projected figure for 2016). The majority of the people are farmers who depend on subsistence farming for their livelihood. The WHO estimates that around 1.2 billion people, or 1 in 6 of the world s population, are adolescents. Adolescents constitute merely one quarter of Bhutan s population, and year old population comprises about 13% of total population. School enrolment exceeds 98% only 1.2% of primary age children are estimated to be out of school. In 2016, there were 169,560 children enrolled in 522 schools, ranging from pre-primary to higher secondary schools (1). Recognizing the utmost importance of this group of population, the Royal Government of Bhutan has initiated and has been implementing various national policies and programmes for their health and well-being. Some of these include implementation of National multi-sectoral youth policy; the Comprehensive School and Adolescent Health Programmes; and inclusion of adolescent health in various national policies and programmes of different sectors. However, in order to effectively and strategically guide policy makers and stakeholders to further promote health and wellbeing of adolescents in Bhutan,

19 there is a lack of comprehensive national data on health behaviours and protective factors which are proven to be the leading causes of morbidity and mortality among adolescents worldwide. Therefore, in order to address the much needed data gap on health behaviours among adolescents in Bhutan, the RGoB has successfully conducted its first Global School-based Student Health Survey in The survey aimed at generating nationally representative data on various health risk behaviours, such as dietary habits, hygienic behaviour, interpersonal violence, mental health, substance abuse (including tobacco, alcohol and drug use), sexual practices and awareness of HIV/ AIDS, and also assessed protective factors among secondary school students of the age of years. 1.1 Objectives The goal of the survey was to obtain systemic information on select risk behaviours among adolescents, using schools as the sampling units, to support youth health programmes and policies in Bhutan. The purpose of the survey was to provide accurate data on health behaviours and protective factors among students to: 5 help Bhutan develop priorities, establish programmes, and advocate for resources for programmes and policies related to the health of school-going children and the youth; establish trends in the prevalence of health behaviours and protective factors to evaluate policies and programmes related to the health of school-going children and the youth; and allow the government, international agencies and others to make comparisons with other countries and within country.

20 2. Methods The GSHS is a school-based cross-sectional survey conducted primarily among students of the age of years. It measures behaviours and protective factors related to the leading causes of mortality and morbidity among the youth. The GSHS initiative developed a standardized scientific sample selection process; a common school-based methodology; and standardized questionnaire modules with core and expanded questions, and country-specific questions that can be administered during one regular class period. The GSHS covered a representative sample of schools, and the method used was one of anonymous reporting by the respondents through a self-administered questionnaire. It is difficult to obtain accurate data from adolescents during in-person household surveys, as their responses regarding certain behaviours considered social taboos may be misleading. Hence, anonymous self-reported surveys may yield better results. Besides offering greater privacy for accurate reporting, using schools rather than households as the sampling unit reduces the costs of a survey substantially, though this strategy misses the out-of-school youth. 2.1 Sampling of schools 6 Bhutan s general school education system consists mainly of public schools and a small proportion of private schools. In 2016, there were 522 schools, of which 486 were public schools and 36 private. The entry age for the formal school system is six years. The school-based education structure in Bhutan comprises 11 years of free basic education, from preprimary class to class 10. This is divided into seven years of primary education (preprimary to class 6) and four years of secondary education (class 7 to class 10). This is followed by two years of upper secondary school, which consists of classes 11 and 12. Typically, those in the primary level (preprimary to class 6) are 6 12 years of age, in the lower secondary level years of age, and in the upper secondary level, years of age. The GSHS covered students enrolled in classes 7 to 11 (mainly secondary school levels), and the MoE provided a complete list of schools, classes and number of students. The Bhutan survey employed a two stage cluster sample design to produce a nationally representative sample of all students enrolled in classes 7 to 11 (which are typically attended by students of the age of years, though some might be younger or older). In the first stage, schools were selected with probability proportional to enrolment size, using a random start. Fifty schools were sampled. In the second stage, systematic equal probability sampling was used, with a random

21 start, to select classes from each of the sampled schools. All the students in the selected classes were eligible to participate. A unique feature of the Bhutanese school system is the relatively high proportion of pupils enrolled as boarding students due to the distance of their homes from school. This is true especially of those who belong to the rural areas, from which it is difficult to commute daily. In this survey about 44% of the students were boarding students. A total of 50 schools and 7990 students were sampled for inclusion. Of these, all 50 schools and 7578 students completed the questionnaires (7576 valid questionnaires). Thus, the overall response rate was 95%. 2.2 Questionnaire and its administration The questionnaire (Annex 1) consisted of 84 core and expanded questions and country-specific questions. The questionnaire was developed in collaboration with WHO and the CDC as part of the GSHS initiative. The questionnaire was field tested in five strategically selected non-sampled schools, both in the rural and urban areas, in two districts of Bhutan. After the pilot test, the questionnaire was refined further for contextualization. Initially, the questionnaire consisted of 90 questions, but after the pilot test, the number of questions was brought down to 84. The final questionnaire was approved by WHO and the core working team. 7 The English language version of the questionnaire was used in the survey since the medium of instruction in Bhutan is English. It was found during the pilot test that translation of the questionnaire was not required. Several different recall periods, such as 7 days, 30 days, past year and within the school year, were used in the various questions. The questionnaire addressed the following topics. Lifestyle behaviours: dietary behaviours, hygiene, physical activity; Substance and drug use: consumption of tobacco, alcohol and betel nut; Sexual behaviour: sexual practices, knowledge of HIV infection or AIDS; and Social relationships and mental health: relationship with parents, friends and schoolteachers, violence and unintentional injury, and mental health. The field work for the survey was carried out between October and November The method of administering the questionnaire and other survey procedures were designed to protect the privacy of the students, allowing as they did for anonymous and voluntary participation. The students self-administered the questionnaire in an anonymous manner.

22 2.3 Data management and analysis The students were asked to fill in the circles of their choice on the answer sheets (optical character recognition [OCR] form). After the survey was completed, the OCR answer sheets were sent to the CDC, where they were scanned and the responses imported into a database. The CDC carried out the necessary cleaning (for inconsistencies and missing responses). Each question/response was weighted to reflect the likelihood of sampling each student and to reduce bias by compensating for differing patterns of nonresponse. The weight used for estimation is given by: W = W1 * W2 * f1 * f2 * f3 W1 = the inverse of the probability of selecting the school. W2 = the inverse of the probability of selecting the classroom within the school. f1 = a school-level nonresponse adjustment factor calculated by school size category (small, medium, large). The factor was calculated in terms of school enrolment instead of number of schools. f2 = a student-level nonresponse adjustment factor calculated by class. 8 f3 = a post-stratification adjustment factor calculated by grade. A complex sample analysis was done to obtain weighted estimates of prevalence and 95% confidence intervals for key indicators. Ninety-five per cent confidence intervals were used to assess the significance of differences in the key indicators by sex and age of the students.

23 3. Results Table 1 shows the characteristics in terms of age, sex and school class of the students who finally participated in the survey. Table 1: Demographic characteristics of the respondent population, GSHS Bhutan, 2016 Males Females Total Age (years) N (%) N (%) N (%) 12 or younger and older , Missing Grade N (%) N (%) N (%) Class Class Class Class Class Missing Type of student Day 1755 (45.2%) 2129 (54.8%) 3884 (100.0%) Boarding 1526 (45.0%) 1874 (55.1%) 3400 (100.0%) Total (all ages) 3384 (48.1%) 4105 (51.9%) 7576 (100.0%) Total (13 17 years) 2515 (43.6%) 3255 (56.4%) 5809 (100.0%) 1. The male and female count in each row may not add up to the exact value given under Total column as 87 students overall did not mention their gender. However, these students were not excluded from calculations of overall prevalence as per global practice. 2. The percentages may not add up to 100 because of missing values. 9 The detailed tabulations that provide information on the sample/denominator used in the computation of the key indicators under each domain are available online at which present the results by sex (male and female), class and age. As the sampling inclusion criteria were based on the class level and not age, the age of the sampled students varied from under

24 12 years to over 18 years. For the sake of uniformity and comparison, the results in the following sections pertain only to the age group of years (N=5809), though online detailes tables also provide the results for those under 12 years of age and those over 18 years of age. The results are presented across five key domains. 3.1 Diet and physical activity Nutritional status and dietary behaviour Nutritional deficiencies as a result of food insecurity (protein energy malnutrition, deficiency of vitamins and different micronutrients) affect students and their learning. In addition, changing dietary habits (e.g. increased consumption of sugary drinks, fast food) are leading to the problems of overweight and other risk factors associated with noncommunicable diseases (NCDs). Hence, an assessment of the dietary behaviours of adolescents is important to inform appropriate youth and school health policies and to check the rising prevalence of NCDs. The survey assessed the prevalence of hunger, the consumption of fruits and vegetables, and that of carbonated drinks and fast food. In addition, anthropometry (measurement of height and weight) was done for all students to calculate the body mass index (BMI). 10 Diet and nutritional status at a glance Percentage of students (13 17 years old) who: Reported going hungry Were underweight Were overweight Were obese Had not eaten any fruit during the past 30 days Had not eaten any vegetable during the past 30 days Had carbonated drinks 1 times per day Had animal protein 2 times a week Had breakfast most of the time/always Had fast food 4 days a week Nutritional status Nutritional status was assessed by calculating the BMI (kg/m 2 ) [(weight in kg)/ (height in m) 2 ] on the basis of the measured weight (in kg) and height (in m) of the

25 students. Students with less than -2 standard deviation (SD) from the median BMI for their age and sex were classified as underweight. Those with more than +1 SD from the median BMI by age and sex were defined as overweight, while students with more than +2 SD from the median BMI by age and sex were defined as obese. The prevalence of underweight was 2%, and there was a significant difference between males (3%) and females (1%), but not by age. The problem of over-nutrition was prevalent: nearly 11% and 2% of the year-old students were recorded as being overweight and obese, respectively. Significantly more females were overweight (15%) than males (8%), and significantly more young students were overweight (13%) than older students (10%). Also, day scholars (13%) were significantly more overweight than boarding students (9%). The prevalence of obesity did not differ significantly by age or sex. Only 3% of the students reported going hungry most of the time or always due to a shortage of food in their homes during the past 30 days. There were no significant differences by sex. When asked about the intake of animal protein, only 33% of the students reported eating foods containing animal protein two or more times a week. Fewer females (29%) than males (37%) reported taking animal source proteins. Similarly, fewer boarding students (27%) reported taking animal source proteins than day scholars (37%). 11 Fruit and vegetable intake About 13% and 4% of students reported not eating any fruits and vegetables, respectively, during the 30 days preceding the survey. Only 32% reported usually eating fruits two or more times a day. While there were no significant differences by sex, there was a significant difference between younger (37%) and older (27%) students. Similarly, about 42% of students reported usually eating vegetables three or more times a day, with no significant differences by sex or age. Also, significantly more day scholars reported eating fruits than boarding students (38% vs 23%), as well as vegetables (45% vs 37%). Consumption of carbonated soft drinks The survey explored the students habits with regard to the consumption of carbonated soft drinks, such as Coca Cola, Pepsi, Fanta and Sprite. About 40% of students reported drinking carbonated soft drinks one or more times a day. While

26 there were no significant differences by sex, a significantly higher percentage of younger students (44%) consumed carbonated drinks than older students (36%). Also, more day scholars (44%) than boarding students (34%) reported drinking carbonated drinks. Table 2: Nutritional status and dietary behaviours among students of years of age in GSHS Bhutan, Obese Went hungry a Fruits 2 times/ day b Veg 3 times/ day b Underweight Overweight Carbonated drinks 1 times/ day b Gender (%) (%) (%) (%) (%) (%) (%) Animal protein 2 times/ week Male 3.1* 7.9* Female Age * * * Type of student Day scholar Boarding student * * 44.6* 44.3* Total (13 17) *Differences across groups are statistically significant at 95% confidence level. a During the past 30 days, because there was not enough food at home or boarding school; b during the past 30 days Physical activity Adequate physical activity helps to build healthy bones and muscles, reduces blood pressure and obesity, and promotes psychosocial well-being (2). Engaging in adequate physical activity throughout one s lifespan and maintaining the normal body weight are the most effective ways of preventing many chronic diseases, including cardiovascular disease and diabetes (3).

27 Physical activity at a glance Percentage of students (13 17 years old) who: Were not physically active for at least 60 min/day during the past 7 days Were physically active for at least 60 min on 5 days/week Were physically active for at least 60 min on all days of the past week Spent 3 hours/day performing activities involving sitting Physical activity About one-quarter (27%) of the students reported being physically inactive, i.e., not physically active for at least 60 minutes a day on any day during the 7 days before the survey. There was no significant difference by age or sex. Only 24% of students reported being physically active for at least 60 minutes a day on 5 or more days during the week before the survey, and only 14% reported being physically active at least 60 minutes a day on all 7 days before the survey. Sedentary behaviours More than half of the students (55%) did not walk or ride a bicycle to or from the school, with no significant difference by age or sex. About 30% spent three or more hours a day performing activities involving sitting (sitting and watching television, playing computer games, talking with friends when not in school or doing homework during a typical or usual day). There was no significant difference by age or sex. Also, a significantly greater proportion of boarding students than day scholars (65% vs 49%)did not walk or ride a bicycle to school, while significantly more day scholars than boarding students (35% vs 22%) performed activities that involved sitting for 3 hours. 13 Proportion of students attending at least one Physical Education (PE) class a week during the school year About 61% of the students had never attended a PE class. However, 19% attended a PE class at least once a week. According to the MoE policy for period allocation, all classes from pre-primary to XII must have one health and physical education class (50 minutes) per week.

28 Table 3: Patterns of physical activity among students of years of age in GSHS Bhutan, 2016 Not physically active for at least 60 min per day on any day during one week a Did not walk / ride a bicycle a Spent 3 hours sitting each day Attended physical education classes 3 days a week b Gender (%) (%) (%) (%) Male Female Age Type of student Day scholar * 35.3* 14.7 Boarding student Total (13 17) *Differences across groups are statistically significant at 95% confidence level. a During the past 7 days; b during this school year. 3.2 Tobacco, betel nut, alcohol and substance abuse Most current users of tobacco, betel nut, alcohol and drugs have developed the habit in early adolescence. Sometimes it is just out of curiosity and sometimes, due to peer pressure, and often, these people go on to become regular users. Smokers have markedly increased risks of several cancers, particularly lung cancer, and are at a far greater risk of heart disease, stroke, emphysema, and many other fatal and nonfatal diseases. Similarly, chewing tobacco and betel nut has a marked association with cancer of the lip, tongue and mouth (4). The use of tobacco, alcohol and drugs has an adverse impact not only on those who use them, but also on their families and communities. It is important to prevent adolescents from developing these habits as quitting later is very difficult and requires intensive resources.

29 Tobacco, betel nut, alcohol and substance use at a glance Percentage of students (13 17 years old) who: Currently use a tobacco product Currently smoke cigarettes Smoked for 6 or more days Currently use tobacco products other than cigarettes Are exposed to second-hand smoke Have made an effort to quit Are susceptible to smoking Currently have Rajnigandha, Dildar, Wiz or Sakila Currently have doma khamtog (areca nut, betel leaves, lime) Currently use any betel nut product Currently drink alcohol (ara, bangchang, singchang, changkoe, beer, etc.) Ever got heavily drunk Currently use marijuana Currently use drugs (N10, RP, SP or dendrite) Use of tobacco and betel nut 15 Age of initiation and prevalence of tobacco use About one-third (29%) of students reported having used any tobacco product (smoke and smokeless) on at least one day during the 30 days before the survey. There were significant differences by sex (43% males vs 18% females) and age. About one-quarter (25%) of the students reported that they were currently smoking cigarettes. Here, too, there were significant differences by sex (38% males vs 13% females) and by age (20% younger vs 30% older). Also, about 18.4% of students reported using any tobacco other than cigarettes. There were significant differences by sex (28% males vs 10% females) and by age (15% younger vs 22% older). About 1 in 10 (11%) had smoked for 1 2 days in the past 30 days and 2% had smoked on all 30 days. Further, 9% were frequent users, meaning that they had smoked cigarettes on 6 or more days in the past 30 days. While 75.3% of the students had not smoked at all in the past 30 days, 78.5% had never smoked in their life.

30 About half of the students (55%) who had ever smoked cigarettes had first tried them before the age of 14 years. This shows that adolescents start using tobacco very early, and any programme to contain the tobacco epidemic has to focus on young adolescents. Tobacco use by parents or guardians and exposure to secondhand smoke Nearly one-third of the students (37%) reported that they had parents or guardians who used some form of tobacco, with no significant difference by sex. In addition, almost half of the students reported that people smoked in their presence (on one or more days during the 7 days before the survey), with a significant difference by sex (59% males and 41% females) but not by age. Exposure to smoking for1 2 days was reported by 28.4% and all 7 days by 6.8% of the students. Desire to quit and susceptibility to smoking 16 Among those who reported smoking cigarettes during the 12 months before the survey, 83% reported that they tried to quit the habit. There were no significant differences by age or sex. The survey assessed the temptation to smoke among the students. About 84% said that they would not smoke if offered a cigarette by friends. More female students (90%) than male (76%) resisted this temptation. About 86% of students did not see themselves smoking a cigarette any time in the next 12 months. There were significant differences by sex (80% male vs 92% female) and age (90% among year-olds vs 82% among year-olds). A comparison by type of students showed that the tobacco use indicators were not significantly different for day scholars and boarding students, except that a higher proportion of day scholars was exposed to secondhand smoke (SHS) (54% vs 44%). Consumption of betel nut and pan masala Areca nut (betel nut) is the fourth most commonly used addictive substance in the world. The use of betel nut causes oral cancer and has also been linked to metabolic syndrome, hypertension, diabetes mellitus and obesity. When taken with tobacco, it causes upper digestive tract cancers, including cancer of the oral cavity, pharynx and oesophagus.

31 In Bhutan, most users of betel nut chew a mixture of areca nut, betel leaf and lime locally known as doma khamtog. Doma khamtog is widely used in the country and its consumption is traditionally accepted. Betel nut is also consumed in the form of meetha pan and a wide variety of packaged pan masalas (a mixture of areca nut and slaked lime, catechu and other flavouring agents). The production, sale, distribution and consumption of betel nut products are not regulated in Bhutan. The survey assessed the prevalence of the use of doma khamtog or meetha pan (i.e., having doma khamtog or meetha pan on one or more days during the 30 days before the survey). Overall, half of students were found to be current users of doma khamtog or meetha pan. More male students (57%) than female (43%) were current users, and the use of doma or meetha pan was more prevalent among students in urban schools (51%) than rural (46%). The survey also assessed the prevalence of the use of pan masala, such as Rajnigandha, Sakila, Wiz and Dildar, all of which are imported from the neighbouring countries. Nearly 6 in 10 students were found to be current users of pan masala (i.e., having panmasala on one or more days during the 30 days before the survey). More male students (66%) than female (51%) used pan masala on one or more days before the survey. Table 4: Patterns of tobacco use among students of years of age in GSHS Bhutan, 2016 Currently using any tobacco product a Tried a Currently smok- cigarette before ing cigarettes a of age 14 years b Tried to quit cigarettes c Currently having Rajnigandha,Dildar, Wiz, etc. a Currently having doma khamtog a Exposure to second-hand smoke d Use of any form of tobacco by parents Will not smoke if friends offer e Will not smoke anytime in next 12 months e Gender (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Male 42.9* 38.0* 58.0* * 55.8* 59.3* * 79.8* Female Age * 20.1* 69.4* * 89.6* Type of student Day scholar Boarding student Total (13 17) *

32 *Differences across groups are statistically significant at 95% confidence level. a On at least 1 day during the 30 days before the survey, and includes use of cigarettes and other tobacco products; b for the first time among students who ever smoked cigarettes; c among students who smoked cigarettes during the 12 months before the survey; d on one or more days during the 7 days before the survey; e includes respondents who said definitely not and probably not Use of alcohol Worldwide, harmful use of alcohol causes 3% of all deaths each year. While intoxication and addiction have certain direct effects, the use of alcohol also causes oesophageal cancer, liver disease and epilepsy, and can lead to homicide, intentional injuries and motor vehicle accidents (5). Heavy use of alcohol also places one at a greater risk for cardiovascular disease (6). In most countries, alcohol-related mortality is the highest among those who are years of age, but the study of alcohol consumption among adolescents is important because of the relationship between the age of initiation of alcohol use and the pattern of its use and abuse in adulthood (7). 18 Intentional and unintentional injuries are far more common among the youth and young adults. Unintentional injuries are the leading cause of death among people of years of age and many of these injuries are related to the use of alcohol (8). Problems with alcohol can impair the psychological development of adolescents and influence both the school environment and leisure time negatively (9). The GSHS 2016 used a set of seven questions to assess the patterns of alcohol use among the surveyed students. Age of initiation and prevalence of alcohol use About one-quarter (24%) of students reported that they currently consumed alcohol defined as having had at least one drink of alcohol (which does not include a few sips for religious purposes) on at least 1 day during the 30 days before the survey. Significant differences were observed by age (18% among year-olds and 31% among year-olds) and by sex (33% among males vs 16% among females). Among those who reported current use of alcohol, 17% said that they usually had two or more drinks per day on the days they drank. There was a significant difference by sex (21% among males vs 12% among females), but not by age. No significant differences by rural or urban schools were found. Among the students who ever drank but a few sips, 56% reported that they consumed alcohol before the age of 14 years. There was a significant difference by age (74% among year-olds vs 43% among year-olds), but not by sex. Almost two in five (40%) students who currently had alcohol reported that they

33 usually obtained the alcohol they drank from friends, followed by stores, shops or street vendors (25.3%). Drunkenness and consequences of drinking About one-quarter (23%) of students reported that they had at some point had so much alcohol that they were really drunk (one or more times in their life). There were significant differences by sex (33% among males vs. 15% among females) and age (16% among younger vs 32% among older students). Also, more boarding school students (27%) than day scholars (20%) reported heavy drinking. About one in 10 (10%) reported that they got into trouble with their family or friends, missed school, or got into fights as a result of drinking alcohol (one or more times during their life). There were significant differences by sex (15% among males vs 6% among females) and age (7% among younger vs 13%among older students). Also, alcohol-related quarrels were reported more by boarding school students than day scholars (12% vs 9%). Table 5: Patterns of alcohol use among students of years of age in GSHS Bhutan, 2016 Currently drink alcohol a Drank 2 or more drinks per day b First drank alcohol before age of 14 c Got heavily drunk at any point d Got into trouble or fights due to alcohol use d Obtained alcohol from friends e Gender (%) (%) (%) (%) (%) (%) Male 33.4* 21.1* * 14.5* 37.5 Female Age * * 15.5* 7.2* Type of student Day scholar Boarding student Total (13 17) * 9.0* *Differences across groups are statistically significant at 95% confidence level. a At least one drink of alcohol on at least one day during the 30 days before the survey; b on the days they drank, among students who drank alcohol during the 30 days before the survey; c for the first time, among students who had only had a few sips earlier; d one or more times during their life; e among students who drank during the 30 days before the survey. 19