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Y.A. Jaffer,¹ M. Afifi,¹ F. Al Ajmi¹ and K. Alouhaishi²

ABSTRACT We investigated the practice of some of health-compromising behaviours among Omani adolescents and their correlates in a nationally representative secondary school-based sample of 1670 boys and 1675 girls. The mean age of the sample was 17.13 (SD 1.35) years. Through a self-administrated questionnaire the adolescents were asked about 6 risky behaviours: current smoking, ever use of alcohol, succumbing to peer pressure to take illicit drugs, driving without a licence, speeding while driving and being involved in a physical fight in the month prior to the survey. Demographic and psychosocial variables related to their risk behaviours were also assessed. The results indicated that 4.6 % were current smokers, 4.3% had drunk alcohol and 4.6% had taken drugs. About 20% had been involved in a physical fight in the month prior to the survey, 33.4% drove without a licence and 33.9% liked to speed. Male sex and low self-esteem were the strongest predictors of risky behaviour.

Connaissances, attitudes et pratiques des élèves du secondaire à Oman : I. Les comportements qui compromettent la santé

RÉSUMÉ Nous avons examiné la pratique de certains comportements qui compromettent la santé chez des adolescents omanais ainsi que leurs corrélats dans un échantillon national représentatif de 1670 garçons et 1675 filles en milieu scolaire secondaire. L’âge moyen de l’échantillon était de 17,13 (E.T. 1,35) ans. Les adolescents ont été interrogés au moyen d’un auto-questionnaire sur 6 comportements à risque : tabagisme au moment de l’enquête, consommation d’alcool au cours de la vie, prise de drogues illicites sous la pression de pairs, conduite sans permis, vitesse au volant et implication dans une bagarre durant le mois précédant l’enquête. Des variables psychosociales et démographiques liées aux comportements à risque ont également été évaluées. Les résultats ont indiqué que 4,6 % des sujets étaient fumeurs au moment de l’enquête, 4,3 % avaient consommé de l’alcool et 4,6 % avaient pris des drogues. Environ 20 % avaient été impliqués dans une bagarre au cours du mois précédant l’enquête, 33,4 % conduisaient sans permis et 33,9 % aimaient la vitesse. Le sexe masculin et la faible estime de soi étaient les facteurs prédictifs les plus forts pour le comportement à risque.

¹Ministry of Health, Muscat, Oman (Correspondence to M. Afifi: This e-mail address is being protected from spambots. You need JavaScript enabled to view it ).
²Department of Research and Studies, League of Arab States, Cairo, Egypt.
Received: 06/01/04; accepted: 12/09/04
EMHJ, 2006, 12(1-2): 35-49

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Introduction

Adolescence, the age period between 10 and 19 years of age, is both a transient stage, between childhood and adulthood, and a formative period during which many life patterns are learned and established [1]. Adolescents are commonly regarded as being in the healthy spectrum of human life and are thus considered to have no special needs [2]. However, health professionals are increasingly realizing the need for information on morbidity of this age group and their special health needs [3].

In the past 30 years, improved child survival and good health care have resulted in a sizeable increase in the adolescent population of the Oman; 30% of its population is in the adolescent age group, which is 10% higher than the average figures for the adolescent population in the world. Despite a 35% drop in the total fertility rate (TFR) in Oman from 1995 to 2000 [4], the TFR is still higher than other Arab and neighbouring countries [5,6]. It indicates that Oman will continue to have a relatively high percentage of adolescents in its population for many more years to come [7].

This relatively rapid growth of the Omani population and the lack of information about Omani adolescents prompted the study of the health profile of adolescents in Oman with the aim of gaining a better understanding of the youth in Oman today. The overall goal of the study was to establish a database on the knowledge, attitudes and practices of secondary-school adolescents regarding health-compromising behaviour (the aim of the current study) and reproductive health (the aim of the second part of the study) [8], in order to establish policies and programmes addressing the needs of this age group [9].

In Oman the prevalence of diabetes and obesity is increasing [10,11], the prevalence of hypertension is relatively high [12], as is the morbidity and mortality due to road traffic accidents [13]. These are undoubt-edly contributed to by a number of beha-viours, including unhealthy diet, sedentary lifestyle, tobacco use and reckless driving. The antecedents, values, and beliefs that influence these behaviours are complex but are usually acquired during childhood and adolescents [14]. Such behaviours can not only lead to serious consequences related to adolescents’ overall health status, but could also adversely affect their educational and academic achievement and hence their careers [15]. Moreover, adolescent risk behaviours would be expected to be interrelated or clustered and thus strategic interventions to prevent or correct them should take into consideration their clustering and cumulative nature [16]. Hence the present study investigated some of the health-compromising behaviours present among Omani adolescents and their correlates.

Methods

This was a cross-sectional study of a nationally representative sample of secondary- school students of both sexes conducted in 2001 by the Ministry of Health in collaboration with other ministries and the United Nations Children’s Fund (UNICEF) and funded in part by the World Health Organization (WHO) Regional Office for the Eastern Mediterranean who also provided technical assistance.

A multi-stage stratified random sampling technique was used, and the sample size was calculated assuming that the least prevalent variable to be studied was 5% at the 90% confidence interval. The sample size of students was calculated in relation to the proportion in each governorate and grades in different strata. The primary sampling unit was the school class. The total number of secondary schools in Oman is 257; the total number of students is 50 716 boys and 54 192 girls. In the same academic year 2001, a number of classes were selected randomly (primary sampling unit) from a list of all classes in the secondary schools ordered according to the region, student sex, grade (I, II, III) and section (Science, Art) and representing all the regions of Oman. After selection of 152 classes from boys’ schools and 152 from girls’ schools in proportional allocation to student population size in each region, 11 students were randomly selected from each selected class. Accordingly, 1670 adolescent boys (3.3% of a total of 50 716 secondary-school boys in Oman) and 1675 adolescent girls (3.1% of a total of 54 192 secondary-school girls) were selected. Of these, 1485 boys and 1629 girls (total 3114 students) responded (response rate 89% and 97% respectively) and their data were entered into the statistical analysis. To avoid a non-response bias due to student’s absence on the day of the survey, sample weights were used for analysis of data.

The survey was conducted using a self-administrated anonymous questionnaire answered by all the students in the sample. The following topics were covered: puberty, marriage issues, birth spacing, sexually transmitted diseases and HIV/AIDS, female genital cutting, sources of information on reproductive health, risk behaviours, social upbringing (in terms of the parental control) and relationships, role of schools and school health services. We made use of the Arabic translation of the Youth Risk Behavior Surveillance System [17] adopted by Lebanon but expanded it to cover knowledge and attitude for some locally selected areas. It was further refined with the help of the WHO Regional Office for the Eastern Mediterranean and fine-tuned during the 2 weeks of training of 32 researchers from the Ministry of Health (school health doctors, nurses and educators). It was then pilot tested in one class each in 2 regions of Oman (Muscat and South Batinah) and modified accor-dingly before putting it in its final form. The data collection phase began in April 2001 and continued for 1 month. The students took around 1–1½ hours to complete the questionnaire. Data entry personnel were trained on ISSA software before embarking on data entry and management.

In this paper, we focus on 6 health-compromising behaviours namely: current smoking, ever use of alcoholic beverages, peer pressure to take drugs, driving without a licence, speeding while driving, and physical fighting in the month prior to the survey. The question relating to peer pressure was used as a proxy for ever use of drugs as is was felt that students would be reluctant to answer a direct question on use.

These 6 behaviours were considered as the dependent or output variables in the statistical models. We included 12 independent or predictor variables categorized into 3 groups: 1) demographic data of students, namely sex, age, socioeconomic class [18]; 2) mental health proxies of students: experiencing sleep disorders, possessing self esteem and confidence [15], having negative traits (anxiety, depression, sadness or frustration), having positive traits (satisfaction, happiness, success, inner peace); 3) social environment of students: pattern of parent relations with each other, parents’ treatment of the student, witnessing of violence in the family and or among friends, experience of physical punishment.

Data entry was done using ISSA; data analysis was done using SPSS, version 6.0. In bivariate analysis, data were presented as percentages and means. The likelihood chi-squared test examined the distribution of data, while group means were compared using ANOVA. Multiple logistic regression models were constructed to test the most important associated factors with the 6 studied dependent binary variables. A P-value ≤ 0.05 was considered statistically significant.

Results

About 48% of the sample were boys and the mean age (standard deviation) of the sample was 17.13 (1.35) years. The majority of the sample (72%) was of middle socioeconomic class according to the scale used which was adapted from Abdul Moati (A.B. Abdul Moati, unpublished report, 2002). About 40% of the sample reported 1 or more negative trait, while 63% reported positive traits. The majority reported some sleep-ing disorder (85%). Parents of 61% of the students were mostly happily married and 80% treated their children with love, respect and equality. However, 8.2% of the students (12.5% males, 3.7% girls) were punished physically. Moreover, the majority had witnessed violence within their families and among their friends – sometimes or often (72.7% and 66.0% respectively). As regards health-compromising behaviours, the boys were more likely than girls to practise such behaviour; 4.6 % (6.4% boys, 2.9% girls) were current smokers and 14.9% (26.2% boys, 3.8% girls) were ever smokers, while 4.3% (6.6% males, 2.0% girls) had drunk alcohol and 4.6% (7.2% males, 2.2% girls) had been persuaded to take drugs by their peers. About 20% (22.9% males, 17.9% girls) had been involved in one or more physical fight in the month prior to the survey, 33.4% (57.5% males, 12.2% girls) drove cars without a licence, and 33.9% (42.1% males, 26.3% girls) liked to speed while driving (data not shown in tables).

Tables 1 , 2 and 3 show the proportion in cross-tabulation of the overall sample of adolescents who reported practising (or not) the 6 health-compromising behaviours with the 11 studied (binary or categorical) independent variables. The likelihood chi-squared test showed significant differences in the majority of variables.

We conducted a multivariate analysis to examine the most significant predictors, adjusted to each other, of the 6 health-compromising behaviours. A logistic regression model was constructed for each risk behavior to test for its most significant predictors adjusted for each other (Table 4). Female sex and a high self-esteem score were found to be protective against practising almost all the health-compromising behaviours. Older adolescents were more likely to drive without a licence. Those with a constant sleeping problem were more likely to have ever drunk alcohol or been involved in physical fights. Those who reported 2 or more positive traits were less likely to drive without a licence, while those who reported 2 or more negative traits were 4 times more likely to drive fast. In addition, students from the highest socioeconomic class were twice as likely to drive without a licence or to speed than students from the lower socioeconomic classes. Students who had experienced physical punishment by their parents or those who often witnessed violence among their family members were about twice as likely to have got involved in physical fights in the month prior to the survey. Poor parental relations as well as uncaring treatment of adolescents by parents also increased the odds of displaying some risk behaviours, namely driving without a licence or speeding.

Discussion

The major findings of this study are that out of the 12 demographic and psychosocial variables entered in the different logistic models, 11 were found to predict health-compromising behaviour among Omani adolescents. Only witnessing violence among friends did not predict the practice of health-compromising behaviours. The 11 could be categorized into 3 groups: 1) adolescent demographic variables (sex, age, socioeconomic class); 2) adolescent mental health proxies (having sleep disorders, self esteem, reporting negative or positive traits) and 3) adolescent social environment (parental relations, how parents treat him/her, being punished by beating, and witnessing violence among family members).

Another major finding from our study is that the Omani adolescents in our sample were generally healthy compared to other Arab or non-Arab countries. The prevalence of smoking in the current study (4.6%) is much lower than other studies of prevalence of current smoking among adolescents which ranges from 20%–29% in Saudi Arabia [19,20], 19% in the United Arab Emirates [21] and 19.6% in Yemen [22]. Smoking was significantly higher among boys, which is consistent with what was found in Saudi Arabia, Yemen and Tunis [19–23]. Similarly, the prevalence of ever drinking alcohol (4.3%) is much less than that found among university students in Lebanon (49.4%) [24]. Reckless driving practices were studied by Arnett et al. who found that the majority of their study sample of both sexes reported driving at high speed, and a quarter reported driving while intoxicated [25]. Hartos et al. also found that risky driving was reported in 80% of the teenagers in their sample [26]. In our study 33.9% liked to drive fast and 33.3% reported driving without a licence. Beck et al. recommended increasing parents’ power to impose and enforce driving restrictions on previously licensed teenaged drivers [27]. In our study risky driving significantly increased with age in both bivariate and multivariate analysis which is consistent with what Schootman et al. found [28]. Non-fatal fight-related injuries among young people result in lost capacity and high costs of medical care and rehabilitation [29]. Witnessing violence is a significant predictor of getting involved in fights [29]. Witnessing violence within the family was found to increase the likelihood of getting involved in physical fights in the current study, where the prevalence was about 20%. Other studies in the United States showed that 39%–53% of studied adolescents had been in physical fights [30]. Loeber et al. found that the prevalence of a psychiatric diagnosis after 7 years follow up was 3 times higher for persistent fighters than for non-fighters [31].

We did not investigate all the 6 categories of priority in the Youth Risk Behavior Surveillance System. These behaviours contribute to unintentional injuries and violence, tobacco use and other drug use, sexual behaviours that contribute to unintended pregnancy and sexually transmitted diseases, HIV infection, unhealthy dietary behaviour, and physical inacti-

vity. Although other studies have compared health risk behaviours among students from different countries [32], our study used a different methodology and accordingly such comparison was not feasible [33]. This is in part because our study was part of a national survey where many other topics were also studied. Some risk behaviours, such as unhealthy dietary behaviour and physical inactivity will be tackled in another paper by the authors and others cannot be easily addressed in the Omani culture. However, some areas that were not touched upon, such as violence and suicidal ideation or attempted suicide, are important and in some other studies in Arab countries these behaviours have not been found uncommon [34,35].

It should also be noted that the findings of this survey cannot not be generalized to the entire adolescent population in Oman as this was a school-based survey. Despite universal education in Oman, some adolescents drop out before secondary school. Furthermore, private and alternative schools were not included in our survey as they do not exist in all regions of the country. Nevertheless, to the best of our knowledge, this study is the first of its kind to investigate health-compromising behaviour among adolescents in a Gulf Cooperation Council country.

The importance of this study is that it not only reports the prevalence of these beha-viours, but also illustrates the psychosocial variables correlated with them. Knowledge of the presence and impact of risk factors on the health of adolescents and youth is not enough. We have to focus on examining the protective factors and sources of disturbance in the lives of adolescents, which can offer insight into possible effective interventions and programmes [36].

Promoting the mental health status of our adolescents and its proxies, provision of a healthy social environment and parental connection are some of the protective factors found in the current study. Accor-dingly, the study findings provide valuable information to policy-makers, educators, health providers and community workers that can be used to improve the health and well-being of adolescents in Oman.

Given that youth-specific health services may promote service utilization and provide a better outcome for young people, our future work will focus on studying the relationship between health-compromising behaviour and use of health services. Previous studies have indicated a strong relationship between service utilization and adolescent psychopathology [37]. In addition, unhealthy dietary behaviour and physical inactivity will be discussed in a separate paper.

Acknowledgements

We would like to thank the Ministry of Health and the WHO for their financial support in conducting this study. Special thanks to Dr. M.H. Khayat for his continuous support and sustained efforts to make this work successful. We would also like to thank His Excellency the Minister of Health, their Excellencies the Undersecretaries of Planning, Health Affairs and Financial Affairs, Director-Generals at the Ministry of Health headquarters as well as in the regions, and a large number of other people within the Ministry of Health for their support.

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