Abstract
The patterns of and prevention strategies for health risk behaviours among in-school adolescents in Jigawa State was investigated as a basis for formulating health risk behaviour prevention strategies. The study utilized descriptive survey design. The population of the study consisted of 159,586 in-school adolescents in Jigawa state secondary Schools. A sample of 3,192 students representing 2 per cent of the population participated in the study. Multi-stage sampling procedure was adopted to draw the sample from the population. Three instruments were used for data collection. These were a 55-item In-School Adolescent Health Risk Behaviours Questionnaire referred to as ISAHRBQ which was adapted from the 2013- National Youth Risk Behaviour Survey Questionaire–YRBSQ-2013, the 12-item researcher developed In-School Adolescent Health Risk Behaviour Focus Group Discussion Guide referred to as ISAHRBFGDG and In-School Adolescent Health Risk Behaviour Prevention Strategies Evaluation Questionnaire (ISAHRBPSEQ).Spearman Brown Prophecy Formula was employed to establish the reliability index of the ISAHRBQ and ISAHRBPSEQ. The reliability coefficients of 0.80 for ISAHRBQ and 0.94 for ISAHRBPSEQ were determined through Spearman Brown Prophecy statistic. Data from the 2886 copies of the returned ISAHRBQ and 28 copies for ISAHRBPSEQ were analyzed. Research questions one to eleven and thirteen were analyzed using mean and standard deviations, while research question 12 was analyzed using frequency and percentages. The null hypotheses two and four were tested using t-test statistics while hypotheses one, three and five were tested using Analysis of Variance (ANOVA), and hypothesis six was tested using Chi-square, all at .05 level of significance. The findings of the study indicated that in-school adolescents never exhibited health risk behaviours (HRBs) like substance use (1.05 0.30), unsafe sex (1.01 0.18), violence (1.48 0.65) and suicidal (1.16 0.35) behaviours. While healthy nutrition (2.07 0.89) and bullying (2.28 1.13) behaviours were rarely exhibited. The Findings further revealed that there were significant differences (p > 0.05) in the mean score rating of in- school adolescents regarding all the HRBs according to age. There were significant differences(p > 0.05) in the mean scores of in- school adolescents regarding sexual, physical activity, nutritional, violent and suicidal behaviours according to gender. There were significant differences (p > 0.05) in the mean scores of in- school adolescents regarding all the HRBs according to class. There were significant differences (p > 0.05) in the mean scores of in- school adolescents regarding substance use, sexual, physical activity, violent and suicidal behaviours according to location. There were significant differences (p > 0.05) in the mean scores of in- school adolescents regarding all the HRBs according to school type. In-school adolescents significantly differed (p > 0.05) in their HRBs according to temporal variations. There were no significant differences (p > 0.05) in the mean score rating regarding substance use behaviours of in- school adolescents according to gender. There was no significant difference (p > 0.05) in the mean scores of in-school adolescents regarding nutritional behaviours according to location. Recommendation such as implementation of Health Risk Behaviour Prevention strategies in Jigawa State schools was made.
CHAPTER ONE
Introduction
Background to the Study
Health risk behaviours among adolescents is a major health concern globally. This is because these behaviours are associated with serious life-threatening consequences among adolescents in both developed and developing nations, including Nigeria. The impact of health risk behaviours (HRBs) on health is of such magnitude that it has become one of the priorities of national and international health organizations, Rutter and Quine, in Baban & Cracium (2007). These organizations have been initiating programmes with a view to curbing this menace globally.
The global estimates of some identified risk behaviours of significance to warrant global concern include, suicide with a prevalence of 7.4 per 100,000 (Wasserman, Cheng, & Jiang, 2005), 185 million drug abusers and 2 billion alcohol users globally (WHO, 2002). According to Onifade, Somoye, Ogunwobi, Ogunwale, Akinhanmi and Adamson (2011), Nigeria has the highest one-year prevalence rate of Cannabis use (14.3%) in Africa. Although, data on drug abuse in Nigeria are sparse, some existing studies show 290 drug abusers in Enugu (Igwe, Ngozi, Ejiofor, Emechebe, & Ibe, 2009), 7.8 per cent in a study in Sokoto, 47 per cent in Ilorin (Oshodi, Aina & Onajole, 2010) and that 149 drug related arrests were made by National Drugs Law Enforcement Agency (NDLEA) between 2011-2012 in Jigawa State (Akubo, 2012). Regarding risky sex practices, 34 million people are infected with HIV/AIDS globally, with 22.9 million in Sub–Saharan Africa and 3.3 million in Nigeria (Avert International, 2010). Death as a result of physical inactivity (WHO, 2013) and unhealthy nutrition accounts for 3.2 million and 1.7 million death yearly respectifully (World Heart Federation, 2013). The aforementioned statistics are some indicators to the growing global health challenges, which mostly occur through health risk behaviours of adolescent.
Health is a state, condition or
level of functional efficiency of an individual. World Health Organization, WHO
(1946) defined health as a state of complete physical, mental and social
wellbeing and not merely the absence of disease or infirmity. According to
American Nurses Association, health is a dynamic state of wellbeing in which
the development and behavioural potentials of an individual is realized to the
fullest extent possible (Davies &
Janosik, 1991). Pender (1996) defined health as positive dynamic state not merely the absence of disease. Flora and Lang (1982) asserted that health can be seen as a dynamic state, or condition of the body that has qualitative and quantitative measurable aspects, that are influenced by both internal and external environment of an individual. In this study, health refers to the dynamic measurable state, condition or quality of individuals’ wellbeing. The influence of internal and external environments brings about changes in individual’s health behaviour.
Behaviour refers to the responses of an organism to its environmental stimuli (both internal and external) (Nwachukwu, 1992). DeClemente, Hansen and Ponton (1997) asserted that problems of behaviour and risk- taking are part of normal adolescent development. They mentioned that behaviour can be positive or negative. Risk taking (exploratory behaviour) that is developmentally constructive, such as exercise, is considered positive behaviour while pathogenic behaviours refer to those behaviours that are negative, and are capable of causing harm to the body, such as HIV infection caused by unprotected sex. Ronald and Seymour (2007) defined behaviour as the actions or reactions of an object or organism to its environment. In this study, behaviour refers to the reactions of in-school adolescents within and around them in relation to their health. When behaviour relates to health it is referred to as health behaviour.
Health behaviours could be regarded as the way a living human being acts. Springer, Selwyn, and Kidder, (2006) perceived health behaviour as acceptable actions that positively influence the knowledge, attitude and practice of an individual in taking decisions regarding his or her health. Glanz, Rimer and Viswanath (2008) referred to health behaviour as the action of individual, group or organizations as well as their determinants, correlates and consequences, including social change, policy development and implementation, and improved coping skills that enhance quality of life.Health behaviour as used in this study, refers to actions that positively or negatively influence the practice and attitude of in-school adolescents in taking decisions regarding their physical, social and mental health. Actions that negatively influence individuals’ attitude could expose them to many risks.
Risk can be seen as a natural phenomenon that can sometimes be taken by an individual including adolescents out of volitional intentions. Risk is the probability that a particular outcome will occur following a particular exposure (Burt, 1998). Risk is conceptualized as a potential negative impact to an asset or other valuables arising from present process or future events (Llona, 2006). Risk is often referred to as the probable occurrence of danger, hazard or loss. In this study, risk refers to potential negative actions by in- school adolescents that may damage or harm their health. Therefore, when risk relates to behaviour, it is referred to as risk behaviour.
Risk behaviour is a volitional health compromising action that may lead to morbidity and mortality. Risk behaviour is defined as ‘voluntary or involuntary actions that threaten self-esteem, health and increase the likelihood of illness, injury, and premature death (Linda & Allan, 1996). Risk behaviour can be healthy and unhealthy. Healthy risk behaviours are those behaviours that positively affect, improve or maitain ones health. These include travelling, participation in sports, making new friends among others, while unhealthy risk behaviours refers to those actions or practices which can negatively impact on our health. These behaviours include unsafe sex, substance abuse, suicide and violent behaviours (Ponton, 1997). Richter (2010) opined that risk behaviour refers to any behaviour that can compromise psychosocial aspect of successful adolescent development. According to Samuel and Andrew (2010), risk behaviour refers to any form of action that has basic or obvious potentials for inflicting danger or harm to the person carrying out the behaviour or to others. In this study, risk behaviour refers to any form of action by in- school adolescents to situations or persons within and around the environment that have a potential source of harm to them and those around them. Risk behaviours that relates to health is referred to as health risk behaviours.
Health risk behaviour (HRBs) is defined as voluntary involvement in established patterns of acting or functioning that could harm the health of adolescents and retard their potentials for responsible adulthood ( Lindbergh, Boggers, & Williams,2000). Springer, Selwyn and Kelder (2006) refers to health risk behaviour as overall term used to describe unfavourable or harmful health actions of people. Health risk behaviour involves actions and related attitudes and perceptions that contribute to people’s propensity to engage in activities that have been deemed by experts to be hazardous or dangerous to health (Lupton, 2007). In this study, HRBs refer to actions that could have a potential harm to the health of in- school adolescents and those around them. Health-risk behaviours contribute to the leading causes of morbidity and mortality among youth and adults (Center for Disease Control – CDC, 2009). They are often established during childhood and adolescence which may extend into adulthood, and they are interrelated and preventable (Eaton, Kann, Kinchen, Shanklin, Flint, Hawkins, Harris, Lowry, McManus, Chyen, Whittle, Lim and Wechsler, (2012). Health risk behaviours are many.
Brener, Kann, Kinchen, Grunbaum, Whalen, Eaton, Hawkins, Ross (2004) reported that Center for Disease Control – CDC in 1992 developed the Youth Risk Behaviour Surveillance System (YRBSS) to monitor priority health-risk behaviors that contribute substantially to the leading causes of death, disability and social problems among youth and adults in the United States. Brener et-al (2004) added that YRBSS monitors the following six categories of priority health-risk behaviours among youth and young adults: Behaviours that contribute to substance abuse, unsafe sexual behaviours that contribute to unintended pregnancy and sexually transmitted infections (STIs), including Human Immunodeficiency Virus (HIV) infection; unhealthy dietary behaviours, physical inactivity violence and suicide. The present study will focus on the six HRBs that have been categorized by YRBSS (substance abuse, unsafe sexual behaviour, unhealthy nutrition, physical inactivity, violence and suicide). Studies by Rutter and Quine, in Baban and Cracium, (2007); Buddy, (2011) have revealed that adolescents engage in various HRBs in many countries. In–school adolescents in Jigawa State may not be an exception because of some reasons such as; insecurity challenges in the northern part of Nigeria that involves violence, political crises, poverty, pornographic media that can influence unsafe sex and the influence of substance use and abuse during festive periods to mention few among others.
Substance abuse can be defined as a pattern of harmful use of any substance for mood-altering purposes. Substance abuse refers to the excessive use of a substance that may eventually lead to some form of addiction (WHO, 1992). Igwe, Ngozi, Ejiofor, Emechebe and Ibe (2009) asserted that abuse of substances by young people has been a significant public health concern for more than two decades. Illegal as well as legal drugs can be abused. Alcohol, prescription and over-the-counter drugs, inhalants and solvents, and even coffee and cigarettes, can all be used in harmful doses (Buddy, 2011). It might be possible that in-school adolescents in Jigawa state may be indulging in one form of substance use or the other. Gill (2002) reported that alcohol drinking was measured by some studies as quantity per week or one to five times in the last six months; he added that one drink is equivalent to one UK unit of beer. According to Gill, many studies used weekly benchmarks of 14 units for female and 21 units for male to monitor drinking behaviour. In this study substance abuse refers to the excessive use of illicit and licit substances by in-school adolescents that can modify body functions and is capable of causing potential harm to their health.
Unsafe sex or risky sex is another health risk behaviour that contributes to adolescent’s mortality and morbidity. Majority of the reproductive health and sexuality problems in Nigeria could be associated with risky sexual behaviours. Ariba (2001) observed that unsafe or risky sexual behaviours lead to many preventable reproductive health problems such as unwanted pregnancy, STIs and AIDS. Schwartz, Forthum, Rvert, Zamboanga, Umana-Taylor, Filton, Kim, ……….. Hudson (2010) identified such unsafe sexual behaviours as unprotected sex, oral sex, anal sex, casual sex and sex while intoxicated. It is through these unsafe sexual behaviours that diseases like sexually transmitted infections (STIs) and HIV/AIDS are spread. Phillip (2010) asserted that sexual behaviour is a crucial aspect of relationships that has proven to have great consequences that may include STIs, HIV/AIDS, or a single parent family. In this study, unsafe sex or risky sex refers to unprotected and inappropriate sexual behaviour carried out by in-school adolescents that seem to have potential harm to their reproductive and general health. In–school adolescents in Jigawa State may engage in unsafe sex because of the influence of pornographic media, poverty and parties organzed during festive periods like Sallah and Christmas that bring male and female closer to each other.
Unhealthy nutrition is another health risk behaviour that leads to morbidity and mortality. Eating habit has a substantial impact on individual’s health which is one of the leading causes of health problems such as coronary heart diseases, cancers, diabetes and kidney diseases (Okafor, 2009). Phillip (2010) explained that food is needed to provide energy for movement and warmth for our bodies. The authors rated that food is needed to build, maintain, and repair the body, and good health starts with eating right, which means eating enough of the right kind of foods. Poor dietary habits can lead to deficient or excess intake of nutrients in relations to the body’s requirement (Lucas & Gilles, 2008), which according to California Department of Public Health-CDPH (2012) leads to the risk and/or incidence of health problems among adolescents, such as obesity and diabetes. In-school adolescents may fall victims of unhealthy nutrition due to the fact that poverty is in the increase in the state because of joblessness coupled with high cost of fuel price, for these reason adolescents who are dependents on their parents may not have the chance of choosing what to eat. Stang and Story (2005) revealed that the recommended minimum number of servings per food for adolescents include grains six servings, vegetables three servings, fruits two , milk two and meat two servings per day. In this study, unhealthy nutrition is used to refer to the poor dietary and eating habits by in- school adolescents which may result to deficient or excess intake of nutrients that may lead to potential harm to their health.
Physical inactivity, which has been linked to many health problems such as cardiovascular diseases, stress, overweight and obesity among others (Lee, Shiroma, Lobelo, Puska, Blair & Katzmarzyk, 2012), is another health risk behaviour. Strong evidence shows that physical inactivity increases the risk of many adverse health conditions, including major non-communicable diseases such as coronary heart disease, type 2 diabetes, breast and colon cancers, and shortening of life expectancy (Lee, Shiroma, Lobelo, Puska, Blair & Katzmarzyk, 2012).National Institute of Health-NIH (2004) states that physically inactive youths with low levels of cardiovascular fitness, high percentage of body fat, and large amounts of visceral adipose tissue have unfavorable cardiovascular risk profiles. Physical inactivity is defined as an insufficient or non participation in physical activities/exercises (WHO, 2013). In this study, physical inactivity is regarded as inadequate or lack of participation in physical activities or exercises by in-school adolescents. This situation could be measured in terms of intensity, frequency or regularity and quantity of activity or exercise. Lack of adequate sports facilities and religious affiliation in Jigawa State may influence in-school adolescent’s physical inactivity in the state. Department of Health and Human Services (2008) revealed that the recommended guidelines for physical activity for children and adolescents include participation in at least 60 minutes of moderate to vigorous intensity physical activity daily for at least three days a week.
There is a great concern about the incidence of violent behaviour among children and adolescents. National Center for Injury Prevention and Control (2004) defined violence as threat or actual physical force or power initiated by individual that result in, or has a high likelihood of resulting in physical or psychological injury or death.This complex and troubling issue needs to be carefully understood by parents, teachers, and other adults. These behaviours include explosive temper tantrums, physical aggression, fighting, threats or attempts to hurt others (including homicidal thoughts), use of weapons, cruelty toward animals, fire setting, destruction of property and vandalism (Academy of Child and Adolescent Psychiatry – ACAP, 2012). Experience shows that, in Nigeria violent behaviours are common, and are mostly political and religious in nature, especially in the past two decades. Violent behaviour is used in this study to refer to aggressive action to self, other people or to property by in-school adolescents who may cause harm or damage to life and property. Experience show that adolescents in Jigawa State involve themselves in violent behaviours during political party’s elections, bullying fellow students and the current insecurity in the neighboring states that involves violence may influence in-school adolescents’ involvement in violent behaviours. This may result to suicidal behahiours.
Suicidal behaviour ranges in degree from merely thinking about ending one‘s life (suicide ideation) through developing a plan to commit suicide, or attempting to kill oneself and finally carrying out the act of completed suicide (Krug, Dahlberg, Mercy, Zwi, & Lozano, 2002). Krug, Dahlberg, Mercy, Zwi, and Lozano, (2002) asserted that suicidal behaviour has a large number of underlying causes. The factors that place individuals at risk for suicide are individual‘s life history, demographic factors, such as age and sex. Other factors include psychiatric, biological, social and environmental conditions. In this study, suicidal behaviour refers to any thought, plan or act of taking one’s life by in- school adolescents. Current insecurity in the northern part of Nigeria is compounded by the already serious economic hardship could make the life of in-school adolescents stressful, depressive and hopeless. This stuations may influence suicidal thought and suicide among in-school adolescents in Jigawa State. Adolescent Suicide Assessment Protocol- ASAP-20 provides a guideline and scoring range from 0-3 for violent, suicidal, sexual and substance use behaviours. 0 score is regarded as “No” or “Never”, 1 as “Mild”, 2 as “Moderate” and 3 as “Severe” risk behaviour (Fremouw,Strunk, Tyner & Musick, 2008).
The aforementioned risk behaviours may occur or prevail across all age groups including adolescents. According to Lotrean, Laza, Ionut and Vries (2010) the leading causes of mortality and morbidity among people could be traced to several preventable health risk behaviours that are often initiated during adolescence and which may extend into adulthood. These health risk behaviours can manifest in different patterns.
According to Ryan, Sponseller, Stuart, and Fisher (2008), pattern is the distribution, occurrence and characteristics of things, substance and events in an environment. Pridemore, Andrew, and Spivak (2003) and Avendo (2005) classified pattern into three forms as spatial, temporal and demographic. They described demographic pattern as the distribution of things, events or substances based on variables such as age, gender, level of education, marital status, occupation, socio-economic status (SES), health status and race. In this study, pattern refers to the exhibition or practise of HRBs by in-school adolescents that relates to their temporal, spatial and demographic characteristics or variations.
Demography is the study of human population, its structures, distributions, processes and dynamics (Klauke, 2000). It is concerned with the study of the distributions of human population such as, changes in the number of births, deaths, diseases by sex, age and socio-economic status (SES) in the community. When this is applied to health risk behaviours it means the distribution of HRBs among in- school adolescents according to age, gender, class and school type. Demographic pattern of health risk behaviours in the present study refers to the distribution of HRBs among in-school adolescents according sex, age, class and school-type. Suicide as one of the health risk behaviours was viewed by Pridemore, Andrew, and Spivak (2003) as the occurrence of suicide according to the different demographic groups including age, sex, marital status, occupation socioeconomic status and health status. This research work, therefore aimed to examine demographic variations such as age, gender, class and school type in relation to health risk behaviours of in-school adolescents. The determination of health risk behaviours based on these variables is necessary because persons of different characteristics who take part in various health risk behaviours would be targeted by directing strategies to reduce the occurrence of such behaviours in them.
Health risk behaviours can occur at different times or periods which are described as temporal pattern of occurrence. Pridemore, Andrew and Spivak (2003) described temporal pattern as the time, days and months or seasons a particular event occurs. Hence, temporal pattern of health risk behaviours refers to the time, period or seasons in-school adolescents engage in health risk behaviours. Such periods include public holidays like Sallah, Christmas, Easter, New Year and Weekends or Weekdays. In this study, temporal pattern or variations refers to the time or period in which adolescents engage in various HRBs. Determining the time or period adolescents in the study area engage in particular health risk behaviour will be helpful in tackling these risky behaviours. For example, Nigeria Drug Enforcemnt Agency (NDLEA) monitor drug users and arrests them based on the time they usually congregate to perpetrate the act.
Health risk behaviours among in-school adolescents could occur at certain locations otherwise described as spatial pattern of occurrence. Pridemore, Andrew, and Spivak (2003) described spatial pattern as involving location, which could be urban or rural areas. They also described spatial pattern based on geographical region in a particular country which could be divided into economic and administrative regions, or a result of the mixture of structural and cultural forces, which may be the socio economic development in the west or eastern part of a country. Office of Management and Budget-OMB (2003) stated that spatial patterns could be based on country type, which reflects different level of urbanicity and metropolitan area such as urban, sub- urban or rural areas. Avendo (2005) described spatial pattern as space, location or distribution of objects or events in a setting. The author further added that in a particular setting, objects can be used to answer questions about location and distribution of point of objects that could be arranged randomly, clustered or evenly distributed. In this study, spatial pattern refers to the occurrence of health risk behaviours according to geographical location of urban or rural area of adolescents. For example, unsafe sex as one of the health risk behaviours may be practised more by adolescents in rural than in urban schools or vice- versa.
Adolescents as defined by WHO are regarded as the young ones within the age range of 10 – 19 years (WHO, 1998; WHO, 2003). Accordind to Kaplan (2004) adolescents are young people between the ages of 10 – 24 years. Samuel (2006) described adolescent as a person or individual transiting from childhood who is capable of begetting an offspring because of his sexual maturity. He added that as adolescents advanced in life, they become more prepared and competent to shoulder responsibilities in the society, and claim autonomy that should be respected to some extent. Adolescence as defined by Morhason, Oladokun, Enakpene, Fabamwo, Obisesan and Ojengbede (2008) is a transition period from childhood to adulthood involving multi-dimensional changes that are characterized by experimenting with new ways of behaving and risk – taking. Because of this developmental process of adolescents’ experimentation and risk- taking they tend to engage in various HRBs that might compromise their health (Terzian, Kristine, Andrews & Moore, 2011). Majority of adolescents are students in secondary schools or other educational institutions.
Student, according Midrange (2006) is a learner who is enrolled in an educational institution. According to Runchey (2009), students can be those who are within the age level of 11-18 years of lower and upper secondary school. In this study, in-school adolescent refer to individuals within the age range of 10 – 19 years who are currently undergoing secondary school education who are regarded as in- school adolescents. Therefore, the two terms (students and in-school adolescents) are used interchangeably in this study. The study targeted in-school adolescents because they are believed to be engaging in HRBs (SANYRBS 2003, Eaton et. al., 2012).Similarly, a South African National Youth Risk Behaviour Survey – (SANYRBS 2003) found that adolescent’s life has drastically changed in the 21st century with an increase in health compromising behaviours such as suicide, violence, substance abuse, unhealthy eating, unsafe sex and physical inactivity.Sychareum, Thomsen, and Faxelid (2011), and Terzian, Kristine, Andrews and Moore (2011) also revealed that such risky behaviours might cause a threat to adolescents health later in life. Mungrulker, Whiteman, and Posner (2001) asserted that by the year 2010 there could be more adolescents (ages 10-19) alive in the world than ever before, who will constitute about 20 per cent of the world’s population with about 85 per cent of them in developing countries (Morhason et–al, 2008) and about 30 per cent of the total population in Nigeria (Muyibi, Ajayi, Irabor, Ladipo, 2010). Therefore, considering the above proportion of adolescents in the world, and in developing countries including b Nigeria, attention should be given to this population group in order to protect them from the challenges posed by HRBs.
Studies have been calling for urgent attention on prevention of adolescents from health risk behaviours (Salami, 1997; Odejide, 2006), and according to SANYRBS (2003) and Eaton Kann, Kinchen, Shanklin, Ross, Hawkins, Harris, Lowry, McManus, Chyen, Lim,Whittle, Brener, Wechsler (2010) most of these risky behaviours are preventable. The researcher used in-school adolescents as subjects in this study for some obvious reasons: Adolescents are challenging targets for research aimed at understanding how health risk behaviours are formed, how they differ by ethnicity, gender, and environment. Adolescents are also seen as a window of opportunity for the development of health promoting or enhancing behavours and on the other hand they are vulnerable to various health risk behavious (Mistery, Maccarthy, Yancy, Lu & Patel, 2009). Studies by Obot, (2000); UNICEF, (2002) and WHO (2004) have revealed that adolescents are found to be involved in various health risk behaviours like substance abuse which can lead to several social, economic and health problems.
