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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 14  |  Issue : 2  |  Page : 109-123

Relationships between health risk behaviors and protective factors among adolescent school students by adopting the Structural Equation Model


1 Community Health Nursing, Faculty of Nursing, Damanhour University, Damanhour, Egypt
2 Department of Biostatistics, High Institute of Public Health, Alexandria University, Alexandria, Egypt

Date of Submission19-Apr-2017
Date of Acceptance30-May-2017
Date of Web Publication12-Jan-2018

Correspondence Address:
Elham H Tawfik
Doctor Degree of Public Health Sciences (Health Education and Behavioral Sciences), High Institute of Public Health, Alexandria University, Community Health Nursing, Faculty of Nursing, Damanhour University, Damanhour
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ENJ.ENJ_22_17

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  Abstract 

Background Many adolescent school students suffer needlessly, unable to access appropriate resources for recognition, support, treatment. Many health risk behaviors are established during adolescence, which often continue into adulthood, affecting their health, well-being in later life.
Aim The aim of the present study was to investigate the relationships between health risk behaviors and protective factors among adolescent school students by adopting a Structural Equation Model.
Research design A cross-sectional, descriptive research design was used.
Participants Preparatory school students of grades 1, 2, and 3 aged 13–15 years were included. Consent for participation was obtained from their parents. The total sample included 969 students.
Setting Six preparatory governmental schools from urban and rural districts in El-Beheira Governorate were included, with three schools from each area.

Keywords: adolescent school student, health risk behavior, protective factors, Structural Equation Model


How to cite this article:
Tawfik EH, Farag S. Relationships between health risk behaviors and protective factors among adolescent school students by adopting the Structural Equation Model. Egypt Nurs J 2017;14:109-23

How to cite this URL:
Tawfik EH, Farag S. Relationships between health risk behaviors and protective factors among adolescent school students by adopting the Structural Equation Model. Egypt Nurs J [serial online] 2017 [cited 2018 Sep 18];14:109-23. Available from: http://www.enj.eg.net/text.asp?2017/14/2/109/223098


  Introduction Top


Adolescence, a time of opportunity, has gained increasing global attention. The WHO defines adolescence as ‘the period of life between the ages of 10–19 years; early adolescence refers to 10–14 years and late adolescence to 15–19 years’ (Patton et al., 2016). It is the transitional period from childhood to adulthood, roughly corresponding to the age of onset of puberty and adult identity. Adolescence is marked by immense turmoil in physical, cognitive, emotional, and social development where experimentation and risky behaviors may begin (Jackson et al., 2012).

In 2009, there were 1.2 billion adolescents in the world, accounting for 18 percent of world’s population (United Nations Children Fund, 2013). The vast majority of adolescents − 88% − live in developing countries (United Nations, 2010). Adolescents comprise nearly one-quarter of the Egyptian population, and Egypt is experiencing an unprecedented ‘youth bulge’. The current situation in Egypt demonstrates that, although adolescents have historically been neglected as an age group requiring particular attention, interest in the rights and needs of adolescents has grown since the 25th of January revolution, which dramatically demonstrated the important role young people play as catalysts for change. There is now national recognition of the importance of investing in the needs and aspirations of adolescents and creating the space for them to engage in national development (Unicef, 2011). Unhealthy lifestyle has increased in Egypt in recent years because of the presence of health risk behaviors such as inappropriate dietary habits, poor hygiene, mental health disorders, physical inactivity, unprotective factors, tobacco use, violence, and unintentional injuries (Ansari et al., 2016).

Health risk behaviors can determine whether an adolescent will become a healthy adult or develops chronic illnesses (Ansari et al., 2016). Overweight acquired during childhood or adolescence may persist into adulthood and increase the risk for coronary heart diseases, diabetes, gall bladder disease, and osteoarthritis. Lower intake of fruits and vegetables are associated with several health problems such as cancer. Nutritional deficiencies as a result of food insecurity (protein–energy malnutrition, iron, vitamin A, and iodine deficiency) affect school attendance and learning (Ansari et al., 2016).

Poor hygiene among adolescent school students may worsen their health and learning achievement. Dental caries and other oral diseases can affect their ability to eat, appearance, communication, overall health status, and ability to learn (Ansari et al., 2016). In addition, diarrhea resulting from contact with fecal material kill 2–3 million adolescents in developing countries every year; hand washing with soap and water alone could reduces these mortality rates in half (Pearson et al., 2015). Worldwide, about 400 million school-aged children are infected with parasites that consume nutrients from children they infect, cause abdominal pain and malfunction, and can impair learning by slowing cognitive development (Murray, 2008). Anxiety disorders, depression, and behavioral and cognitive disorders are among the most common mental health problems among adolescents in the world. Half of all lifetime cases of mental disorders start by the age of 14. Every culture has children and adolescents struggling with mental health problems such as abuse, neglect, suicide, alcoholism, drug abuse, violence, and criminal activities (WHO, 2008b).

Adequate physical activity also helps build and maintain healthy bones and muscles, control weight, build lean muscle, reduce fat, reduce feelings of depression and anxiety, and promote psychological well-being. A positive relationship of adolescents with their teachers, friends and peers, positive attitudes towards school with higher attendance rate, and living in a social environment with parental and family members are considered protective factors (Tian et al., 2007). All these factors provide meaningful relationships, encourage self-expression, and provide structure and boundaries with lower levels of depression, tobacco use, and violence (Dolzan et al., 2015). Most people who use tobacco initiate use before the age of 10. Exposure to tobacco smoke in the environment can aggravate allergies and increase the severity of symptoms in children and adolescents with asthma and heart disease; it is also associated with lung cancer (Page and Danielson, 2011).

Unintentional injuries are a major cause of death and disability among adolescents. Each year, 875 000 children under age 18 die from injuries, and 10–30 million have their lives affected by injury. For every youth homicide, ∼20–40 victims of nonfatal youth violence receive hospital treatment. Many injuries lead to permanent disability and brain damage. Victims of bullying have increased stress, depression, reduced ability to concentrate, increased risk for substance abuse, and aggressive behavior (Beck et al., 2016). These are considered modifiable health risk behaviors and are important issues during adolescence. This has led to a focus on adolescence and the opportunities to promote health and prevent onset of risky behaviors known to persist into adulthood and result in morbidity and premature death from noncommunicable diseases (Catalano et al., 2012).

Addressing these health risk behaviors as a public health issue needs the implementation of a global strategy; therefore, building the foundation is essential to control and prevent these issues. The availability of reliable data will enable experts to examine the impact of health risk behaviors on adolescents worldwide and develop health policies and interventions to decrease undesired health impacts on population health. The WHO had designed and supported a Global School-based Student Health Survey (GSHS) to measure and assess behavioral risk and protective factors among adolescents across diverse populations in many regions, specifically African, American, Eastern Mediterranean, European, southeast Asian, and western pacific regions. The GSHS have been used to develop priorities, establish programs, and advocate for resources for school health. It is an inexpensive school-based survey that gathers data on student’s health risk behavior and protective factors related to the leading causes of death across the world (Ziaei et al., 2014). The GSHS was used in Egypt in 2006 and 2011 among students in preparatory grades 1, 2, and 3 aged 13–15 years. There are some behaviors or states that particularly stand out, including poor dietary habits, underweight/overweight/obesity, inadequate physical activity, unsatisfactory hygienic habits, mental health disorders, violence/unintentional injury/bullying, tobacco use, and insufficient protective factors. (WHO, 2006, 2011a, 2011b).

Nurses were at the forefront of the movement to use statistics to improve healthcare. For example, Florence Nightingale (1820–1910) used data from British army files to show how most of the deaths in the British army during the Crimean War (1853–1856) were not caused by direct combat but by illnesses contracted off the field of battle or as a result of unattended wounds. Her statistical analyses convinced the British government to maintain field hospitals and supply nursing care to soldiers (Plichta and Garzon, 2009). Structural Equation Modeling (SEM) is a statistical innovative unprecedented approach in nursing sciences to test hypotheses about the direct and indirect relationships among a cluster of risk behaviors that may be observed or latent (Santoso, 2007). Observed variables are called indicator variables or manifest variables that are measured directly using questions to be answered such as questions for each risky behavior domain in this study tool. Latent variables are denoted as unobserved variables or factors that are reflected by answers for the individual items (questions), such as overall risk behavior domains. In the present study, a SEM was used to estimate the direct and indirect relationship (bidirectional or unidirectional) between different health risk behaviors, which are bundle clustered together (Jackson et al., 2012). Direct relationships will be reflected by the unidirectional arrow between any pair of the studied behaviors, whereas indirect relationships will be extracted through intermediate relations. The goals are to present a powerful, flexible, and comprehensive technique for investigating relationships between measured variables and latent constructs as well as to challenge participants to design and plan research using SEM as an appropriate analysis tool (McDonald and Ho, 2002). To date, most intervention programs have targeted single risk behaviors, but SEM is a proposal for interventions to take a broader approach and to address multiple problems and precursors (Jackson et al., 2012).

Traditional approaches differ from the SEM approach in several areas, where analyzing research data and interpreting results can be complex and confusing. Traditional statistical approaches to data analysis specify default models, assume that measurement occurs without error, and are somewhat inflexible. However, SEM requires specification of a model based on theory and previous research hypothesis, is a multivariate technique incorporating measured variables and latent constructs, and explicitly specifies measurement error (Santoso, 2007). It is a highly flexible and comprehensive methodology for investigating different health issues such as health risk behaviors. A model (path diagram) provides a convenient and powerful way to present complex relationships in SEM. In addition, SEM can measure direct and indirect relationships while traditional models measure only direct relationships. The nature of relationships between studied variables depends on the sign of the regression weight, which in term indicates the strength of the relationship between variables (the same as correlation coefficient) (Ullman and Bentler, 2003).


  Significance of the study Top


Living in developing countries such as Egypt with low economic resources, adolescents reported difficulty in accessing healthcare services. Insufficient time spent with their physician or school health nurse is an indirect message that healthcare providers either lack necessary training and knowledge or interest in addressing adolescent health. In addition, unsuitable physical and nonphysical school environment for students, with high density in the classes, especially in the governmental schools (Albuhairan et al., 2015), may also contribute.

Nowadays, rapid urbanization and modernization have exposed adolescent students to changes in society. In the past, the main health risk behaviors among adolescents were inappropriate dietary habits and poor hygiene. There is a rise in new health risk behaviors such as tobacco use, violence and unintentional injury, mental disorders, and decreased protective factors among adolescents as a result of breakdown in family structure and poor relationships between their teachers and colleagues. Moreover, adolescents exposed to the negative aspects of using new technology such as internet games, social media, and television rather than active participating in physical activities are contributing factors. All these factors confuse adolescents and make him/her vulnerable to maladaptive patterns of thinking and behavior (Pathak et al., 2011).

Schools have long been viewed as good settings for encouragement of healthy lifestyles among children, and schools in many countries aspire more comprehensive, integrated approaches to health promotion (Pearson et al., 2015). However, prioritizing health risk behaviors, measuring cumulative risks, and exploring direct and indirect relationships between them in the scientific statistical background of health promotion programs for adolescents are neglected. Having the capacity to prevent the onset of risk behavior clusters or intervene synergistically to improve many health behaviors would have substantial public health impact. There is a pressing need for a body of basic, translational, and applied science to help tackle the co-occurring health risk behaviors that characterize most adults (Spring et al., 2012).

Community health nursing is a population-focused, community-oriented approach aimed at health promotion of an entire population and prevention of disease, disability, and premature death in a population. Community nurses are expected to have greater professional autonomy to provide ethical and legal nursing care services in different community settings such as schools, homes, and healthcare centers. The school health nurse has a crucial role in the seamless provision of comprehensive health services to adolescent students within increasing numbers of students entering schools with noncommunicable diseases that require management during the school day. The role of the school health nurse in serving as a team member in providing preventive services, early identification of health risk behaviors, interventions, and referrals is important to foster health and educational success. Controlling these risky behaviors early in life may help decrease the burden of noncommunicable diseases in adult life, and thus decrease the pressure on society and the healthcare system (Lundy and Janes, 2016). The emerging and evolving new health risk behaviors and decreasing protective factors are creating an era for school health nurses to use innovative school health programs considering decreasing costs and saving effort and time. Structure Equation Model is objective measure help the school nurse to determine the exact percent of cumulative risk improvement at any risk behavior, and explore the direct and indirect relations between variables. All these steps facilitate preparing school health promotion programs with low cost and high quality (Turnock, 2016).


  Aim Top


The aim of the present study was to investigate the relationships between health risk behaviors and protective factors among adolescent school students by adopting a SEM.

Research question

What are the relationships between health risk behaviors and protective factors among adolescent school students?


  Materials and methods Top


Research design

A cross-sectional descriptive research design was used for the present study.

Participants

Preparatory school students were selected using a proportionally stratified probability random sample design to produce a representative sample of all students in grades 1, 2, and 3 aged 13–15 years. The initial sample included 1050 students from the above-mentioned settings. Evening schools and schools for students with special needs, such as blind schools, were excluded. Classes were randomly selected using a simple random sample within each school. Among the students who were selected to fill the questionnaire, 81 of them excluded because of refusal from their parents to participate in the present study. The final sample included 969 students.

Setting

The present study was conducted at six preparatory governmental schools of urban and rural districts in El-Beheira Governorate. A stratified two-stage cluster probability sampling technique was used. At the first stage, three districts in El-Beheira Governorate were randomly selected (Damanhur, Hosh Eisaa, and Kafr El-Dewar). In the second stage, one preparatory school from each urban and rural area in each district was randomly selected. Three schools from urban areas − namely, Ahmed Moharram, Galal Koratum, and Port Said − and three schools from rural areas − namely, Taha Hussein, Aly Ebn Abetaleb, and Abo Saleh − were selected.

Tools

Data collection involved two tools:

Tool I: Global School-Based Student Health Survey questionnaire

This tool was developed by the WHO and the Centers for Disease Control and Prevention in collaboration with UNICEF, UNESCO, and UNAIDS to be shared by all countries. The Arabic version of 2011 unique Egypt Global School-Based Student Health Survey (GSHS) questionnaire was used. This GSHS is a self-administered questionnaire design for measuring the most important health risk behaviors and protective factors related to the leading causes of mortality and morbidity among students aged 13–17 years. It includes 57 questions representing eight domains and respondent sociodemographics (three questions include age, sex, and grade). These domains are hygiene (seven questions on brushing teeth, washing hands, etc), dietary behaviors (12 questions on eating breakfast, fruits, vegetables), physical activity (five questions on practicing physical activity, benefits of physical activity, and sitting activities), tobacco use (six questions on smoking status, quitting, etc.), protective factors (six questions on school attendance and relationships between student and their parents), violence and unintentional injury (nine questions on frequency of physical attacks and physical fights and seriously injured before), HIV infection or AIDS (four questions on awareness about HIV/AIDS, receiving any education about HIV/AIDS), and mental health (five questions on presence of close friends, sleep disturbance, or eating habits due to worries) (WHO, 2011a).

Egypt is an Islamic country with specific traditional habits, culture, and behaviors. Four questions on HIV infection or AIDS that were found to be culturally sensitive were not included in the study tool. The researchers discarded two items on height and weight, which are included in the dietary behaviors domain, as the majority of participants did not self-report height or weight and were also weighed and measured by the researchers. The version of the GSHS questionnaire included in this study had 51 items. The α coefficient of this scale in the present study was 0.89 (Ziaei et al., 2014).

Tool II: anthropometric measurements

Height was measured to the nearest 0.5 cm and weight to the nearest 0.1 kg using an electronic scale. BMI was calculated on the basis of the Center for Disease Control and Prevention BMI charts. BMI was interpreted based on the norm for age and sex as underweight, healthy weight, overweight, or obese: underweight less than 5 centile; healthy weight 5 to less than 85 centile; overweight at least 85 to less than 95 centile; and obese at least 95 centile (CDC, 2000).

Method

  1. Permission to conduct the present study was obtained by submission of official letters issued from the dean of the faculty of nursing at Damanhur University to the undersecretary of the Ministry of Education in El-Beheira Governorate after explaining the study purpose.
  2. Permission from the selected schools’ principals, written parental (or guardian) informed consent, and student assent were obtained for each study participant after detailed explanation of the aim of the study, the date, and the time of data collection.
  3. Parents and guardians were informed about the study in a letter distributed with support from the school in advance; student assent was obtained in person at the first visit.
  4. Tool I was modified according to the Egyptian culture by the researchers and revised by five experts in the community health nursing field for content validity.
  5. Tool I reliability was asserted using the Cronbach’s coefficient α test.
  6. A pilot study was carried out on a sample of 50 students in grades 1, 2, and 3 of preparatory school to test clarity of the instructions, the format of the questionnaire, comprehension of the items, and to estimate the exact time required for filling the questionnaire. Necessary modifications were done accordingly. The participants involved in the pilot study were excluded from the main study sample.
  7. The researchers distributed the written form of consent in classrooms at the respondents’ respective schools, which was completed within 2 days by each respondent at time 1 visit.
  8. Students who voluntarily consented to complete the survey recorded their own answers on a questionnaire sheet distributed by the researchers during one standard class period at time 2 visit. After orienting the study participants to the questionnaire (tool I) and procedures (tool II), researchers responded to queries about the meaning of the terms throughout assessment (e.g. words such as ‘bullied’ and ‘difference between physical attack and fight’). Participants returned the assessments to the researchers and waited while they were checked for completeness if time permitted; when missing or duplicate responses were identified, the researchers invited participants to complete or clarify their intended response before their departure.
  9. In addition, during the time 2 visit, the researchers measured height and weight of students who completed the GSHS questionnaire.
  10. The average time to complete the self-administered questionnaire sheet ranged from 30 to 45 min. Data collection continued for 5 days a week from Sunday through Thursday during regular class period. Data were collected for 5 months, starting from the beginning of October to the end of December 2014 and continued from the beginning of March to the end of April 2015, including pilot study, tool validity, and reliability. The researchers dropped the time of mid-educational year examination and vacation.


Ethical considerations

Ethical considerations were followed throughout the data collection process. Informed written consent was obtained from all parents (or guardian). Privacy and anonymity of the study subjects and confidentiality of the collected data were maintained throughout the study.

Statistical analysis

The data collected were analyzed using the IBM company headquartered in Armonk, New York, United States. All used statistical methods based on two-tailed techniques with P values less than 0.05 were considered significant. Frequencies and percentages were used for categorical variables (risky behavior rate). Answers for each item were scored on the basis of the degree of risk, and then the overall risk score was obtained by summing the discrete scores for each measured risk behavior. The overall risk was obtained after adjusting for the weight given to each risky behavior domain depending on its risky hazard. The risk contribution for each measured behavior was obtained relative to the overall risk. The χ2-test was used to compare frequency of risky behavior by gender. Correlation analysis was used to identify the nature and magnitude of relationship between the different measured behaviors, whereas the SEM was used for direct and indirect relationships.


  Results Top


The characteristics of the study participants revealed that their age ranged from 13 to 15 years. Boys and girls aged 13 to less than 14 years comprised 32.2 and 34.1% of the sample, from 14 to less than 15 years comprised 52.6 and 51.3% of the sample, and above 15 years comprised 15.3 and 14.6% of the sample, respectively. As for grades, 33.1% of boys and 34.9% of girls were in grade I, whereas 51.7% of boys and 50.5% of girls were in the grade II. The remaining boys and girls were in grade III (15.2 and 14.6%, respectively). Boy comprised 56.14% and girl comprised 43.86% of the sample.

[Table 1] represents the participants’ dietary behaviors during the past 30 days, where 92.4% of them mostly/always starved because there was no enough food in their homes. In contrast, they rarely/never ate breakfast at home before going to school, rarely/never ate fruits such as bananas, dates, mangoes, or grapes, and rarely/never ate vegetables such as green peppers, watercress, eggplant, or cucumbers (73.9, 97.3, and 92.6%, respectively). Only 8.2% of them drank carbonated soft drinks such as Pepsi, Coca-Cola, or 7-Up one or more times per day. They also ate fast foods and foods from a street hawker or peddle for one or more times per day during the past 7 days (13.6 and 7.5%, respectively). A minority of boys (27.9%) and girls (12.6%) perceived their weight as underweight and overweight, respectively. In addition, 31.9% of all students were trying to lose/gain weight, and 38% of them never had their weights measured. All these recorded differences were found to be statistically insignificant. Regarding BMI, 27.3, 12.1, and 0.5% of the study subjects were underweight, overweight, and obese, respectively.
Table 1 Health risk behaviors among school adolescents in El-Beheira Governorate

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Regarding physical activity, 38.2% of all students were physically inactive for 60 min/day last week. During this school year, 14.9% of boys and girls had physical education classes for one or less times per day and 8.1% of them never had any information on the benefits of physical activity. Only 5.1% of students spend 5 h or more per day sitting and watching television, playing computer games, talking with friends, or doing other sitting activities such as playing cards or chess when they were not in school or doing homework.

As for hygiene-related behaviors, during the past 30 days, overall, the percentages of study participants who rarely/never cleaned or brushed their teeth, washed their hands before eating or after using the toilet or latrines, and used soap when washing their hands were 76.6, 77.6 or 85.7, and 92.7%, respectively. A substantial proportion (89%) of the study participants had no available source of clean drinking water at school, with a higher rate among girls (92%) than boys (85.9%), which was statistically significant. In addition, 68.2 and 59.3% of students never got any information about modes of infection of parasitic diseases and how to protect themselves during the school year.

Regarding mental health-related issues, 26.5% of all students felt lonely most of the time or always during the past 12 months, and 9.7% of students had no close friends. In addition, 16.5% of students indicated that they felt so worried about something that prevented them from sleeping at night or did not feel hungry most of the time or always during the past 12 months. The large sample (71.8 and 56%) of boy and girl students rarely/never got any information about how to manage anger and how to handle stress in a healthy way during the school year.

Regarding violence and unintentional injuries, overall, boys and girls were involved in physical attacks, and 56.1% of them were in a physical fight for one or more times during the past 12 months. All the boys engaged in physical fights, while the girls did not, with a statistically significant difference. Regarding serious injury during the past 12 months, 66.1% of boys and girls had serious injuries once or more, 20% of them reported that cut wounds were the most serious injury by higher rate among girls (64.5%) than boys (12.1%), with a statistically significant difference; 9.8% of injured students reported that the major cause of most serious injuries was fights with others, with a higher rate among girls (35.4%) than boys (5.3%), with a statistically significant difference. On or near roads for boys and home for girls were the places where serious injuries were reported by 23.8 and 25.6%, respectively. In addition, 26.1% of injured students were seriously injured because they hurt themselves accidentally; this was higher among girls (71.8%) than boys (18%), with a statistically significant difference. Regarding bullied students, 71.4% of all students were bullied for 1 or more days during the past 30 days. Among them, 40.3% were bullied most often by being hit, kicked, pushed, shoved around, or locked indoors.

Regarding tobacco use, 2.9% of participants smoked their first cigarette at the age of 13 or younger. Only 12 boys and one girl smoked cigarettes for 1 or more days during the past 30 days. In all, 76.9% of them never tried to stop their smoking habit. The majority (83.3%) of boys never tried to stop their smoking habit, while the girls did not smoke, with a statistically significant difference. Only two boys used shisha as a form of tobacco for 1 or more days during the past 30 days, but none of female students used it. In addition, 22.7% of students reported that other people smoked in their presence for 1 or more days during the past 7 days. Overall, 36.5% of students had at least one parent or guardian using any form of tobacco.

Regard protective factors during the past 30 days, overall, 74.6% of the students missed their classes or school without permission for 10 days or more; 48.3% of them reported that they were rarely or never treated kindly at school. Regarding the relationship between students and their parents or guardians, 41.1% rarely or never checked whether their children completed homework, 45.6% understood their problems and worries, 33.2% knew what the students were doing in their free time, and 49.9% went through their things without their approval.

[Table 2] illustrates that the most recorded health risk behaviors among the studied students were violence and unintentional injury (48.8%) followed by lack of protective factors (48.5%), poor personal hygiene (48.3%), and tobacco use (47.3%). Whereas mental health disorders, physical inactivity, and inappropriate dietary behaviors were the least frequently recorded risk behaviors (25.1, 23.6, and 19.4%, respectively). Regarding the weighted contribution of each individual risky behavior, it was observed that violence and unintentional injury, protective factors, hygiene, and tobacco use weighted higher by 18.7, 18.6, 18.5, and 18.1%, respectively, whereas dietary behaviors weighted the least percentage of total risk by 7.4%.
Table 2 Health risk behaviors by weighted risk rate among school adolescents in El-Beheira Governorate

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[Figure 1] shows data on weighted contribution of each individual risky behavior: violence, lack of protective factors, poor personal hygiene and tobacco use contributed cumulatively to 73.9% of the recorded risk among the study sample (Pareto chart).
Figure 1 Health risk behaviors by adjusted cumulative risk among school adolescents in El-Beheira Governorate

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[Table 3] shows the correlation matrix of multiple health risk behaviors of the selected students. It shows a significant positive correlation between all health risk behaviors except for dietary behaviors, which was negatively correlated with violence. Both hygiene and mental health were negatively correlated with tobacco use. The violence domain was negatively correlated with the mental health status of the study participants. There was no correlation between protective factors and multiple health risk behaviors. All correlation coefficients ranged from 0.004 between violence and physical activity to 0.29 between violence and mental health.
Table 3 Correlation matrix between multiple health risk behaviors at the selected students sample in El-Beheira Governorate

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[Figure 2] explains the SEM for direct and indirect relationships between multiple studied health risk behaviors among the study subjects, which indicates that there was a direct significant relationship between dietary habits, hygiene, and physical activity, which by the way negatively affected violence and positively affected mental health. Violence was also affected by tobacco use, which also affected physical activity and was affected by mental health. There was no direct or indirect relationship between protective factors and multiple health risk behaviors. All that are mentioned are direct relationships, and all the other relationships are considered indirect, such as the relationships among dietary habits, hygiene, violence, mental health, and tobacco use, which are mediated by physical activity. The model showed considerable fitting criteria with CFI and GFI both exceeding 0.85 and P close to less than 0.5.
Figure 2 Structural equation model for direct and indirect relations between multiple studied health risk behaviors at the selected students sample in El-Beheira Governorate

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  Discussion Top


Adolescence is viewed as an opportune time to prevent the onset of certain behaviors and promote healthy states with the increasing burden of noncommunicable disease. Although adolescents comprise a considerable portion of the Egyptian population, they have received insufficient attention and indicators of their health status, as a first step in a prevention cycle are unavailable. The multiple domains addressed in this study have clearly shown that the behaviors that place adolescents at risk for serious health problems exist, and indeed such problems are saliently present. However, adolescents in Egypt, similar to those in other parts of the world, engage in health risk behaviors (Albuhairan et al., 2015). It is essential that school health nurses, parents, educators, and other concerned adults become aware of the prevalence of these behaviors and plan programs that can reduce or prevent them (Lundy and Janes, 2016).

Regarding dietary behaviors of adolescents in the present study, it was found that the majority of boys and girls went hungry because there was no enough food in their homes fand did not eat breakfast at home before going to school with low intakes of fruit and vegetables. However, a few of them drank carbonated soft drinks with low intake of fast food and ate food from street hawkers or peddlers ([Table 1]). These results are in agreement with a study carried out by Albuhairan et al. (2015) who found that poor dietary choices, such as low intakes of fruit and vegetables, were dominant among their school adolescents. The same findings were also supported by a GSHS survey carried out in (WHO 2007c, Libya). It asserted that a few adolescents aged 13–15 old usually ate fruits and vegetables. Another GSHS survey performed in Maldives in 2009 confirmed that only one-third of the school students usually drank carbonated soft drinks and a minority of them ate fast food from restaurants. However, another GSHS survey performed in (WHO 2007d, China) contradicted the present findings and reported that the majority of their participants ate breakfast before going to school. Another GSHS survey performed in (WHO 2007e, Lebanon) reported that a few of their participants went hungry and a higher percentage ate breakfast, fruits, and vegetables. In addition, a study performed by Albuhairan et al. (2015) found that most of the school students consumed carbonated soft drinks. In addition, a study carried out in (WHO 2010a, Oman) found that almost half of the school students ate fast food because it was tasty. Regarding the small sample size that drank carbonated soft drinks and ate fast food and food from a street hawker in the present study, the school adolescents were from rural areas associated with governmental preparatory schools with low socioeconomic status. Such a status did not allow the opportunity to purchase soft drinks or fast food compared with their peers in urban areas or private schools with higher socioeconomic statuses. This may be the cause for a number of patients not eating breakfast, fruits, and vegetables as there was no food at home.

Regarding BMI, in the present study, it was found that underweight was prevalent among the study participants than overweight and obesity ([Table 1]). These results are supported by a GSHS survey performed in (WHO 2003a, Ugandan). The study reported that, almost half of the school children aged 13–15 years were underweight and a few percent were overweight and obese. Another GSHS survey performed in (WHO 2007c, Libya) had confirmed that the percent of underweight students are higher than overweight students. Another GSHS survey performed in (WHO 2010c, Tonga) contradicted the present findings. It reported that overweight and obese students were predominant than underweight students. Another GSHS survey performed in Kuwait in 2011 had reported that almost half of the students were overweight and one-quarter of them were obese, whereas very few of them were underweight. Underweight students were dominant in the present study than overweight/obese students; this can be justified by the poor rural community of students and their families without enough food in their homes.

Concerning physical activity, in the present study, it was found that more than one-third of the students were physically inactive for 60 min/day during the past 7 days ([Table 1]). More than one GSHS surveys contradicted this present finding, such as surveys performed in (WHO 2010b, Cook Island, WHO 2007a, Jordan, WHO 2007b, Indonesia), which revealed that the majority of the school students aged 13–15 years old were physically inactive. There was no GSHS report of any country confirming the present findings, and all previous surveys showed decreased level of activity among school students. It can be justified as the students of the present study work with their parents in the farm, and they have no time or money for sitting activities such as social media or games.

As for hygiene-related behaviors, the majority of the students in the present study never brushed their teeth, washed their hands before eating, washed their hands after using the toilet/latrine, and wash their hands with soap ([Table 1]). These results are supported by a GSHS survey carried out in Kuwait in 2011, which reported that the majority of their students did not brush their teeth and more than half of them washed their hands without using a soap. Another GSHS survey performed in (WHO 2003b, Zimbabwe) confirmed that more than half of the students never washed their hands under running water before eating. However, another GSHS survey performed in the United Arab Emirates in 2005 contradicted the present findings, which reported that the majority of their school students usually washed their hands before eating, washed their hands after using the toilet, and used soap when washing their hands. Another GSHS survey performed in (WHO 2008a, Tanzania) reported that the majority of their students cleaned or brushed their teeth and washed their hands before eating and after using the toilet. Because of the low educational level and economic state of the students’ families, there was no or little concern for practicing hygienic behaviors such as washing their hands or brushing teeth. Rural areas are characterized by low sanitation with low available sources of clean water.

Regarding mental health-related issues in the present study it was found that one-quarter of students always felt lonely, a small percentage of them were always so worried that they could not sleep/feel hungry, and a few of them had no close friends ([Table 1]). The same findings were reported in the GSHS survey performed in (WHO 2007e, Lebanon) and another GSHS survey performed in (WHO 2007a, Jordan). Both confirmed that a minority of their students felt lonely most of the time, were worried, and had no close friends. These findings are contradicted by a study by Albuhairan et al. (2015). They found that almost half of the adolescent students felt lonely and worried. In addition, the GSHS survey performed in (WHO 2004, Zambia) reported that most of the students felt so worried about something that they could not sleep. Decreased mental health problems among school adolescents in the present study can be justified as presence of extended families in the rural community with more strong ties and decreased leisure time, as most of the time they were busy with their parents in agricultural work.

As for violence and unintentional injuries among boys and girls in the present study, it was observed that all of them were physically attacked, and only boys engaged in physical fights. All boys were seriously injured compared with girls, with a statistically significant difference between them. The majority of students reported that they were bullied by being hit, kicked, pushed, shoved around, or locked indoors, with no statistically significant difference between boys and girls ([Table 1]). A GSHS surveys performed in (WHO 2010a, Oman, WHO 2010c, Tonga) confirmed these findings. It showed that the majority of students were physically attacked, engaged in a physical fight, and were exposed to bulling. The (WHO 2006b, Tajikistan) GSHS survey contradicted the present study. It reported that a minority of school students were involved in physical attacks and fights. A small percentage of them were seriously injured, and a few had been bullied. In addition, another GSHS survey performed in the United Arab Emirates in 2005 revealed that almost one-third of their school students were in a physical fight and were bullied often by being hit, kicked, pushed, shoved around, or locked indoors. Increasing rates of violence among the study subjects may be related to effects of media, as a lot of violence is broadcasted in TV shows and cinemas. School adolescents see such programs and try to imitate the same in their real life, and there is lack of guidance, support, and counseling If children do not receive proper guidance or care at this stage, then the possibilities of getting violent are high. Children cannot solve problems or take decisions on their own, and this is quite an irritating task for them.

In the present study, tobacco use was not prevalent among the school students. A few of them were found to be current cigarette smokers with higher a percentage of boys compared with girls, and most of them never tried to quit smoking. In addition, almost one-third of the school students had at least one parent or guardian use any form of tobacco ([Table 1]). These findings are supported by the GSHS survey performed in (WHO 2007c, Libya). It asserted that a few students smoked cigarettes and never tried to quit smoking, with the percentage comparable with the present study who had at least one parent or guardian who used any form of tobacco. Another GSHS survey performed in (WHO 2003a, Ugandan) reported a small number of students who smoked cigarettes, and a higher percentage of them never tried to stop smoking. A survey conducted in (WHO 2007a, Jordan) contradicted the present findings, which found that a higher percentage of students had a parent or guardian who used any form of tobacco. In addition, in (WHO 2008a, Tanzania), a GSHS survey’s final report represented a few school students WHO had a parent or guardian who used any form of tobacco.

Regarding protective factors among students in the present study, it was found that the majority of school students missed classes or school without permission, and almost half of them reported that their parents never checked whether their homework was completed or understood their problems and worries ([Table 1]). These findings are supported by the GSHS survey performed in Kuwait in 2011. It asserted that the majority of their students missed classes or school without permission, and almost half of them had parents or guardians who never checked whether their homework was complete or understood their problems and worries. Another GSHS survey performed in (WHO 2007a, Jordan) had revealed that almost half of the parents never checked whether the homework was completed and never understood the problems and worries of their children. Moreover, two GSHS surveys performed in (WHO 2007d, China, WHO 2007e, Lebanon) contradicted the present findings − a few percentage of students missed classes or school without permission and a lower percentage of parents/guardians, compared with the present study, checked whether the homework was done and understood their problems and worries. The higher rate of missed classes among school students in the present study may be related to the lack of concern from their parents with regard to their education and academic achievement, because they were highly concerned with agricultural work. A positive school environment plays a significant role in determining students’ sense of belonging and satisfaction. Students who experience acceptance and connection are more highly motivated and engaged in learning, and they also become more committed to school (Dolzan et al., 2015). This situation is different among governmental schools in El-Beheira governorate compared with private ones, because of a higher number of students in classes with little concern from their teachers.

The Pareto chart was used as usual for quality control. In this study, the researchers tailored it for nursing science. The Pareto chart is extremely useful for analyzing what health risk behavior need attention first, by using hard data instead of intuition. There can be no question about what risky behaviors influence the outcome most. The taller bars on the chart represent the highest occurring type of health risk behaviors among the studied students. They clearly illustrate which risky behavior has the greatest cumulative effect on a given health promotion program (Balakrishnan, 2014).

In the present study, some health risk behaviors were observed among students that may affect their health during adulthood. The researchers surveyed the health risk behaviors using GSHS. After collecting data and displaying it in a Pareto chart, the researchers could see which health risk behaviors were having the most influence (Clapham and Nicholson, 2013). In this study, the most recorded health risk behaviors among its participants were violence and unintentional injury, followed by lack of protective factors, poor personal hygiene, and tobacco use. Regarding the weighted contribution of each individual risky behavior, violence, lack of protective factors, poor personal hygiene, and tobacco use contributed cumulatively to 73.9% of the recorded risk among the study sample ([Table 2] and [Figure 1]). Following the Pareto principle, these are the health risk behaviors that school health nurses should focus their attention on to build a health promotion program for adolescents. By systematically searching the literature, which reported cumulative risk of multiple domains of health risk behavior, the researchers found no studies that focus on it in nursing sciences (Jackson et al., 2012).

The concept of ‘behavior bundling’ to guide intervention development by characterizing how an individual’s health behaviors are functionally inter-related was invoked. An implication is that when intervening upon one health behavior, corollary changes in other health behaviors can be expected. The mechanisms that give rise to health behavior bundling are poorly understood, as are their implications for intervention (Spring et al., 2012). In this study, the researchers examined direct and indirect relationships between multiple studied health risk behaviors of the school students using the Structure Equation Model. The results indicated that there were direct significant relationships between dietary habits, hygiene, and physical activity, which by the way negatively affected violence and positively affected mental health. Violence was also affected by tobacco use, which also affected physical activity and was affected by mental health. All these mentioned relationships are direct and all other relationships were considered indirect, such as the relationship among dietary habits, hygiene, violence, mental health, and tobacco use, which are mediated by physical activity. Unexpectedly, there was no relationship between protective factors and multiple health risk behaviors ([Figure 2]).

A study performed by Turagabeci et al. (2008) confirmed these present findings and revealed that good nutrition decreases the risk of being frequently bullied and experiencing violence/injuries in both sexes. It also revealed that adolescents with poor hygiene labeled ‘dirty’ by their peers are prone to being victimized or bullied, and the stigma could therefore lead to mental health disorders and violent behavior. In addition, this study confirmed that there is a direct relationship between smoking, bullying, violence, and unintentional injury. In contrast, the present findings showed increase in the risk of being frequently bullied, violence, and injury associated with physical activity among both sexes. Although regular exercise has been suggested to be a health-enhancing behavioral practice, it can be perceived that physically active students are fit, and may therefore be able to protect themselves. Moreover, hygienic behavior was weakly associated with violence and injury; a similar trend of association was notable among those with better nutritional practices. Another study performed by Beck et al. (2016) revealed that there is a direct relationship between violence, mental health, tobacco use, and protective factors. A study performed by Spring et al. (2012) revealed that there is a direct relationship between dietary habits and tobacco use among adolescent students.

It can be justified from these studies that SEM identifies direct and indirect relationships between health risk behaviors and protective factors among adolescent school students, whereas other statistical measures identified only a direct relationship, making SEM superior in identifying the priority of health education programs requirements.

Strengths and limitations

Strengths of this study included the application of SEM as the statistical approach in nursing sciences, especially community health nursing to test hypotheses about the direct and indirect relationships among cluster of risk behaviors that can assist in developing comprehensive and effective health education programs. Another strength of this study was its use of data from preparatory school students using a proportional stratified probability random sample design to produce a representative sample of all students in El-Beheira governorate in the grades 1, 2, and 3 aged 13–15 years.

However, this study has several limitations including difficulties in controlling adolescent school students’ behaviors in the class room, worries of girl students about answering sensitive questions such as smoking and violence, and the need of support from the researchers. Another limitation was the decreased rate of student attendance and some uncooperative school managers during data collection.


  Conclusion Top


The present study revealed the presence of many different problems related to health behaviors and protective factors of school students in El-Beheira governorate, as well as regarding dietary behaviors (went hungry, never ate breakfast, fruits, and vegetables, drank carbonated soft drinks, and ate fast foods and foods from street), BMI, (underweight was prevalent), physical inactivity among students. About hygienic-related behaviors (participants who never brushed their teeth, wash hands before eating/after using toilet, and never using a soap). In addition to mental health problems (students felt lonely, no close friends and so worried). According to violence and unintentional injury (boys and girls were involved in physically attacked and fight, had seriously injured and bullied). Concerning tobacco use (participants were current cigarette smokers and never tried to quit), finally for protective factors (boy and girl students missing classes and never checked by their parents). The most recorded health risk behaviors were violence and unintentional injury followed by lack of protective factors, poor personal hygiene, and tobacco use whereas mental health disorders, physical inactivity and inappropriate dietary behaviors were the least frequently recorded risk behaviors. Regarding the weighted contribution of each individual risky behavior, violence, lack of protective factors, poor personal hygiene, and tobacco use contributed cumulatively 73.9% of recorded risk among the study sample.

There were direct significant relationships between dietary habits, hygiene, and physical activity, which negatively affected violence and positively affected mental health. Violence was also affected by tobacco use, which also affected physical activity and mental health. The above-mentioned relationships are direct, and all other relationships are considered indirect, such as relationships among dietary habits, hygiene, violence, mental health, and tobacco use, which are mediated by physical activity. There was no relationship between protective factors and other multiple health risk behaviors. The present results help in developing health education programs targeting multiple domains involving a combination of the direct and indirect relationships of health risk behaviors among adolescent school students in El-Beheira governorate.

Recommendations

  1. Application of the SEM in processing health promotion programs of multiple health risk behaviors for adolescents by community health nurses.
  2. The community health nurse should disseminate the current findings at the local level in El-Beheira governorate through conducting stakeholder workshops and engage the printed and social network applications in providing strategies for solution of health risk behaviors.
  3. Awareness campaigns on multiple health risk behaviors for students and public should be conducted by community health nurse. These campaigns include health education, preventive and screening services such as immunization against preventable diseases, and periodically measuring weight and height.
  4. Students, teachers, family, and community must be taught the importance of healthy eating, benefits of engaging in physical activity, prevention of violence and tobacco use, mode of infection of parasitic diseases and how to protect themselves, ways to manage anger, and how to handle stress by the school health nurse.
  5. School health nurses should provide or refer for confidential counseling and other social services for students and or parents. They should be encouraged and supported to become involved in their children’s life through the Parent Teacher Association and other support groups.
  6. School health nurses should assess sanitation of the school environments and safety of snacks/food and report any problems to the responsible authority, which must improve clean water system and drainage system for hand washing in the school for students and staff.
  7. The school health nurse should prepare educational materials about the effects of health risk behaviors, assists on health education curriculum development teams, and provide programs for undergraduate and postgraduate students of the faculty of nursing, Damanhur University.
  8. A follow-up GSHS at the local level of El-Beheira governorate has to be conducted periodically to obtain data on adolescent health behaviors by community health.


Further research

  1. Further local studies on a larger scale focusing on risky behaviors should be conducted in Egyptian governorates.
  2. A health risk behavior GSHS survey during early childhood may have a greater impact than only intervening in adolescence.
  3. A health risk behavior GSHS survey on secondary education for all adolescents presents the single best investment for adult health and well-being.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
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