Report on Bhutan Global School-Based Student Health Survey 2016 Report on Bhutan Global School-Based Student Health Survey 2016
World Health House Ministry of Health Indraprastha Estate Mahatma Gandhi Marg Royal Government of Bhutan New Delhi-110002, India 2017 www.searo.who.int 9 789290 226208
Report on Bhutan Global School-Based Student Health Survey 2016
Comprehensive School Health Programme Health Promotion Division, Department of Public Health, Ministry of Health, Royal Government of Bhutan and World Health Organization Regional Office for South-East Asia, New Delhi, India 2017
Ministry of Health Royal Government of Bhutan 2017 This survey and report have been made possible by the joint efforts of the United States Centers for Disease Control and Prevention (CDC), the World Health Organization Regional Office for South-East Asia (WHO- SEARO) and the Ministry of Health, Royal Government of Bhutan. Online repositories for Bhutan GSHS can be found at: https://nada.searo.who.int/index.php/catalog/10 http://www.searo.who.int/entity/noncommunicable_diseases/data/bhu_ncd_reports/en/ www.who.int/chp/gshs/bhutan/en/ www.cdc.gov/gshs/countries/seasian/bhutan.htm Suggested citation: World Health Organization, Regional Office for South-East Asia and Comprehensive School Health Programme, Health Promotion Division, Department of Public Health, Thimphu, Ministry of Health, Royal Government of Bhutan. Report on Bhutan Global School-based Student Health Survey (GSHS) 2016.New Delhi: WHO-SEARO, 2017.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 ISBN: 978 92 9022 620 8 © World Health Organization 2017 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial- ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization.. Suggested citation. World Health Organization, Regional Office for South-East Asia and Comprehensive School Health Programme, Health Promotion Division, Department of Public Health, Thimphu, Ministry of Health, Royal Government of Bhutan. Report on Bhutan Global School-based Student Health Survey (GSHS) 2016.New Delhi: WHO-SEARO, 2017.. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris. Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Cover photo credit: Mr Sangay Thinley Acknowledgements
The Ministry of Health, Royal Government of Bhutan, expresses its sincere and profound gratitude to all individuals and organizations that contributed immensely towards the conduct of Bhutan’s First Global School-Based Student Health Survey (GSHS) in 2016. Many individuals and organizations were involved in the planning of, pretesting for and conduct of the survey, as well as in the analysis of the data and writing of the report for the Bhutan GSHS.
We would like to thank Ms Leanne Riley (WHO headquarters, Geneva); Dr Laura Kann, Yoshimi Yamakawa, Tim McManus, Connie Lim and Denise Bradford from the CDC, Atlanta; Dr Thaksaphon Thamarangsi, Dr Manju Rani, Dr Gampo Dorji, Mr Naveen Agarwal and Dr Rizwan SA from the WHO-SEARO; and Dr Ornella Lincetto, Dr Rui Paulo De Jesus and Mr Tshering Dhendup from WHO Country for Bhutan for their valuable technical support and constant guidance.
We would also like to express our gratitude to the Ministry of Education, particularly to Ms Karma Dechen from the School Health and Nutrition Division, for all her hard work which contributed to the smooth and successful conduct of the fieldwork in the schools. iii We would like to make a special mention of the Steering Committee members, survey administrators, and writers (from the WHO-SEARO and Country Programmes) of the Bhutan GSHS report. Their enormous contributions at various stages of the survey are highly appreciated.
Lastly, we would like to sincerely thank the principals, teachers, school health coordinators, class captains and health captains of the 50 sampled schools for their support during the stage of data collection. Last but not the least, we are extremely thankful to all the students and parents for their participation in this survey, the first of its kind in Bhutan.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Contents
Acknowledgements iii
List of tables vi
Abbreviations vii
Foreword by Health Secretary, Royal Government of Bhutan ix
Foreword by the WHO Regional Director for South-East Asia xi
Executive summary 1
1. Introduction 4
1.1 Objectives 5
2. Methods 6
2.1 Sampling of schools 6
2.2 Questionnaire and its administration 7
2.3 Data management and analysis 8
3. Results 9 iv 3.1 Diet and physical activity 10
3.1.1 Nutritional status and dietary behaviour 10
3.1.2 Physical activity 12
3.2 Tobacco, betel nut, alcohol and substance abuse 14
3.2.1 Use of tobacco and betel nut 15
3.2.2 Use of alcohol 18
3.2.3 Use of drugs 20
3.3 Mental health 21
3.3.1 Suicidal behaviour 21
3.3.2 Loneliness 22
3.3.3 Missing classes and school experience 22
3.3.4 Engagement of parents/guardians 23
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.4 Violence and injury 24
3.4.1 Physical violence 25
3.4.2 Sexual violence 25
3.4.3 Bullying in schools 26
3.4.4 Injuries 26
3.5 HIV/AIDS 27
3.5.1 Sexual behaviours 28
3.5.2 Awareness of and attitude to HIV infection/ AIDS 29
3.6 Personal hygiene 30
3.6.1 Oral hygiene 31
3.6.2 Hand-washing behaviours 31
4. Discussion 33
4.1 Nutritional status 34
4.2 Dietary behaviours and physical activity 35
4.3 Tobacco, alcohol and substance use 36 v 4.4 Mental health 38
4.5 Violence and injuries 40
4.6 Sexual behaviours and HIV/AIDS awareness 41
4.7 Hygiene 42
4.8 Limitations 43
5. Recommendations 44
References 46
Annexes
1. Bhutan GSHS 2016 questionnaire 50 2. Bhutan GSHS 2016 key findings factsheet 62 3. Bhutan GSHS 2016 detailed tabulations for all indicators (available online at https://nada.searo.who.int/index.php/catalog/10) 4. Bhutan GSHS 2016 – List of steering committee members 74 5. Bhutan GSHS 2016 – List of survey administrators 75
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 List of tables
Table 1: Demographic characteristics of the respondent population, GSHS Bhutan, 2016 9 Table 2: Nutritional status and dietary behaviours among students of 13–17 years of age in GSHS Bhutan, 2016 12 Table 3: Patterns of physical activity among students of 13–17 years of age in GSHS Bhutan, 2016 14 Table 4: Patterns of tobacco use among students of 13–17 years of age in GSHS Bhutan, 2016 17 Table 5: Patterns of alcohol use among students of 13–17 years of age in GSHS Bhutan, 2016 19 Table 6: Patterns of drug use among students of 13–17 years of age in GSHS Bhutan, 2016 20 Table 7: Mental health of students of 13–17 years of age in GSHS Bhutan, 2016 23 Table 8: Level of parental engagement with students of 13–17 years vi of age in GSHS Bhutan, 2016 24 Table 9: Violence and injuries among students of 13–17 years of age in GSHS Bhutan, 2016 27 Table 10: Sexual behaviours and knowledge of HIV/AIDS among students of 13–17 years of age in GSHS Bhutan, 2016 30 Table 11: Oral hygiene and oral health among students of 13–17 years of age in GSHS Bhutan, 2016 32
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Abbreviations
BMI body mass index CDC Centers for Disease Control and Prevention, Atlanta, United States FGDs focus group discussions GSHS Global School-based Student Health Survey GYTS Global Youth Tobacco Survey HIV/AIDS Human immunodeficiency virus/acquired immune deficiency syndrome MoE Ministry of Education MoH Ministry of Health NCD noncommunicable disease OCR optical character recognition PE physical education PTSD post-traumatic stress disorder RGoB Royal Government of Bhutan SD standard deviation vii SEARO WHO Regional Office for South-East Asia SHS secondhand smoke STDs sexually transmitted diseases STH soil-transmitted helminths UNAIDS Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Social and Cultural Organization UNICEF United Nations Children’s Fund WHO World Health Organization
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016
ix
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016
Foreword by the WHO Regional Director for South-East Asia
Adolescents constitute an important social and demographic group in the WHO South-East Asia Region, accounting for almost one fifth or 18.8% (362.2 million individuals) of the total regional population. Of this group, 13–17-year-olds account for 181 million or nearly one tenth (9.4%) of the total regional population. Adolescent health is not only important in its own right, but is also an important predictor of the overall adult disease burden in the future. Given the importance of understanding health risk behaviours among adolescents, WHO is actively supporting the implementation of integrated adolescent risk factor surveys in all Member States of the Region as part of the Global School-based Student Health Survey (GSHS) Initiative.
The purpose of an integrated adolescent risk factor survey such as the GSHS is to generate comprehensive and nationally representative data on major health risk factors among adolescents, ranging from nutritional status and dietary habits to mental health issues, to violence and unintentional injuries and risky sexual xi behaviours. Using the school as the venue for selecting and interviewing students results in substantial cost savings compared with household surveys, and provides greater privacy for students. If implemented regularly (every 3–5 years), these surveys will provide valuable data not only for tracking the health of adolescents but also for predicting the overall future disease burden, with almost 35% of the global burden of disease having its roots in adolescence.
I congratulate the Ministry of Health and Ministry of Education of the Royal Government of Bhutan for completing the first GSHS survey in the country. While the survey revealed certain encouraging findings such as a high level of personal hygiene practices and high levels of HIV/AIDS awareness, it also revealed unacceptable levels of tobacco and alcohol use, high levels of mental health issues, poor dietary habits and low levels of physical activity. However, it is heartening to note that Royal Government of Bhutan has already acknowledged these issues and has already started appropriate policy and programmatic actions to address them.
The survey findings suggest that action is required at the national and school levels to ensure the physical, mental and social well-being of adolescents and youth. I
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 sincerely hope that the Ministry of Health and Ministry of Education will institutionalize adolescent risk factor surveillance as part of their overall health information system, and will conduct this survey every 3–5 years to enable monitoring of these risk factors over time, and also undertake evaluation of the policies and programmes put in place to control these risk factors.
Dr Poonam Khetrapal Singh Regional Director WHO South-East Asia Region
xii
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Executive summary
The first Global School-Based Student Health Survey (GSHS 2016) in Bhutan was conducted among school children of the age of 13–17 years attending classes 7–11 to assess the trends in the prevalence of key health behaviours and protective factors. A two-stage cluster sampling method was used to select a nationally representative sample of 50 schools and 7990 students. Of these, all 50 schools participated and 7578 (7576 usable data) students participated, giving an overall response rate of 95%. The students anonymously self-administered an 84-item questionnaire, covering demographics (age, gender); nutritional status; dietary habits and physical activity; violence and unintentional injuries; mental health; tobacco, alcohol and substance use; sexual behaviours; knowledge of HIV/AIDS; and habits related to personal hygiene. Of the 7576 students who completed the questionnaire, 87 did not report their gender, and of the remaining 7489, 48.1% were male and 51.9% female. Of the total respondents, 4.8% were 12 years old or younger and 18.8% were 18 years old or older. The main report presents findings mainly for the age group of 13–17 years (n=5809, 2515 male and 3255 female students, 39 did not report gender).
The key findings of the survey were as follows.
1. Nutritional status: The prevalence of undernutrition was 2.1% and 3.1% of 1 students reported going hungry most of the time or always because of the lack of food in their homes or boarding school. However, over-nutrition seems to be emerging, with 11.4% being overweight and 2% obese according to the BMI classification. 2. Risky dietary behaviour and limited physical activity: About 40% of the students reported drinking carbonated soft drinks one or more times a day. In addition, only 32.1% reported eating fruits two or more times a day and 42% reported eating vegetables three or more times a day. About 32.2% of the students reported eating fast food on 4 or more days during the 7 days preceding the survey. Only 23.5% reported being physically active for at least 60 minutes per day on 5 or more days during the 7 days preceding the survey and 30% spent 3 or more hours per day doing sedentary activities. 3. Tobacco and betel nut use: The prevalence of tobacco use (any tobacco product smokeless or smoking) was estimated at 29.4%, with the prevalence of cigarette smoking being 24.7% as defined by using a tobacco product or smoking tobacco product on 1 or more days in the last 30 days 9.4% of students were frequent smokers, smoking cigarettes 6 or more days in the
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 past 30 days. The rate of exposure to second-hand smoke, as measured by people smoking in their presence on one or more day in the last seven days, was high at 49.7%. In addition, 36.8% of student reported use of some form of tobacco by their parents or guardians. Though 55.2% of the respondents had tried to smoke tobacco before the age of 14 years, it was encouraging to note that 83% had tried to quit in the year preceding the survey. The reported rate of betel nut use was very high, with almost two-thirds of the students (65.8%) reporting that they consumed either of the two categories of betelnut products: Rajnigandha, Dildar, Wiz and others (58%), and doma khamtog (betel product) (49%) on one of more days in the last 30 days. 4. Alcohol and substance use: Almost one-quarter (24.2%) of students reported that they currently consumed alcohol – defined as having had at least one drink of alcohol (which does not include a few sips for religious purposes) on at least 1 day during the 30 days before the survey. In addition, about one in 10 (12%) students said they currently used marijuana (one of more days in the past 30 days) and 7.2% reported current using drugs like N10, RP, SP or dendrite. 5. Mental health: About 11% of students reported having attempted suicide one or more times during the 12 months before the survey, while nearly half (43.3%) felt that their parents or guardians understood their problems 2 and worries most of the time or always. 6. Violence and injuries: About 39% of the students reported having been physically assaulted at least once in the past year and about a quarter (26.5%) reported having been bullied on one or more days during the 30 days before the survey. 7. Sexual behaviour and awareness of HIV/AIDS: About 15% of students had ever had sexual intercourse, with just 59% of these reporting that they had used a condom during the last sexual intercourse. It is worrisome that among those who had ever had sexual intercourse, nearly half (49.3%) reported that their first sexual intercourse was before the age of 14 years. The students’ awareness of HIV/AIDS was high, with 86.3% reporting that they had ever heard about HIV/AIDS. 8. Personal hygiene: A small percentage of students (4.2%) said they never or rarely washed their hands after using the toilet or latrine, while 3.7% reported never or rarely washing their hands before eating. About one-third (33.6%) reported having no access to clean drinking water in school.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Some of the findings of the survey were encouraging. For example, a high proportion of students followed healthy practices related to personal hygiene and the level of knowledge of HIV/AIDS was high. However, some areas need urgent such as reducing the tobacco, alcohol and drug use, increasing parental engagement, creating a better environment at school with control of bullying and inter-personal violence and encouraging physical activity. However, Bhutan’s school-going adolescents require focused interventions for reducing the risk factors for noncommunicable diseases (NCDs) and mental health issues. Programmatic measures must be developed to implement the holistic policies adopted so as to intervene early, since these behaviours may extend into adult life, fueling an NCD epidemic and mental health problem. There is a need for intensification of actions both at the upstream policy level as well as the downstream programmatic level that is, the community and school levels, to ensure the physical, mental and social well-being of adolescents and the youth. Any laxity in taking measures for this age group and during this time period could represent a missed opportunity to improve the health of the overall population.
3
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 1. Introduction
Adolescence (persons aged 10-19 years old) is a critical transition period in a human being’s life, as it is during this time that the foundations for health and well-being are established. The rapid biological and psychosocial changes taking place during this period give rise to new health needs and risks, thereby making this age group especially vulnerable. The health status of an adult is mostly an outcome of the health behaviours initiated at a younger age. Several behavioural risk factors, such as an unhealthy diet, the lack of physical activity, poor personal hygiene and sanitation, drug abuse, and tobacco and alcohol consumption, deserve special attention. Many of these risk factors (use of tobacco, physical inactivity, harmful use of alcohol, unhealthy diet) have their origin in adolescence and lead to full-blown noncommunicable diseases in adulthood, and finally, contribute to premature mortality. The prevention or control of these risk factors later during life becomes extremely difficult because over time, they become an integral part of a person’s lifestyle. Therefore, the primary prevention of risk factors among children and adolescents is of critical importance.
Bhutan is a small landlocked country, located between the two most populous countries in the world – India and China – with a total land area of 38,394 square
4 kilometres. A peaceful mountainous kingdom in the Himalayas, Bhutan has a total population of 768,577 (projected figure for 2016). The majority of the people are farmers who depend on subsistence farming for their livelihood.
The WHO estimates that around 1.2 billion people, or 1 in 6 of the world’s population, are adolescents. Adolescents constitute merely one quarter of Bhutan’s population, and 13–17 year old population comprises about 13% of total population. School enrolment exceeds 98% – only 1.2% of primary age children are estimated to be out of school. In 2016, there were 169,560 children enrolled in 522 schools, ranging from pre-primary to higher secondary schools (1).
Recognizing the utmost importance of this group of population, the Royal Government of Bhutan has initiated and has been implementing various national policies and programmes for their health and well-being. Some of these include implementation of National multi-sectoral youth policy; the Comprehensive School and Adolescent Health Programmes; and inclusion of adolescent health in various national policies and programmes of different sectors.
However, in order to effectively and strategically guide policy makers and stakeholders to further promote health and wellbeing of adolescents in Bhutan,
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 there is a lack of comprehensive national data on health behaviours and protective factors which are proven to be the leading causes of morbidity and mortality among adolescents worldwide.
Therefore, in order to address the much needed data gap on health behaviours among adolescents in Bhutan, the RGoB has successfully conducted its first Global School-based Student Health Survey in 2016. The survey aimed at generating nationally representative data on various health risk behaviours, such as dietary habits, hygienic behaviour, interpersonal violence, mental health, substance abuse (including tobacco, alcohol and drug use), sexual practices and awareness of HIV/ AIDS, and also assessed protective factors among secondary school students of the age of 13–17 years.
1.1 Objectives
The goal of the survey was to obtain systemic information on select risk behaviours among adolescents, using schools as the sampling units, to support youth health programmes and policies in Bhutan.
The purpose of the survey was to provide accurate data on health behaviours and protective factors among students to: 5
¤¤ help Bhutan develop priorities, establish programmes, and advocate for resources for programmes and policies related to the health of school-going children and the youth;
¤¤ establish trends in the prevalence of health behaviours and protective factors to evaluate policies and programmes related to the health of school-going children and the youth; and
¤¤ allow the government, international agencies and others to make comparisons with other countries and within country.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 2. Methods
The GSHS is a school-based cross-sectional survey conducted primarily among students of the age of 13–17 years. It measures behaviours and protective factors related to the leading causes of mortality and morbidity among the youth. The GSHS initiative developed a standardized scientific sample selection process; a common school-based methodology; and standardized questionnaire modules with core and expanded questions, and country-specific questions that can be administered during one regular class period. The GSHS covered a representative sample of schools, and the method used was one of anonymous reporting by the respondents through a self-administered questionnaire. It is difficult to obtain accurate data from adolescents during in-person household surveys, as their responses regarding certain behaviours considered social taboos may be misleading. Hence, anonymous self-reported surveys may yield better results. Besides offering greater privacy for accurate reporting, using schools rather than households as the sampling unit reduces the costs of a survey substantially, though this strategy misses the ‘out-of-school’ youth.
2.1 Sampling of schools
6 Bhutan’s general school education system consists mainly of public schools and a small proportion of private schools. In 2016, there were 522 schools, of which 486 were public schools and 36 private. The entry age for the formal school system is six years. The school-based education structure in Bhutan comprises 11 years of free basic education, from preprimary class to class 10. This is divided into seven years of primary education (preprimary to class 6) and four years of secondary education (class 7 to class 10). This is followed by two years of upper secondary school, which consists of classes 11 and 12. Typically, those in the primary level (preprimary to class 6) are 6–12 years of age, in the lower secondary level 13–16 years of age, and in the upper secondary level, 17–18 years of age. The GSHS covered students enrolled in classes 7 to 11 (mainly secondary school levels), and the MoE provided a complete list of schools, classes and number of students.
The Bhutan survey employed a two–stage cluster sample design to produce a nationally representative sample of all students enrolled in classes 7 to 11 (which are typically attended by students of the age of 13–17 years, though some might be younger or older). In the first stage, schools were selected with probability proportional to enrolment size, using a random start. Fifty schools were sampled. In the second stage, systematic equal probability sampling was used, with a random
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 start, to select classes from each of the sampled schools. All the students in the selected classes were eligible to participate. A unique feature of the Bhutanese school system is the relatively high proportion of pupils enrolled as boarding students due to the distance of their homes from school. This is true especially of those who belong to the rural areas, from which it is difficult to commute daily. In this survey about 44% of the students were boarding students.
A total of 50 schools and 7990 students were sampled for inclusion. Of these, all 50 schools and 7578 students completed the questionnaires (7576 valid questionnaires). Thus, the overall response rate was 95%.
2.2 Questionnaire and its administration
The questionnaire (Annex 1) consisted of 84 core and expanded questions and country-specific questions. The questionnaire was developed in collaboration with WHO and the CDC as part of the GSHS initiative. The questionnaire was field tested in five strategically selected non-sampled schools, both in the rural and urban areas, in two districts of Bhutan. After the pilot test, the questionnaire was refined further for contextualization. Initially, the questionnaire consisted of 90 questions, but after the pilot test, the number of questions was brought down to 84. The final questionnaire was approved by WHO and the core working team. 7 The English language version of the questionnaire was used in the survey since the medium of instruction in Bhutan is English. It was found during the pilot test that translation of the questionnaire was not required. Several different recall periods, such as 7 days, 30 days, past year and “within the school year”, were used in the various questions. The questionnaire addressed the following topics.
¤¤ Lifestyle behaviours: dietary behaviours, hygiene, physical activity;
¤¤ Substance and drug use: consumption of tobacco, alcohol and betel nut;
¤¤ Sexual behaviour: sexual practices, knowledge of HIV infection or AIDS; and
¤¤ Social relationships and mental health: relationship with parents, friends and schoolteachers, violence and unintentional injury, and mental health.
The field work for the survey was carried out between October and November 2016. The method of administering the questionnaire and other survey procedures were designed to protect the privacy of the students, allowing as they did for anonymous and voluntary participation. The students self-administered the questionnaire in an anonymous manner.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 2.3 Data management and analysis
The students were asked to fill in the circles of their choice on the answer sheets (optical character recognition [OCR] form). After the survey was completed, the OCR answer sheets were sent to the CDC, where they were scanned and the responses imported into a database. The CDC carried out the necessary cleaning (for inconsistencies and missing responses). Each question/response was weighted to reflect the likelihood of sampling each student and to reduce bias by compensating for differing patterns of nonresponse. The weight used for estimation is given by:
W = W1 * W2 * f1 * f2 * f3
W1 = the inverse of the probability of selecting the school.
W2 = the inverse of the probability of selecting the classroom within the school.
f1 = a school-level nonresponse adjustment factor calculated by school size category (small, medium, large). The factor was calculated in terms of school enrolment instead of number of schools.
f2 = a student-level nonresponse adjustment factor calculated by class.
f3 = a post-stratification adjustment factor calculated by grade. 8 A complex sample analysis was done to obtain weighted estimates of prevalence and 95% confidence intervals for key indicators. Ninety-five per cent confidence intervals were used to assess the significance of differences in the key indicators by sex and age of the students.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3. Results
Table 1 shows the characteristics in terms of age, sex and school class of the students who finally participated in the survey.
Table 1: Demographic characteristics of the respondent population, GSHS Bhutan, 2016 Males Females Total Age (years) N (%) N (%) N (%) 12 or younger 116 1.8 187 2.7 326 4.8 13–15 1273 18.4 1735 22.1 3027 40.4 16–17 1242 17.3 1520 18.9 2782 36.0 18 and older 746 10.6 657 8.3 1,417 18.8 Missing 7 – 6 – 24 – Grade N (%) N (%) N (%)
Class 7 746 11.5 954 13.1 1720 24.7
Class 8 740 10.4 925 11.2 1693 21.8
Class 9 733 10.3 871 11.1 1617 21.3 9 Class 10 671 8.9 771 9.4 1454 18.2 Class 11 424 6.8 514 7.2 940 13.9 Missing 70 – 70 – 152 – Type of student Day 1755 (45.2%) 2129 (54.8%) 3884 (100.0%) Boarding 1526 (45.0%) 1874 (55.1%) 3400 (100.0%) Total (all ages) 3384 (48.1%) 4105 (51.9%) 7576 (100.0%) Total (13–17 years) 2515 (43.6%) 3255 (56.4%) 5809 (100.0%) 1. The male and female count in each row may not add up to the exact value given under ‘Total column’ as 87 students overall did not mention their gender. However, these students were not excluded from calculations of overall prevalence as per global practice. 2. The percentages may not add up to 100 because of missing values.
The detailed tabulations that provide information on the sample/denominator used in the computation of the key indicators under each domain are available online at https://nada.searo.who.int/index.php/catalog/10, which present the results by sex (male and female), class and age. As the sampling inclusion criteria were based on the class level and not age, the age of the sampled students varied from under
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 12 years to over 18 years. For the sake of uniformity and comparison, the results in the following sections pertain only to the age group of 13–17 years (N=5809), though online detailes tables also provide the results for those under 12 years of age and those over 18 years of age. The results are presented across five key domains.
3.1 Diet and physical activity
3.1.1 Nutritional status and dietary behaviour
Nutritional deficiencies as a result of food insecurity (protein–energy malnutrition, deficiency of vitamins and different micronutrients) affect students and their learning. In addition, changing dietary habits (e.g. increased consumption of sugary drinks, fast food) are leading to the problems of overweight and other risk factors associated with noncommunicable diseases (NCDs). Hence, an assessment of the dietary behaviours of adolescents is important to inform appropriate youth and school health policies and to check the rising prevalence of NCDs. The survey assessed the prevalence of hunger, the consumption of fruits and vegetables, and that of carbonated drinks and fast food. In addition, anthropometry (measurement of height and weight) was done for all students to calculate the body mass index (BMI).
Diet and nutritional status at a glance 10 Percentage of students (13–17 years old) who:
Reported going hungry 3.1 Were underweight 2.1 Were overweight 11.4 Were obese 2.0 Had not eaten any fruit during the past 30 days 12.7 Had not eaten any vegetable during the past 30 days 4.4 Had carbonated drinks ≥1 times per day 40.1 Had animal protein ≥2 times a week 32.8 Had breakfast most of the time/always 74.1 Had fast food ≥4 days a week 29.1
Nutritional status
Nutritional status was assessed by calculating the BMI (kg/m2) [(weight in kg)/ (height in m)2] on the basis of the measured weight (in kg) and height (in m) of the
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 students. Students with less than -2 standard deviation (SD) from the median BMI for their age and sex were classified as underweight. Those with more than +1 SD from the median BMI by age and sex were defined as overweight, while students with more than +2 SD from the median BMI by age and sex were defined as obese.
The prevalence of underweight was 2%, and there was a significant difference between males (3%) and females (1%), but not by age. The problem of over-nutrition was prevalent: nearly 11% and 2% of the 13–17-year-old students were recorded as being overweight and obese, respectively. Significantly more females were overweight (15%) than males (8%), and significantly more young students were overweight (13%) than older students (10%). Also, day scholars (13%) were significantly more overweight than boarding students (9%). The prevalence of obesity did not differ significantly by age or sex.
Only 3% of the students reported going hungry most of the time or always due to a shortage of food in their homes during the past 30 days. There were no significant differences by sex.
When asked about the intake of animal protein, only 33% of the students reported eating foods containing animal protein two or more times a week. Fewer females (29%) than males (37%) reported taking animal source proteins. Similarly, fewer boarding students (27%) reported taking animal source proteins than day 11 scholars (37%).
Fruit and vegetable intake
About 13% and 4% of students reported not eating any fruits and vegetables, respectively, during the 30 days preceding the survey. Only 32% reported usually eating fruits two or more times a day. While there were no significant differences by sex, there was a significant difference between younger (37%) and older (27%) students. Similarly, about 42% of students reported usually eating vegetables three or more times a day, with no significant differences by sex or age. Also, significantly more day scholars reported eating fruits than boarding students (38% vs 23%), as well as vegetables (45% vs 37%).
Consumption of carbonated soft drinks
The survey explored the students’ habits with regard to the consumption of carbonated soft drinks, such as Coca Cola, Pepsi, Fanta and Sprite. About 40% of students reported drinking carbonated soft drinks one or more times a day. While
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 there were no significant differences by sex, a significantly higher percentage of younger students (44%) consumed carbonated drinks than older students (36%). Also, more day scholars (44%) than boarding students (34%) reported drinking carbonated drinks.
Table 2: Nutritional status and dietary behaviours among students of 13–17 years of age in GSHS Bhutan, 2016 Car- bonat- Animal Veg Fruits≥2 ed protein Under- Over- Went ≥3 Obese times/ drinks ≥2 weight weight hungrya times/ dayb ≥1 times/ dayb times/ week dayb Gender (%) (%) (%) (%) (%) (%) (%) Male 3.1* 7.9* 1.9 3.3 29.4 40.5 40.5 36.9 Female 1.3 14.5 2.1 2.9 34.3 42.2 39.5 29.3 Age 13–15 2.1 13.0* 2.5 2.8 36.9* 43.9 43.8* 35.4 16–17 2.2 9.7 1.4 3.5 26.8 38.7 35.9 29.9 Type of student 12 Day 2.9 13.0* 2.7 2.6 38.4* 44.6* 44.3* 36.8 scholar Boarding 1.2 9.3 1.0 3.6 23.2 37.3 34.1 27.2 student
Total 2.1 11.4 2.0 3.1 32.1 41.5 40.1 32.8 (13–17)
*Differences across groups are statistically significant at 95% confidence level. aDuring the past 30 days, because there was not enough food at home or boarding school; bduring the past 30 days.
3.1.2 Physical activity
Adequate physical activity helps to build healthy bones and muscles, reduces blood pressure and obesity, and promotes psychosocial well-being (2). Engaging in adequate physical activity throughout one’s lifespan and maintaining the normal body weight are the most effective ways of preventing many chronic diseases, including cardiovascular disease and diabetes (3).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Physical activity at a glance
Percentage of students (13–17 years old) who:
Were not physically active for at least 60 min/day during the past 7 days 26.8 Were physically active for at least 60 min on ≥5 days/week 23.5 Were physically active for at least 60 min on all days of the past week 14.4 Spent ≥3 hours/day performing activities involving sitting 29.9
Physical activity
About one-quarter (27%) of the students reported being physically inactive, i.e., not physically active for at least 60 minutes a day on any day during the 7 days before the survey. There was no significant difference by age or sex. Only 24% of students reported being physically active for at least 60 minutes a day on 5 or more days during the week before the survey, and only 14% reported being physically active at least 60 minutes a day on all 7 days before the survey.
Sedentary behaviours
More than half of the students (55%) did not walk or ride a bicycle to or from the 13 school, with no significant difference by age or sex. About 30% spent three or more hours a day performing activities involving sitting (sitting and watching television, playing computer games, talking with friends when not in school or doing homework during a typical or usual day). There was no significant difference by age or sex. Also, a significantly greater proportion of boarding students than day scholars (65% vs 49%)did not walk or ride a bicycle to school, while significantly more day scholars than boarding students (35% vs 22%) performed activities that involved sitting for ≥3 hours.
Proportion of students attending at least one Physical Education (PE) class a week during the school year
About 61% of the students had never attended a PE class. However, 19% attended a PE class at least once a week. According to the MoE policy for period allocation, all classes from pre-primary to XII must have one health and physical education class (50 minutes) per week.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Table 3: Patterns of physical activity among students of 13–17 years of age in GSHS Bhutan, 2016 Not physically Attended active for at physical least 60 min Did not walk / Spent ≥3 hours education per day on any ride a bicyclea sitting each day classes ≥3 days day during one a weekb weeka Gender (%) (%) (%) (%) Male 23.5 55.0 28.7 15.5 Female 29.6 55.7 30.9 13.9 Age 13–15 29.0 54.1 28.5 16.2 16–17 24.2 56.8 31.6 12.9 Type of student Day scholar 26.4 48.6* 35.3* 14.7 Boarding student 27.4 64.9 22.3 14.4 Total (13–17) 26.8 55.4 29.9 14.7 *Differences across groups are statistically significant at 95% confidence level. 14 aDuring the past 7 days; b during this school year.
3.2 Tobacco, betel nut, alcohol and substance abuse
Most current users of tobacco, betel nut, alcohol and drugs have developed the habit in early adolescence. Sometimes it is just out of curiosity and sometimes, due to peer pressure, and often, these people go on to become regular users. Smokers have markedly increased risks of several cancers, particularly lung cancer, and are at a far greater risk of heart disease, stroke, emphysema, and many other fatal and nonfatal diseases. Similarly, chewing tobacco and betel nut has a marked association with cancer of the lip, tongue and mouth (4).
The use of tobacco, alcohol and drugs has an adverse impact not only on those who use them, but also on their families and communities. It is important to prevent adolescents from developing these habits as quitting later is very difficult and requires intensive resources.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Tobacco, betel nut, alcohol and substance use at a glance
Percentage of students (13–17 years old) who:
Currently use a tobacco product 29.4 Currently smoke cigarettes 24.7 Smoked for 6 or more days 9.4 Currently use tobacco products other than cigarettes 18.4 Are exposed to second-hand smoke 49.8 Have made an effort to quit 83.0 Are susceptible to smoking 13.9 Currently have Rajnigandha, Dildar, Wiz or Sakila 58.1 Currently have doma khamtog (areca nut, betel leaves, lime) 48.9 Currently use any betel nut product 65.9 Currently drink alcohol (ara, bangchang, singchang, changkoe, beer, etc.) 24.2 Ever got heavily drunk 23.3 Currently use marijuana 12.0 Currently use drugs (N10, RP, SP or dendrite) 7.2
3.2.1 Use of tobacco and betel nut 15
Age of initiation and prevalence of tobacco use
About one-third (29%) of students reported having used any tobacco product (smoke and smokeless) on at least one day during the 30 days before the survey. There were significant differences by sex (43% males vs 18% females) and age. About one-quarter (25%) of the students reported that they were currently smoking cigarettes. Here, too, there were significant differences by sex (38% males vs 13% females) and by age (20% younger vs 30% older). Also, about 18.4% of students reported using any tobacco other than cigarettes. There were significant differences by sex (28% males vs 10% females) and by age (15% younger vs 22% older).
About 1 in 10 (11%) had smoked for 1–2 days in the past 30 days and 2% had smoked on all 30 days. Further, 9% were frequent users, meaning that they had smoked cigarettes on 6 or more days in the past 30 days. While 75.3% of the students had not smoked at all in the past 30 days, 78.5% had never smoked in their life.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 About half of the students (55%) who had ever smoked cigarettes had first tried them before the age of 14 years. This shows that adolescents start using tobacco very early, and any programme to contain the tobacco epidemic has to focus on young adolescents.
Tobacco use by parents or guardians and exposure to secondhand smoke
Nearly one-third of the students (37%) reported that they had parents or guardians who used some form of tobacco, with no significant difference by sex.
In addition, almost half of the students reported that people smoked in their presence (on one or more days during the 7 days before the survey), with a significant difference by sex (59% males and 41% females) but not by age. Exposure to smoking for1–2 days was reported by 28.4% and all 7 days by 6.8% of the students.
Desire to quit and susceptibility to smoking
Among those who reported smoking cigarettes during the 12 months before the survey, 83% reported that they tried to quit the habit. There were no significant differences by age or sex. 16 The survey assessed the temptation to smoke among the students. About 84% said that they would not smoke if offered a cigarette by friends. More female students (90%) than male (76%) resisted this temptation. About 86% of students did not see themselves smoking a cigarette any time in the next 12 months. There were significant differences by sex (80% male vs 92% female) and age (90% among 13–15-year-olds vs 82% among 16–17-year-olds).
A comparison by type of students showed that the tobacco use indicators were not significantly different for day scholars and boarding students, except that a higher proportion of day scholars was exposed to secondhand smoke (SHS) (54% vs 44%).
Consumption of betel nut and pan masala
Areca nut (betel nut) is the fourth most commonly used addictive substance in the world. The use of betel nut causes oral cancer and has also been linked to metabolic syndrome, hypertension, diabetes mellitus and obesity. When taken with tobacco, it causes upper digestive tract cancers, including cancer of the oral cavity, pharynx and oesophagus.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 In Bhutan, most users of betel nut chew a mixture of areca nut, betel leaf and lime – locally known as doma khamtog. Doma khamtog is widely used in the country and its consumption is traditionally accepted. Betel nut is also consumed in the form of meetha pan and a wide variety of packaged pan masalas (a mixture of areca nut and slaked lime, catechu and other flavouring agents). The production, sale, distribution and consumption of betel nut products are not regulated in Bhutan. The survey assessed the prevalence of the use of doma khamtog or meetha pan (i.e., having doma khamtog or meetha pan on one or more days during the 30 days before the survey). Overall, half of students were found to be current users of doma khamtog or meetha pan. More male students (57%) than female (43%) were current users, and the use of doma or meetha pan was more prevalent among students in urban schools (51%) than rural (46%). The survey also assessed the prevalence of the use of pan masala, such as Rajnigandha, Sakila, Wiz and Dildar, all of which are imported from the neighbouring countries. Nearly 6 in 10 students were found to be current users of pan masala (i.e., having panmasala on one or more days during the 30 days before the survey). More male students (66%) than female (51%) used pan masala on one or more days before the survey.
Table 4: Patterns of tobacco use among students of 13–17 years of age in GSHS Bhutan, 2016 17 Cur- Currently Cur- Use Will not rently Tried a Will not Current- having rently Exposure of any smoke using cigarette Tried to smoke ly smok- Rajni- having to sec- form of anytime any before quit ciga- if ing cig- gand- doma ond-hand tobacco in next tobacco 14 years rettesc friends arettesa ha,Dildar, kham- smoked by par- 12 pro- of ageb offere Wiz, etc.a toga ents monthse ducta Gender (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) Male 42.9* 38.0* 58.0* 83.5 66.1* 55.8* 59.3* 33.7 76.3* 79.8* Female 17.6 13.1 48.6 81.7 51.2 43.0 41.3 39.2 90.4 91.7 Age 13–15 24.2* 20.1* 69.4* 86.6 55.3 41.9 46.4 34.1 87.9* 89.6*
16–17 35.1 29.8 44.5 80.5 61.3 56.6 53.5 39.8 79.3 82.2
Type of student
Day 29.7 25.3 57.3 83.7 60.9 47.8 53.9* 37.1 84.7 86.4 scholar Boarding 28.4 23.1 52.4 81.9 54.0 50.0 43.6 36.4 83.0 86.1 student Total 29.4 24.7 55.2 83.0 58.1 48.9 49.7 36.8 83.9 86.1 (13–17)
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 *Differences across groups are statistically significant at 95% confidence level. aOn at least 1 day during the 30 days before the survey, and includes use of cigarettes and other tobacco products; b for the first time among students who ever smoked cigarettes; c among students who smoked cigarettes during the 12 months before the survey; d on one or more days during the 7 days before the survey; e includes respondents who said “definitely” not and “probably” not.
3.2.2 Use of alcohol
Worldwide, harmful use of alcohol causes 3% of all deaths each year. While intoxication and addiction have certain direct effects, the use of alcohol also causes oesophageal cancer, liver disease and epilepsy, and can lead to homicide, intentional injuries and motor vehicle accidents (5). Heavy use of alcohol also places one at a greater risk for cardiovascular disease (6). In most countries, alcohol-related mortality is the highest among those who are 45–54 years of age, but the study of alcohol consumption among adolescents is important because of the relationship between the age of initiation of alcohol use and the pattern of its use and abuse in adulthood (7).
Intentional and unintentional injuries are far more common among the youth and young adults. Unintentional injuries are the leading cause of death among people of 15–25 years of age and many of these injuries are related to the use of alcohol (8). Problems with alcohol can impair the psychological development of adolescents 18 and influence both the school environment and leisure time negatively (9). The GSHS 2016 used a set of seven questions to assess the patterns of alcohol use among the surveyed students.
Age of initiation and prevalence of alcohol use
About one-quarter (24%) of students reported that they currently consumed alcohol – defined as having had at least one drink of alcohol (which does not include a few sips for religious purposes) on at least 1 day during the 30 days before the survey. Significant differences were observed by age (18% among 13–15-year-olds and 31% among 16-17-year-olds) and by sex (33% among males vs 16% among females). Among those who reported current use of alcohol, 17% said that they usually had two or more drinks per day on the days they drank. There was a significant difference by sex (21% among males vs 12% among females), but not by age. No significant differences by rural or urban schools were found.
Among the students who ever drank but a few sips, 56% reported that they consumed alcohol before the age of 14 years. There was a significant difference by age (74% among 13–15-year-olds vs 43% among 16–17-year-olds), but not by sex. Almost two in five (40%) students who currently had alcohol reported that they
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 usually obtained the alcohol they drank from friends, followed by stores, shops or street vendors (25.3%).
Drunkenness and consequences of drinking
About one-quarter (23%) of students reported that they had at some point had so much alcohol that they were really drunk (one or more times in their life). There were significant differences by sex (33% among males vs. 15% among females) and age (16% among younger vs 32% among older students). Also, more boarding school students (27%) than day scholars (20%) reported heavy drinking. About one in 10 (10%) reported that they got into trouble with their family or friends, missed school, or got into fights as a result of drinking alcohol (one or more times during their life). There were significant differences by sex (15% among males vs 6% among females) and age (7% among younger vs 13%among older students). Also, alcohol-related quarrels were reported more by boarding school students than day scholars (12% vs 9%).
Table 5: Patterns of alcohol use among students of 13–17 years of age in GSHS Bhutan, 2016 Got into Drank 2 First drank Obtained Currently Got heavily trouble or or more alcohol alcohol drink drunk at fights due drinks per before age from alcohola any pointd to alcohol dayb of 14c friendse used 19 Gender (%) (%) (%) (%) (%) (%) Male 33.4* 21.1* 58.0 33.3* 14.5* 37.5 Female 16.1 11.5 52.4 14.7 6.1 44.4 Age 13–15 18.2* 14.8 74.0* 15.5* 7.2* 36.4 16–17 30.9 19.1 42.6 32.2 13.3 42.4 Type of student Day 23.5 17.8 53.8 20.4* 9.0* 40.4 scholar Boarding 24.8 16.5 59.0 27.2 11.6 39.5 student Total 24.2 17.4 55.7 23.3 10.1 40.0 (13–17) *Differences across groups are statistically significant at 95% confidence level. aAt least one drink of alcohol on at least one day during the 30 days before the survey; b on the days they drank, among students who drank alcohol during the 30 days before the survey; c for the first time, among students who had only had a few sips earlier; d one or more times during their life; e among students who drank during the 30 days before the survey.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.2.3 Use of drugs
Prevalence of drug use and age of initiation
The survey assessed the use of drugs by the students and the age of initiation. About one in 10 (12%) students said they currently used marijuana. There were significant differences by sex (21% among males vs 4% among females) and age (9% among younger vs 16% among older students). About 16% reported ever having used marijuana. There were significant differences by sex (28% among males vs 5% among females) and age (12% among younger vs 21% among older students).
Of the current users of marijuana, 6.3% had smoked it once or twice in the past 30 days and 1.5% had used it frequently i.e. 20 or more times.
Of those who reported ever having used drugs (such as N10, SP, RP, inhalants and marijuana), about 41% said they had used them before the age of 14 years. There was a significant difference by age (61% among younger vs 26% among older students), but not by sex. A higher proportion of day scholars (44%) than boarding school students (37%) reported starting the use of drugs early.
Table 6: Patterns of drug use among students of 13–17 years of age in GSHS Bhutan, 2016 20 Currently use Used drugs for Currently use Ever used drugs like first time before marijuanaa marijuanab N10, RP, SP or age of 14 yearsc dendritea Gender (%) (%) (%) (%) Male 21.0* 28.3* 11.2* 42.6 Female 4.1 5.3 3.5 34.2 Age 13–15 8.9* 11.9* 6.4 60.5* 16–17 15.5 20.6 8.0 26.3 Type of student Day scholar 11.7 15.3 7.3 43.8* Boarding student 12.1 16.7 6.9 37.2 Total (13–17) 12.0 16.0 7.2 40.9 *Differences across groups are statistically significant at 95% confidence level. aOne or more times during the 30 days before the survey; b one or more times during their life; c among students who ever used drugs.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.3 Mental health
Most young people suffer needlessly from various mental health problems, having to go without a diagnosis, support and treatment. These people are at a risk of being abused and neglected. They are also susceptible to the use of alcohol and drugs, and have a relatively higher risk of committing suicide and failing in school. Further, they are more likely to engage in violent and criminal activities. Their mental illness is likely to continue into adulthood.
Mental health at a glance
Percentage of students (13–17 years old) who:
Felt lonely 12.4 Always felt worried 7.6 Had suicidal ideation 11.6 Had suicidal ideation with a plan 13.7 Attempted suicide 11.3 Had no close friends 8.7
3.3.1 Suicidal behaviour 21
Almost one in 10 (11%) of the students surveyed reported having attempted suicide one or more times during the 12 months before the survey. There were no significant differences by sex or age. However, significantly more boarding school students than day scholars (13% vs 10%) had attempted suicide. A similar proportion of students reported that they had seriously considered attempting suicide. There was a significant difference by sex (12% in all, 10% among males vs 13% among females). About 14% had made a plan about how they would attempt suicide during the 12 months before the survey. There was a significant difference by sex (11% among males vs 16% among females).
In addition, 8% of students reported feeling so worried about something most of the time or always that they could not sleep at night. There was a significant difference by sex (6% among males vs 9% among females), but not by age.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.3.2 Loneliness
Being liked and accepted by one’s peers is crucial to the mental health development of young people, and those who are not socially integrated are more likely to undergo difficulties with their physical and emotional health. Isolation from one’s peers in adolescence can lead to feelings of loneliness and psychological symptoms. Interaction with friends tends to improve a person’s social skills and strengthen his/her ability to cope with stressful events (10). Hence, the study elicited the adolescents’ responses to the questions of loneliness/worrying and having friends.
Twelve per cent of the students reported that they had felt lonely most of the time or always during the 12 months before the survey. There was a significant difference by sex (10% among males vs 14% among females), but not by age. Significantly more boarding school students than day scholars (15% vs 10%) reported feeling lonely. About 9% of students reported that they did not have any close friends. There were no significant differences by age, location of schools (rural, urban) or sex.
3.3.3 Missing classes and school experience
Adolescents who have a positive relationship with teachers and positive attitudes towards school are less likely to indulge in substance abuse and to experience 22 depression.
Missing classes is a sign of the school environment being unfavourable, or of a student disliking school or being ill. This may imply that the student needs more care and support. About a quarter (24.6%) of students missed classes or school without permission on one or more days during the 30 days before the survey. There was a significant difference by sex (30% among males vs 20% among females), but not by age. Significantly more day scholars than boarding school students (27% vs 22%) reported missing classes without permission.
In addition, nearly 42% of students reported that most of the students in their school were helpful and kind most of the time or always during the 30 days before the survey. There were no significant differences by sex or age.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Table 7: Mental health of students of 13–17 years of age in GSHS Bhutan, 2016 Reported Wor- Made Did most Seriously ried so Missed At- a plan not students consid- much Felt classes tempt- to at- have in their ered at- that lone- without ed sui- tempt any school tempting could lyb permis- cidea sui- close were kind suicidea not sionc cidea friends and help- sleepb fuld Gender (%) (%) (%) (%) (%) (%) (%) (%) Male 10.3 9.8* 11.2* 6.2* 10.0* 7.4 29.9* 41.4 Female 12.1 13.1 15.8 8.8 14.4 9.8 19.9 42.2 Age 13–15 10.7 11.4 13.6 6.7 11.2 9.2 23.5 40.4 16–17 11.9 11.8 13.7 8.6 13.7 8.0 25.9 43.3 Type of student Day 10.1* 11.4 13.4 6.9* 10.4* 8.3 26.7 41.9 scholar Boarding 12.9 11.8 14.2 8.7 15.0 8.9 21.5 41.7 student Total 23 11.3 11.6 13.7 7.6 12.4 8.7 24.6 41.8 (13–17) *Differences across groups are statistically significant at 95% confidence level. a One or more times during the 12 months before the survey ; b most of the time or always during the 12 months before the survey; c on one or more days during the 30 days before the survey; d most of the time or always during the 30 days before the survey.
3.3.4 Engagement of parents/guardians
Adolescents who live in a social environment which provides meaningful relationships, encourages self-expression and is characterized by structure and boundaries are less likely to initiate sex at a young age, to experience depression and to indulge in substance abuse. Parental bonding and connection is associated with relatively lower levels of depression and suicidal ideation, alcohol use, sexual risk behaviours and violence (11). The survey assessed the students’ perceptions of their parents’ or guardians’ engagement with them, using four questions, with a recall period of the 30 days before the survey.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Nearly half (43%) of the students (40% male and 47% female) reported that their parents or guardians understood their problems and worries most of the time or always. About 37% reported that most of the times or always, their parents and guardians really knew what they were doing with their free time. There were no significant differences by sex or age. Just one quarter (27%) reported that most of the time or always, their parents or guardians checked to see if their homework had been done. About 54% said that their parents never or rarely went through their things without their approval. There was a significant difference by age (51% in younger vs 58% in older students), but not by sex. A higher proportion of boarding students than day scholars (58% versus 52%) reported that their parents or guardians never or rarely went through their things without their approval.
Table 8: Level of parental engagement with students of 13–17 years of age in GSHS Bhutan, 2016 Parents never Parents knew Parents Parents checked or rarely went what they were understood to see if their through their doing with their their problems homework was things without free timea and worriesa donea their approvalb Gender (%) (%) (%) (%) Male 35.8 39.8* 27.5 54.4 24 Female 38.4 46.6 26.1 54.1 Age 13–15 39.2 42.2 29.6* 50.5* 16–17 34.9 44.6 23.5 58.3 Type of student Day scholar 43.9* 43.7 26.9 51.5* Boarding student 27.1 42.5 26.2 58.2 Total (13–17) 37.2 43.3 26.7 54.2 *Differences across groups are statistically significant at 95% confidence level. aMost of the time or always during the 30 days before the survey; b never or rarely during the 30 days before the survey.
3.4 Violence and injury
Adolescents are more prone to injury, intentional or unintentional, than their older counterparts (12).Unintentional injuries are a major cause of death and disability among young children. Each year, globally, about 875 000 children under the age of 18 years die from injuries and the lives of 10–30 million are affected by injury (13).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Violence and injuries at a glance
Percentage of students (13–17 years old) who:
Were physically attacked 39.0 Were involved in a physical fight 40.2 Were forced to have sexual intercourse 7.1 Were bullied 26.5 Were seriously injured 43.7
3.4.1 Physical violence
The prevalence of injuries, either intentional or unintentional, among students reflects deterioration in the psychosocial environment in schools. The survey collected data to assess the prevalence of physical attacks, physical fights and serious injuries in the 12 months before the survey.
When the students were asked about how many times they were physically attacked in the past 12 months, about two in five (39%) answered ≥1 times. Of those who reported having been physically attacked, 5.3% experienced such attacks 6 or more times. More males (45%) than females (33%) reported having been physically 25 attacked in the past 12 months. Also, the prevalence of physical attacks was higher among students in boarding school (43%) than among day scholars (36%).
In a similar finding, as for how many times the students had been involved in a physical fight with other student(s) during the past 12 months, 40% replied in the affirmative, the proportion of males (49%) being higher than that of females (32%).
The survey also found that 44% of students suffered serious injuries, on account of which they had to miss atleast one full day of their usual activities (such as school, sports or a job), or for which they required treatment by a doctor or nurse. This was true of more males (49%) than females (39%). However, there were only slight differences in the prevalence of serious injuries by type of students and by rural- urban residence.
3.4.2 Sexual violence
The survey also assessed the prevalence of sexual violence, eliciting the students’ responses on whether or not they had ever been forced to have sexual intercourse.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Overall, 7% of students reported ever having been sexually violated. By sex, more male students (8%) experienced sexual violence compared to their female (7%) counterparts. The survey also found that the prevalence of sexual violence was greater among students in boarding school (9%) than those in day school (9%). Also, the prevalence of sexual violence was higher among students in schools in rural areas (8%) than those in schools in urban areas (7%).
3.4.3 Bullying in schools
Victims of bullying have increased levels of stress and a reduced ability to concentrate, and the risk of their abusing substances, behaving aggressively and attempting suicide is relatively higher. The survey included two specific questions related to the prevalence of bullying and how the students were bullied in the past 30 days. Bullying occurs when a student or group of students say or do bad and unpleasant things to another student. Teasing a student excessively in an unpleasant way and leaving a student out of things on purpose also constitute bullying. When two students of about the same strength or power argue or fight, or when a person is teased in a friendly and fun way, it cannot be termed bullying.
About a quarter of the students (27%) reported having been bullied on one
26 or more days during the 30 days before the survey. Of those who reported having been bullied, 2.4% were bullied 10 or more times. While there were no differences in the prevalence of bullying by age or sex, more boarding students (31%) than day scholars (24%) were found to have been bullied.
3.4.4 Injuries
When comparing the type of students in terms of violence- and injury-related indicators, it was found that most of these indicators were higher among boarding students than day scholars: being physically attacked (43% vs 37%), being involved in a physical fight (45% vs 37%), being bullied (31% vs 24%) and the prevalence of serious injury (46% vs 42%).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Table 9: Violence and injuries among students of 13–17 years of age in GSHS Bhutan, 2016 Students who were Students Students Students bullied who were Students who Students who were most bullied who were were in a who were physically often by and could seriously physical bulliedb attackeda being hit, not sleep injureda fighta kicked, at nightd etc.c Gender (%) (%) (%) (%) (%) (%) Male 45.4* 49.2* 26.3 23.2* 37.6 48.8* Female 33.2 32.2 26.3 11.6 42.2 39.0 Age 13–15 40.7 42.5 30.1 18.0 45.4 44.4 16–17 37.0 37.7 22.4 15.5 36.5 42.9 Type of student Day scholar 36.4* 37.0* 23.5* 18.0 Small N 42.2* Boarding student 42.7 44.5 31.4 15.8 Small N 46.0 Total (13–17) 39.0 40.2 26.5 17.0 40.6 43.7 27 *Differences across groups are statistically significant at 95% confidence level. a One or more times during the 12 months before the survey; bon one or more days during the 30 days before the survey; c among students who were bullied during the 30 days before the survey; d among students who had been so worried about something most of the time or always that they could not sleep at night during the 12 months before the survey. Small N: Fewer than 100 students in this subgroup
3.5 HIV/AIDS
School health programmes can help the youth adopt lifelong attitudes and behaviours that support overall health and well-being. These behaviours include those which can reduce unwanted pregnancy and sexually transmitted diseases (STDs).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.5.1 Sexual behaviours
About 15% of students reported ever having had sexual intercourse. There were significant differences by sex (23% among males vs 9% among females) and age (13% among younger vs 18% among older students). Almost half of the students (49%) who reported ever having had sexual intercourse reported having had the first sexual intercourse before the age of 14 years. There was a significant difference by age (73% among younger vs 35% among older students). About 6% of students reported that they had sexual intercourse with two or more persons in their life. There were significant differences by sex (10% among males vs 1.6% among females) and age (4% among younger vs 8% among older students). Significantly more boarding school students than day scholars reported having ever had sexual intercourse (18% vs 13%) and multiple-partner sex (7% vs 5%). However, there were no significant differences by rural–urban and type of students with respect to having the first sexual intercourse before 14 years of age and the number of partners.
Sexual behaviours and HIV/AIDS at a glance
Percentage of students (13–17 years old) who:
Had ever had sexual intercourse 15.1 28 Initiated sexual activities at less than 14 years of age 49.4 Had multiple sexual partners 5.5 Used condom during last sexual intercourse 59.3 Had ever heard of HIV infection/ AIDS 86.3 Had been taught about HIV infection/ AIDS 66.2 Had ever talked with parents about HIV/ AIDS 45.4
Use of and access to contraceptives
Among the students who ever had sexual intercourse, during the last sexual intercourse, 76% had used a method of birth control (such as condoms, withdrawal, rhythm or birth control pills). About 60% of these students reported using a condom during the last sexual intercourse. There was a significant difference by age (50% among younger vs 65% among older students), but not by sex. About 36% reported using a birth control method other than condoms. There was a significant difference by age (28% among younger vs 41% among older students), but not by sex.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 The survey also assessed the accessibility of condoms by asking where the students were the most likely to get a condom if they wanted one. While the most common sources were found to be basic health units/hospitals (38.8%) and shops and pharmacies or medical stores (14.6%), about 42.5% of the students did not know where to get a condom if they wanted one.
3.5.2 Awareness of and attitude to HIV infection/ AIDS
Young people between the ages of 15 and 24 years are among the groups most vulnerable to HIV infection, accounting for more than half of those newly infected with HIV. Studies show that adolescents who begin sexual activity early are likely to have sex with more partners and with partners who have been at risk of HIV exposure, and are not likely to use condoms. In many countries, HIV infection and AIDS are reducing average life expectancy, overloading the health care system, leading to a decline in economic growth and development, and bringing down the number of those enrolled in school and the availability of teachers (14).
Overall, 86% of students reported that they had heard of HIV infection or the disease called AIDS. This was claimed by an almost equal proportion of males and females (84% and 88%, respectively). About two-thirds of the students (66.2%) reported that they had been taught in class about HIV infections or AIDS during 29 the current school year. There were no significant differences by age or sex. About 45.4% of students reported that they had talked about HIV/AIDS to their parents at some point. There were significant differences by sex (38% among males vs 52% among females) and age (43% among younger vs 48% among older).
Globally, there is widespread stigma and discrimination associated with HIV/AIDS. For the effective prevention and control of the HIV pandemic, it is of vital importance to address the stigma and discrimination, as well as the myths and misconceptions surrounding HIV.
The survey collected data to assess the students’ attitude towards HIV/AIDS. Overall, it is encouraging to note that 77.5% of students reported that they were willing to help, become friends with, or care for a person with HIV infection or AIDS. An almost equal proportion of males (75%) and females (80%) displayed such positive attitudes towards HIV/AIDS.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Table 10: Sexual behaviours and knowledge of HIV/AIDS among students of 13–17 years of age in GSHS Bhutan, 2016 Had sex- First ual inter- Ever sexual Ever Taught Ever had course talked to inter- heard about sexual with two Used parents course of HIV HIV inter- or more condomsa about before infection infection course persons HIV/ age of or AIDS or AIDS in their AIDS 14a life Gender (%) (%) (%) (%) (%) (%) (%) Male 22.5* 49.5 10.0* 60.0 84.1* 65.0 37.7* Female 8.8 46.9 1.6 58.5 88.3 67.4 52.2 Age 13–15 12.6* 73.1* 3.5* 50.3* 86.2 63.8 42.9* 16–17 17.9 35.2 7.7 64.5 86.3 68.9 48.3 Type of student Day scholar 13.0* 47.4 4.5* 60.9 86.2 65.7 43.8* Boarding 17.7 53.1 6.5 56.0 86.5 67.0 47.7 student 30 Total 15.1 49.3 5.5 59.3 86.3 66.2 45.4 (13–17) *Differences across groups are statistically significant at 95% confidence level. a For the first time among who had sexual intercourse.
3.6 Personal hygiene
Washing one’s hands properly, particularly before meals and after using the toilet, can significantly improve one’s health status and prevent infections, such asking infections, trachoma and diarrhoea. Dental hygiene reduces the risk of dental caries and periodontal disease, as well as that of respiratory tract infections. Behaviours related to hygiene may also be linked to mental health status, as psychological distress, low self-esteem and unhappiness may be associated with poor personal hygiene. The survey assessed oral and hand hygiene, and also elicited information on sources of safe drinking water in school.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Oral, hand hygiene and source of safe drinking water at a glance
Percentage of students (13–17 years old) who:
Cleaned or brushed their teeth ≥1 time/day 92.4 Never/rarely washed their hands before eating 3.7 Never/rarely washed their hands after using the toilet 4.2 Never/rarely used soap to wash hands 5.8 Had no access to safe drinking water in school 33.6 Had access to hand-washing facility after using toilets/latrines 91.5 Toilets/latrines never or rarely clean 8.5
3.6.1 Oral hygiene
Overall, 92% of students reported that they usually cleaned or brushed their teeth (one or more times a day during the 30 days before the survey). There were hardly any differences between males (91%) and females (94%); day scholars (92%) and boarding students (92%); and students in rural (91%) and urban schools (93%).
3.6.2. Hand-washing behaviours 31 Hand-washing is an effective method of primary prevention of diarrhoea and respiratory infections, including influenza. An estimated one million deaths annually from infectious diseases worldwide could be averted by improved hand hygiene practices.
In the GSHS 2016, a small percentage of students (3.7%) reported never or rarely washing their hands before eating (during the 30 days before the survey). There were no significant differences by sex or age. A similar proportion of students (4.2%) never or rarely washed their hands after using the toilet or latrine (during the recall period of 30 days before the survey). There were no significant differences by sex or age. In addition, 5.8% of students never or rarely used soap when washing their hands during the 30 days before the survey. More males (7.2%) than females (4.6%) were found to never or rarely use soaps when washing their hands.
The survey also collected information on safe drinking water facilities, such as filtered or boiled water, in schools. Overall, one-third of the students (33.6%) reported
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 having no access to safe drinking water in school. The non-availability of safe drinking water facilities varied between rural (26%) and urban schools (39%). The proportion of students who reported not having access to safe drinking water was much higher among day scholars (46%) than boarding students (16%).
Table 11: Oral hygiene and oral health among students of 13–17 years of age in GSHS Bhutan, 2016 Never/ Never/ Cleaned Never/rarely No source of rarely rarely used or brushed washed safe drinking washed soap when teeth ≥1 hands before water in hands after washing time/daya eatinga school using toileta handsa Gender (%) (%) (%) (%) (%) Male 90.9* 3.9 4.5 7.2* 33.3 Female 93.7 3.5 4.0 4.6 33.8 Age 13–15 92.3 3.7 4.1 5.1 37.1 16–17 92.5 3.7 4.3 6.6 29.7 Type of student Day scholar 92.4 3.8 4.1 5.5 45.7* 32 Boarding 92.3 Small N 4.2 6.0 16.2 student Total 92.4 3.7 4.2 5.8 33.6 (13–17) *Differences across groups are statistically significant at 95% confidence level. aOne or more times during the 30 days before the survey. Small N: Fewer than 100 students in this subgroup
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 4. Discussion
Over the past two decades, Bhutan has made great strides in advancing its development agenda in general and the health of its population in particular. Its success story with regard to development has been widely recognized, but a number of challenges continue to hinder the health of its adolescents. Bhutan has been constantly developing programmes for adolescent health and bringing out publications related to the subject since the introduction of its school health programme in 1984. The publications and programmes include the comprehensive school health promotion guidebook of 1998; the 2001 guidebook on the management of minor ailments in schools; national standards for youth-friendly health services (15), formulated in 2008; adolescent health programme, launched in 2010; national youth policy of 2011 (16) ;and national adolescent health strategic plan of 2013 (17).The latest are the suicide prevention action plan and the multisectoral national action plan for the prevention and control of NCDs in 2015 (18).
Despite all the efforts, some reports have shown that control over and improvement in critical areas of adolescent behaviour and health have proved elusive. According to the Bhutan population perspective plan 2010, knowledge of HIV/AIDS among the youth was poor, with 30% of out-of-school individuals believing that 33 AIDS can be cured. The report also stated that crime related to drug/narcotics had increased from 23 cases in 2001 to 60 in 2005, and reflected an increase in substance abuse (19). Further, a report published by the National Statistics Bureau showed that 28% of 10–19-year-olds felt lonely, about 15% felt worried, 4% reported having had suicidal ideation, and 4% had attempted suicide. The report also highlighted that 64% had consumed alcohol in the past month, 43% drank the alcohol brewed at home and 19% got it from friends and relatives. Twenty-nine per cent of young people reported drinking heavily for a good part of their lives; about 6% reported that they had used drugs at some point; and about 75% said they had started using drugs at 10–19 years of age (20).
In 2009, a study using mixed methods, combining qualitative and quantitative aspects, was carried out to understand the behaviours and needs of vulnerable and at-risk adolescents (n=400) of the age of 13–18 years in Bhutan. The study reported that 36% of the respondents were sexually active. Sixty-nine per cent of the males had used condoms during the last sexual encounter. The study also found that 22% smoked cigarettes daily, 20% consumed alcohol and 18% smoked marijuana.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 The same study reported that 52% were bullied and 16% were involved in physical fights (21).
4.1 Nutritional status
In this survey, over-nutrition was found to be a major problem among adolescents, with about 11.4% being overweight –a figure higher than that of most countries in the region. A comparison between Bhutan and three relevant countries (Nepal, Myanmar and Sri Lanka) of the key indicators from the latest available GSHS data on 13–17-year-olds revealed that with regard to nutrition, Bhutan had the lowest prevalence of underweight but the highest prevalence of overweight (22–24). According to an analysis of the GSHS data for 13–15-year-olds for eight Asian countries, the prevalence of overweight or obesity was the highest in Brunei (36%), followed by Malaysia (24%), the Philippines (10%), Thailand (9%), Indonesia (7%), Vietnam (6%), Cambodia (4%) and Myanmar (3% – the lowest) (25). This shows that Bhutan has made remarkable progress in controlling the problem of underweight among adolescents.
Although undernutrition did not seem to be a problem among this study population, the 2008 National Nutrition Survey found that 34.9% of Bhutanese
34 preschool children were stunted, 10.4% were underweight, 4.7% were wasted, and 4.4% were overweight. Similar rates were noted later in the Bhutan Multiple Indicator Survey, 2010: stunting (34%), underweight (13%). However, the latest National Nutrition Survey 2015 estimated much lower prevalence rates of stunting (21.2%), underweight (9%), and wasting (4.3%) showing major improvements in the nutritional status of Bhutanese children over the past two decades (26). The problem of undernutrition may progress from childhood into adolescence and cause health problems while the child is growing up (27). Therefore, it is important to reduce the burden of undernutrition among young children as well.
According to the 2015 Global Nutrition Report, Bhutan is currently off course – although some progress has been made in achieving the global World Health Assembly targets for reducing stunting, wasting and overweight among children under the age of five years and anaemia among women of reproductive age (28).
A systematic review of South Asian countries identified the factors responsible for overweight and obesity among adolescents as lack of physical activity, watching television/playing computer games for a prolonged time, frequent consumption of fast food/junk food and frequent consumption of calorie-dense food items (29). A report on adolescent nutrition in the South-East Asian countries identified a number of
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 strategies for improving the nutritional status of adolescents – food-based strategies, addressing modification of diet and sedentary life-style, school-based interventions for nutrition, social marketing, behavioural change through communication, mobilization of the family and community, control of micronutrient deficiencies, nutrition assessment of adolescents, intersectoral linkages at the community level and linkages to adolescent-friendly health services (30). These need to be taken into account while planning initiatives for adolescent health in Bhutan.
4.2 Dietary behaviours and physical activity
WHO recommends that a healthy diet should include fruits and vegetables (at least 400g of fruits and vegetables a day), legumes, nuts and whole grains. In this survey, only 32–42% of adolescents reported regularly eating fruits and vegetables. What is more worrisome is that almost half of the students reported consuming carbonated soft drinks one or more times a day. WHO recommends that the intake of free sugars be restricted to less than 10% of the total energy intake to make for a healthy diet, and be further limited to 5% for additional health benefits. Sugary, sweetened beverages, led by carbonated drinks, are the leading source of free sugars consumed by young people. Fast food outlets, too, often provide foods and beverages high in fat, sugar, salt and energy. 35 A comparison between Bhutan and three low to middle-income South-Asian countries (Nepal, Myanmar and Sri Lanka), using the latest available GSHS data on 13–17-year-olds, revealed that fruit consumption in Bhutan was similar to that in Sri Lanka. Vegetable consumption was much lower than in Sri Lanka but comparable to that in Myanmar. The consumption of carbonated drinks was among the highest, as was the case with Myanmar.
The proportion of those who engaged in adequate physical activity on all 7 days of the week was comparable in the four countries. Bhutan, together with Sri Lanka, had among the highest figures for those who sit for more than three hours in a day. An analysis of the GSHS data collected between 2007 and 2013 on 13–15-year-olds in seven Asian nations showed that the prevalence of physical activity (on less than 5 days per week) was 80%, the highest being in Cambodia (91%).The prevalence in the rest of the countries (Indonesia, Malaysia, Myanmar, the Philippines, Thailand, Vietnam) was between 75% and 86%.The prevalence of sedentary behaviour (sitting for more than 3 hours a day) was 33%, the highest being in Malaysia (43%) and the lowest in Cambodia and Myanmar (11%).The prevalence reported by the rest of the countries was between 33% and 40% (31).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 As shown by the survey findings, the dietary habits and pattern of physical activity, along with the relatively high prevalence of obesity, are harbingers of a future burden of NCDs and should be taken seriously. National school health programmes could play a major role in promoting healthy dietary habits and physical activity among the youth. Regular physical activity should be encouraged right from childhood, as patterns of physical activity acquired during childhood and adolescence are more likely to be maintained throughout a person’s lifespan (32).
4.3 Tobacco, alcohol and substance use
A comprehensive ban on the sale of tobacco products (both smoked and smokeless forms) has been in force in Bhutan since 2004. Comprehensive provisions for a smoke-free country were put in place in 2005. These initiatives for tobacco control were further strengthened through the enactment of the Tobacco Control Act 2010, which provides a comprehensive legal framework for the implementation of tobacco control policies and prohibits the cultivation, manufacture, distribution and sale of tobacco products (both smoked and smokeless forms) within Bhutan. A comparison between Bhutan and three relevant countries (Nepal, Myanmar and Sri Lanka), using the latest available GSHS data on 13–17-year-olds, revealed that Bhutan had the second highest prevalence of the use of any kind of tobacco (Nepal having the 36 highest), but it had the highest prevalence of cigarette smoking.
According to the Global Youth Tobacco Survey, which measures tobacco use among 13–15-year-old school students, the prevalence of current tobacco use increased from 33.5%% in 2006 to 39.0% in 2013 among boys and from 13.3 in 2006 to 23.2% in 2013 among girls. It was suggested that the main reason for this rise was an increase in the use of smokeless tobacco. According to the GYTS 2013 survey, 14.0% of students reported currently smoking cigarettes and more boys than girls smoked (23.1% vs 6.6%). Exposure of students to second hand smoke (SHS) fell significantly in homes, from 30% to 15.3%, and fell from 50% to 43% in public places. However, over half of the students (51.3%) were exposed to SHS inside and outside the school property. In the GSHS 2016survey, a significantly higher proportion of day scholars (54%) than boarding school students (44%) reported exposure to SHS. The policy initiated earlier for “tobacco-free schools” has been somewhat effective, but needs to be strengthened and implemented to further improve the situation. Though the sale of tobacco products is strictly banned by law in Bhutan, 54.5% of student smokers reported that they obtained tobacco products from stores, shops or street vendors (33).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 The Eleventh Five-Year Plan (2013–2018) envisions a 20% reduction in the prevalence of tobacco use among adolescents and the youth. It also aims to identify various cessation measures and establish cessation services in all district hospitals, and to intensify its efforts to eliminate the illicit trade and sale in tobacco and tobacco products in the country (34). In addition, the Royal Government of Bhutan will continue to implement the total bank on sale, promotion and use of tobacco products in public places.
While Bhutan scores very high on the MPOWER progress report according to the WHO Report on the Global Tobacco Epidemic, 2015, gaps in the implementation of laws remain (35).
Alcohol consumption among the Bhutanese youth remains high. According to the ATLAS of Substance Use Disorders, Bhutan does not have an adequate mechanism for the collection of data on alcohol and drugs, but it has endorsed a National Policy to Reduce Harmful Use of Alcohol and the policy framework has been since fully implemented. In addition, there are programmes for diverting clients away from the criminal justice system towards treatment and treatment services for alcohol and drug abuse are now made available in all the health facilities including BHU Grade II (primary health centres) with referral mechanisms for tertiary care. There are community-based programmes for the prevention of alcohol and drug use, as well as for harm reduction, initially started in a few priority districts, but now have been 37 expanded to all the 20 districts. Although the sale of home-made alcohol is prohibited in Bhutan, many homes in the rural areas produce alcohol, the most common types being spirits (ara), and wines (changkoe, singchang and bangchhang). These are brewed from cereals, such as maize, rice, wheat and millet, and sometimes, fruits. Bhutan may have the highest per capita alcohol consumption among the South-East Asia member countries, but the data on the patterns of alcohol consumption at the community level are inadequate (36).
In a study conducted among eight sub districts of Trashiyangtse in Bhutan in 2010, the prevalence of alcohol consumption among young adults was reported to be 19.7% (14% among females and 23%among males), and the annual per capita consumption of alcohol was 5,442g and 2,566g among men and women, respectively. The main reasons for alcohol abuse in this study population seemed to be the production of home-made alcohol and drinking at home in the belief that alcohol has medicinal effects (37). An analysis of 13–15-year-olds from 12 developing countries around the world, using the GSHS data, found that the prevalence of alcohol consumption in the past 30 days was about 40–60% in Seychelles, St Vincent, St Lucia, Grenada
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 and Trinidad, 10–20% in Botswana, Thailand, Kenya, the Philippines and Uganda, and 2–3% in Myanmar and Indonesia (38).
With regard to drug use, A UNICEF report on Bhutan revealed that about 80% of drug users were young persons of the age of 13–24 years and about 40% of them were students. The same report also mentioned that the number of substance abusers has been increasing consistently since 2001. Several measures have been suggested to reduce the problem of drug use among the Bhutanese youth. These include enhancing their participation and engagement in social and civic life, investing in after-school programmes, programmes for mentoring, building skills and providing training for jobs, and promoting intersectoral coordination between various ministries, such as education, employment, health and sports, and community leaders, parents and youth groups (39). A comparison between Bhutan and three other South-Asian countries (Nepal, Myanmar and Sri Lanka), using the latest available GSHS data on 13–17-year-olds (15–17),revealed that the prevalence of alcohol and marijuana abuse was the highest in Bhutan, by a large margin. The current alcohol use prevalence as measured in latest GSHS surveys was 24.2% (Bhutan), 4.6% (Myanmar), 5.1% (Nepal) and 3.2% (Sri Lanka). Similarly the current marijuana use prevalence in Bhutan, Myanmar, Bhutan and Sri Lanka was 12.0% (Bhutan), 1.1 % (Myanmar), 2.6% (Nepal) and 2.6% (Sri Lanka). Marijuana grows prolifically in Bhutan and this may be one of the reasons for its high use in Bhutan. 38 4.4 Mental health
Mental health problems have complex multidirectional interactions with many other risks to which the youth is susceptible, including interpersonal violence, tobacco and alcohol use, and substance abuse. Bullying others and being bullied by others are common among adolescents with mental health problems. In the absence of proper support systems, young people run a great risk of developing mental health problems, abusing substances, dropping out of school and engaging in violent behaviour. Every year, millions of adolescents attempt suicide worldwide (40).
Adolescents need protection and support from their parents, schools and peers for their physical, mental and social well-being. According to the WHO’s report on balancing protective factors and risks for adolescents, depression was found to be less common among students who had a positive relationship with their teachers and positive attitudes towards school.
A comparison between Bhutan and three other small South Asian countries with recent GSHS survey (Nepal, Myanmar and Sri Lanka), using the latest available GSHS
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 data for 13–17-year-olds of (15–17), revealed that Bhutanese adolescents reported comparable prevalence of loneliness, feeling worried, , attempted suicide and lack of close friends. In addition, the indicators for parental engagement were similar to those of the other countries.
According to the 2014 mental health atlas (41), the burden of mental disorders in Bhutan was 2350 DALYs per 100,000 and the suicide rate was 17.8 per 100,000. The government launched a three-year action plan for the prevention of suicide in Bhutan (18).The plan’s overarching purpose was stated to be to promote, coordinate and support appropriate intersectoral action plans and programmes for the prevention of suicidal behaviours at the national and community levels. The report charts a pathway for understanding the pitfalls in the suicide prevention programmes running in the country and suggests ways to overcome them. It lays down clear objectives, responsibilities, and monitoring and evaluation plans to make sure that the plan remains on track. Hopefully, this plan will meet its objectives in time. Bhutan has also launched and implementing a National Mental Health Strategy now.
An analysis of the GSHS data on 13–15-year-olds from seven Asian countries showed that the prevalence of suicidal ideation was about 12.3%, and was significantly higher among girls (15.1%) than boys (9.3%) (42). Another analysis of 12 developing countries around the world, using the GSHS data on 13–15-year-olds, found that the prevalence of sleeplessness in the past 12 months was about 70–80% 39 in Indonesia and the Philippines, 57–70% in Seychelles, St Vincent, St Lucia, Grenada, Trinidad, Botswana, Thailand, Kenya and Uganda, and 36% in Myanmar (38).
A number of findings were reported by a qualitative study in which focus group discussions (FGDs) were conducted among adolescents, students, leaders and parents in Bhutan. The adults felt that suicide among school students was influenced by rapid economic and social changes, modernization and westernization, and the competitive education system. Collaboration between schools and parents was recognized as a requisite for the care of students. The students said that the fear of ruthless academic pressure in school, the disintegration of the family, and their parents’ academic expectations of them were important factors leading to suicidal ideation. The study made recommendations to the MoE and suggested that school guidance counsellors play a major role in the prevention of suicide among students (43).
WHO’s report on protective factors affecting adolescents’ reproductive health in developing countries showed that school attendance was related to the prevalence of several health risk behaviours, including violence and sexual risk behaviours (44). Bonding and connection with the parents was associated with lower levels of
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 depression and suicidal ideation, alcohol use, sexual risk behaviours and violence. In this survey, a little more than one-quarter of the respondents reported missing school without permission and more than half reported adequate parental engagement in their activities, indicating fair family support systems. Future surveys must explore the reasons for students missing school without permission.
The present survey showed that only 40% of students viewed other students in their school as helpful most of the time or always. Interaction with one’s peers and support from friends are always important for an adolescent. Isolation leads to loneliness and other mental problems. Young people who are social outcasts have more problems with their physical and emotional health. The school authorities and teachers should encourage supportive and respectful relationships among students to ensure the physical, mental and social well-being of adolescents in schools.
School is the most important setting outside of the family, and sometimes in spite of the family, for many adolescents. Positive relationships with teachers and peers have been shown to reduce risky sexual behaviours, the incidence of drug abuse and mental health issues, such as depression, and improve the ability to deal with stressful life situations (10,40).
4.5 Violence and injuries 40 Injuries and violence, particularly road traffic injuries and interpersonal violence, are a leading cause of death among adolescents and young people, and should form an important part of the development of school health programmes. Adolescents are more prone than others to be involved in violence and physical attacks and fights. This survey found that more than two-thirds of the students had been physically assaulted at least once in the past year, and a quarter reported having been bullied. Apart from physical injuries, bullying can lead to mental health problems, including stress, deterioration in academic performance, a high risk of substance abuse, aggressive behaviour and suicide attempts. Nearly 246 million children worldwide are bullied in school and the prevalence of such bullying varies from 10–65% across various countries. An example of child protection activities in Bhutan is the UNICEF initiative of setting up child protection mechanisms in monasteries, where over 4000 Bhutanese children study and grow up (45).
A comparison between Bhutan and three relevant countries (Nepal, Myanmar and Sri Lanka) (15–17), using the latest GSHS data available on 13–17-year-olds,revealed that Bhutan had the highest number of adolescents who had been physically attacked, among the highest number of those who had got into a physical fight (similar to Sri
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Lanka), and the highest number of those who had sustained a serious injury. However, on the other hand, the prevalence of bullying at school was the lowest in Bhutan.
Using nationally representative GSHS data, a study examined the prevalence of physical fighting among the youth in 27 countries and cities, and reported that the prevalence varied from 58% in Djibouti to 16% in Myanmar. As for the Asian countries, the prevalence was 17% in China, 33% in Thailand, 34% in Indonesia, 47% in Sri Lanka and 50% in the Philippines (46).
According to the 2014 Global status report on violence prevention, Bhutan had national action plans for the prevention of violence among the youth, and laws against bringing weapons into the school premises and against gang memberships. However, there was no programme to provide high-risk youth with incentives to complete their schooling to de-concentrate poverty. Also, there was limited implementation of programmes on pre-school enrichment, training in life skills and social development, mentoring, after-school supervision and prevention of bullying in school. There were no national survey data on non-fatal violence among the youth (47).
The GSHS data on 13–15-year-old students in Indonesia, Myanmar, Sri Lanka and Thailand were analysed by a study, which reported that the prevalence of one or more serious injuries was 42.2% in all countries, ranging from 27.0% in Myanmar to 46.8% in Thailand. The prevalence was greater among boys (50.5%) than girls 41 (34.3%) (48).
Unintentional injuries are a major cause of death and disability among young children. Injury is highly associated with age and gender –the rate of death due to injury is 60% higher among males of 10–14 years of age than females, while it is higher among those of the age of 15–19 years than those of the age of 10–14 years. Global data show that the homicide rate for males of the age of 15–17 years is 9 per 100,000. Many unintentional injuries lead to permanent disability and brain damage. Victims of bullying suffer from an increased level of stress and their ability to concentrate becomes relatively low. Further, the risk of their abusing substances, behaving aggressively and attempting suicide is increased (12,13,47,49).
4.6 Sexual behaviours and HIV/AIDS awareness
According to the annual health bulletin of 2016, the prevalence of HIV among 15–19-year-olds has been consistently below 0.1%. The proportion of the population of the age of 15–24 years with a comprehensive knowledge of HIV/AIDS was just 20% (50).
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 According to the Bhutan Multiple Indicator Survey, 2010, about 15% of girls of the age of 15–19 were married and 70% of young women of the age of 15–24 years accepted domestic violence as the norm. In the latter age group, only 21% had a comprehensive knowledge of HIV/AIDS. Among women between the age of 20 and 24 years, 15% had had a live birth before the age of 18 years. Child marriage is a violation of child rights, compromising the development of girls and often resulting in premature pregnancy and social isolation (27).
A study conducted among 15–49-year-olds in two rural districts of Bhutan reported that about 31% of the respondents had engaged in sex with a non-regular partner in the past year. The prevalence of condom use was just 49%. Most of the respondents reported that they had their first sexual intercourse between 15 and 24 years of age, and in about 14% of cases, the age reported was below 15. This study also reported that the group of students’ knowledge of STI was poor (51).
In 2006, an exploratory study on HIV/AIDS was conducted among 1312 out- of-school youth, of the age of 15–24 years, in Bhutan. Among the respondents, 80% knew about HIV/AIDS but misconceptions about the transmission of HIV were common. More than half (58%) of those surveyed had had sex. The mean age for sexual initiation was 16 years for males and 18 years for females. Overall, the preferred source of information and messages on health were health workers (43%), although 42 the rural youth found it difficult to interact with health workers when it came to the subject of reproductive and sexual health problems (52).
The respondents in this survey had a high level of knowledge of HIV/AIDS and nearly two-thirds reported being taught about HIV in school. A comparison between Bhutan and three relevant countries (Nepal, Myanmar and Sri Lanka), using the latest GSHS data available on 13–17-year-olds, revealed that the indicators for Bhutan were comparable to those of the others.
4.7 Hygiene
Sanitation and basic hygiene are a must for adolescent health. Globally, almost 2 million children and adolescents die of diarrhoeal diseases every year and half of these cases can be easily prevented through effective education on hygiene and hand- washing. Inadequate oral health care can lead to dental caries, which are prevalent in 60–90% of children in the developing countries. Poor personal hygiene can lead to worm infestations, which affect nearly 400 million school-aged children globally, and can adversely affect growth and development.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 The current survey showed that Bhutan’s school going adolescents had relatively good habits so far as personal hygiene is concerned. More than 90% brushed their teeth regularly and had satisfactory hand-washing behaviours. However, one-third of the students reported lack of access to a source of safe water for drinking such as filtered or boiled water at the school. A comparison between Bhutan and three relevant countries (Nepal, Myanmar and Sri Lanka) (15–17), on the basis of the latest GSHS data available on 13–17-year-olds,showed that the hand and dental hygiene practices of Bhutanese adolescents were comparable to those of adolescents in the other countries. A study that compared GSHS data on 13–15-year-olds from four Asian countries (India, Indonesia, Myanmar and Thailand) found that 22% brushed their teeth twice a day;45% did not wash their hands before eating; 27% did not wash their hands after using the toilet; and 60% did not washing their hands with soap (53).
According to the Annual Education Statistics 2016, (1) only about 88% of schools in the country have access to improved water sources, such as piped water supply and protected springs, and only about 65% have improved sanitation facilities. Also, only about 73% of middle and higher secondary schools have trained school health coordinators.
In October 2017, a nationwide survey among school children revealed an overall prevalence of any soil-transmitted helminthic infection at just 1.4%. This is a 43 substantial improvement since 2003, when a similar survey done in selected schools of the western region of Bhutan revealed the overall prevalence of STH at16.5% (54). This shows that the STH control programme involving regular mass deworming has been very successful in controlling the STH infections. However, in order to control or prevent possible prevalence rebound, it is of immense importance to provide access to improved water sources and improved sanitation facilities in all schools, mostly focused towards rural schools.
4.8 Limitations
This study has captured the health risk behaviours of only school-going adolescents, whereas any policy for the whole group of adolescents must take into account the vulnerability of out-of-school adolescents, who undoubtedly run greater risks than their school-going counterparts. The data are self-reported and not validated by direct observations or any other means.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 5. Recommendations
The GSHS has yielded nationally representative findings on specific health behaviours and risk factors among 13–17-year-old school-going adolescents in Bhutan. The results may be used to prioritize and inform policies, and develop programmes and services targeted at adolescents. It is of the utmost importance to remember that the GSHS only captures the behaviours of school-going adolescents and any policy for the whole group of adolescents must take into account the vulnerability of out-of-school adolescents, who are undoubtedly at a higher risk than their school-going peers.
The following recommendations have been made on the basis of the findings of the GSHS Bhutan, 2016.
1. Strengthen policies and programmes to control tobacco, alcohol, doma and pan masala use focusing specifically on adolescents, considering the progressively increasing prevalence of tobacco use and other NCD risk factors among adolescents. 2. Promote healthy diet focusing on improved food diversity in schools. 3. Promote physical activity and encourage schools to make use of the time 44 allocated for PE classes, abiding by the MoE’s policy of reserving 50 minutes a week for PE. 4. Strengthen the School Parent/Guardian Education Awareness Programme to address health and behavioural needs of the children. 5. Local Governments to integrate the promotion of mental health, and reduction in the risk factors for NCDs in their sectoral plans and programmes., 6. Further strengthen comprehensive sex education in schools, focusing on sexually transmitted diseases and unintended pregnancies. . 7. Encourage schools to strengthen programmes for mental health and appropriate referral of children. Strengthen reporting mechanism bullying and monitoring of strict implementation of Strengthen, implement and monitor a zero tolerance policy to bullying in schools. Consider establishing a national micro-data repository for the purpose of cataloguing and archiving data from all the large-scale surveys conducted in the country to ensure their long-term use to study the trends in core health indicators.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 8. Promote sustainable development of national capacity in analysis of large- scale survey data through the involvement of local universities. 9. Consider carrying out an in-depth analysis of the prevalence of tobacco use and other priority areas in Bhutan using the data available from multiple sources. 10. Conduct School-based Student Health Survey at regular intervals (every 3-5 years) as per the national strategy and action plan for prevention and control of NCDs.
45
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 References
1. Ministry of Education, Royal Government of Bhutan. Annual education statistics 2016. Thimphu, 2016. http://www.education.gov.bt/documents/10180/12664/ Annual+Education+Statistics+2016.pdf/8dc6828d-4de3-4e57-bc8c- 0f6e9930422e?version=1.0 - accessed 1 November 2017. 2. Warburton DER, Nicol CW, Bredin SSD. Health benefits of physical activity: the evidence. Can Med Assoc J. 2006 Mar 14;174(6):801–9. 3. World Health Organization, 2003, Physical activity – Information sheet, Global strategy on diet, physical activity and health http://www.who.int/dietphysicalactivity/ media/en/gsfs_pa.pdf - accessed 1 November 2017. 4. Guha N et al, Betel quid chewing and the risk of oral and oropharyngeal cancers: a meta-analysis with implications for cancer control. Int J Cancer. 2014 Sep 15;135(6):1433-43. doi: 10.1002/ijc.28643. Epub 2014 May 14. 5. World Health Organization. The World Health Report 2002—Reducing Risks, Promoting Healthy Life. Chapter 4. Geneva http://www.who.int/whr/2002/en/ whr02_ch4.pdf - accessed 1 November 2017. 6. World Health Organization. Global Status Report on Alcohol 2004. Geneva, 2004. http://www.who.int/substance_abuse/publications/global_status_report_2004_ overview.pdf - accessed 1 November 2017. 7. Poikolainen K, Tuulio-Henriksson A, Aalto-Setälä T, Marttunen M, Lönnqvist J. 46 Predictors of alcohol intake and heavy drinking in early adulthood: a 5-year follow- up of 15-19-year-old Finnish adolescents. Alcohol Alcohol. 2001 Feb;36(1):85–8. 8. Facy F, La place de lalcool dans la morbidite et mortalite des jeunes in Acts du colloque les jeunes et Lalcool en Europe, 2010. 9. Currie C, Hurrelmann K, Settertobulte W, Smith R, Todd J, eds., Health and Health Behaviour Among Young People. WHO Regional Office for Europe, 2002. 10. World Health Organization Regional Office for Europe. Health and health behaviour among young people. WHO policy series: health policy for children and adolescents. Issue 1. Copenhagen, 2000. http://www.euro.who.int/__data/assets/ pdf_file/0006/119571/E67880.pdf - accessed 1 November 2017. 11. BK, Barber, Regulation, connection, and psychological autonomy: Evidence from the Cross National Adolescent Project (C-NAP), 2002. 12. World Health Organization. Child and adolescent injury prevention : a global call to action. Geneva, 2005. http://apps.who.int/iris/bitstream/10665/43279/1/9241593415_ eng.pdf - accessed 1 November 2017. 13. Anti-Bullying Centre, Trinity College. School bullying: key facts. Dublin, 2002. - accessed 1 November 2017. 14. UNAIDS. Global AIDS update 2016. Geneva, 2016. http://www.unaids.org/sites/default/ files/media_asset/global-AIDS-update-2016_en.pdf - accessed 1 November 2017.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 15. Ministry of Health, Royal Government of Bhutan. National standards and implementation guide for youth friendly health services. Thimphu, 2009. https:// www.mindbank.info/item/4435 - accessed 1 November 2017. 16. Ministry of Education, Royal Government of Bhutan. National youth policy. Thimphu, 2011. http://www.youthpolicy.org/national/Bhutan_2011_National_Youth_Policy. pdf - accessed 1 November 2017. 17. Ministry of Health, Royal Government of Bhutan. National adolescent health strategic plan 2013-2018. Thimphu, 2013. https://www.mindbank.info/item/4434 - accessed 1 November 2017. 18. Royal Government of Bhutan. Suicide prevention in Bhutan a three year action plan (2015-2018).Thimphu: Royal Government of Bhutan; 2015 http://www.searo.who. int/bhutan/suicide_action_plan.pdf - accessed 1 November 2017. 19. Gross National Happiness Commission, Royal Government of Bhutan. Bhutan population perspective plan: goals and strategies. Thimphu, 2010. http://www. gnhc.gov.bt/en/wp-content/uploads/2017/05/Population-Perspective-Plan.pdf - accessed 1 November 2017. 20. National Statistics Bureau, Royal Government of Bhutan. Crime and mental health issues among young Bhutanese people. Thimphu, 2015. http://bhutan.unfpa.org/ sites/default/files/pub-pdf/CRIME%20AND%20MENTAL%20HEALTH.pdf - accessed 1 November 2017. 21. Ministry of Education, Royal Government of Bhutan, The Nossal Institute for Global Health, University of Melbourne, Centre for Research Institute, Unicef Bhutan. An assessment of vulnerable and at-risk adolescents (13-18 years) in Bhutan: exploring social 47 and health risk behaviours. Thimphu, 2011. http://www.aidsdatahub.org/sites/default/ files/publication/Bhutan_At_Risk_Assessment_2011.pdf - accessed 1 November 2017. 22. Ministry of Health and Sports, Union of Myanmar. Global school-based student health survey: Myanmar 2016 fact sheet. Naypyidaw, 2016. http://www.who.int/ chp/gshs/factsheets/en/ - accessed 1 November 2017. 23. Ministry of Health, Government of Nepal. Global school-based student health survey: Nepal 2015 fact sheet. Kathmandu, 2015. http://www.who.int/chp/gshs/ factsheets/en/ - accessed 1 November 2017. 24. Ministry of Health, Nutrition and Indigenous medicine, Government of Sri Lanka. Global school-based student health survey: Sri Lanka 2016 fact sheet. Colombo, 2016. http://www.who.int/chp/gshs/factsheets/en/ - accessed 1 November 2017. 25. Pengpid S, Peltzer K. Overweight, obesity and associated factors among 13-15 years old students in the association of southeast Asian nations member countries, 2007-2014. Southeast Asian J Trop Med Public Health. 2016 Mar;47(2):250–62. 26. Zangmo U, de Onis M, Dorji T. The nutritional status of children in Bhutan: results from the 2008 National Nutrition Survey and trends over time. BMC Pediatr. 2012 Sep 19;12:151. 27. National Statistics Bureau, Royal Government of Bhutan. Bhutan multiple indicator survey 2010. Thimphu, 2011. http://www.aidsdatahub.org/sites/default/files/ documents/MICS_Bhutan_2010.pdf - accessed 1 November 2017.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 28. International Food Policy Research Institute. Global nutrition report 2015: actions and accountability to advance nutrition and sustainable development. Washington, DC, 2015. http://ebrary.ifpri.org/utils/getfile/collection/p15738coll2/id/129886/ filename/130097.pdf - accessed 1 November 2017. 29. Mistry SK, Puthussery S. Risk factors of overweight and obesity in childhood and adolescence in South Asian countries: a systematic review of the evidence. Public Health. 2015 Mar;129(3):200–9. 30. World Health Organization Regional Office for South-East Asia. Adolescent nutrition: a review of the situation in selected South-East Asian countries. New Delhi, 2006. http://www.searo.who.int/entity/child_adolescent/documents/sea_nut_163/en/ - accessed 1 November 2017. 31. Peltzer K, Pengpid S. Leisure Time Physical Inactivity and Sedentary Behaviour and Lifestyle Correlates among Students Aged 13-15 in the Association of Southeast Asian Nations (ASEAN) Member States, 2007-2013. Int J Environ Res Public Health. 2016 Feb 15;13(2):217. 32. World Health Organization. Global recommendations on physical activity for health. Geneva, 2010. http://www.who.int/dietphysicalactivity/ publications/9789241599979/en/ - accessed 1 November 2017. 33. World Health Organization, Regional Office for South-East Asia. Global youth tobacco survey (GYTS): Bhutan report 2013. New Delhi, 2015. http://apps.who. int/iris/bitstream/10665/164336/1/9789290224808-GYTS-TFI.pdf - accessed 1 November 2017. 34. Gross National Happiness Commission, Royal Government of Bhutan. Eleventh five 48 year plan - main document volume I (2013-2018). Thimphu, 2013. http://www. gnhc.gov.bt/12rtm/wp-content/uploads/2013/10/Eleventh-Five-Year-Plan-Volume- I-Final.pdf - accessed 1 November 2017. 35. World Health Organization. WHO report on the global tobacco epidemic, 2015: raising taxes on tobacco. Geneva, 2015. http://www.who.int/tobacco/surveillance/ policy/country_profile/btn.pdf - accessed 1 November 2017. 36. Ministry of Health, Royal Government of Bhutan. Annual health bulletin 2011. Thimphu, 2011. http://www.health.gov.bt/wp-content/uploads/ftps/annual-health- bulletins/Annual%20Health%20Bulletin-2011/ahbContent2011.pdf - accessed 1 November 2017. 37. Subady BN, Assanangkornchai S, Chongsuvivatwong V. Prevalence, patterns and predictors of alcohol consumption in a mountainous district of Bhutan. Drug Alcohol Rev. 2013 Jul;32(4):435–42. 38. Balogun O, Koyanagi A, Stickley A, Gilmour S, Shibuya K. Alcohol consumption and psychological distress in adolescents: a multi-country study. J Adolesc Health. 2014 Feb;54(2):228–34. 39. Unicef Bhutan. Protecting adolescents and youth in Bhutan from substance abuse. Thimphu, 2015. http://www.unicefbhutan.org.bt/wp-content/uploads/2015/10/7.- Protecting-Adolescent-and-Youth-in-Bhutan-from-Substance-Abuse.pdf - accessed 1 November 2017.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 40. World Health Organization. Broadening the horizon: balancing protection and risk for adolescents. Geneva, 2002. http://apps.who.int/iris/bitstream/10665/67242/1/ WHO_FCH_CAH_01.20.pdf - accessed 1 November 2017. 41. World Health Organization. Mental health atlas 2014. Geneva,, 2015. http://www. who.int/mental_health/evidence/atlas/profiles-2014/btn.pdf?ua=1 - accessed 1 November 2017. 42. Peltzer K, Pengpid S. Suicidal ideation and associated factors among students aged 13-15 years in Association of Southeast Asian Nations (ASEAN) member states, 2007-2013. Int J Psychiatry Clin Pract. 2017 Mar 20;1–8. 43. Pelden S. Making sense of suicides by school students in Bhutan: documenting a societal dialogue. Australia: Curtin University, 2016. https://espace.curtin.edu.au/ bitstream/handle/20.500.11937/2393/246865_Pelden%202016.pdf?sequence=2 - accessed 1 November 2017. 44. Blum RW, Mmari KN. Protective factors affecting adolescent reproductive health in developing countries. Geneva: World Health Organization, 2004. http://apps. who.int/iris/handle/10665/43045 - accessed 1 November 2017. 45. United Nations Educational, Scientific and Cultural Organization. School violence and bullying: global status report. France, 2017. http://unesdoc.unesco.org/ images/0024/002469/246970e.pdf - accessed 1 November 2017. 46. Swahn MH, Gressard L, Palmier JB, Yao H, Haberlen M. The prevalence of very frequent physical fighting among boys and girls in 27 countries and cities: regional and gender differences. J Environ Public Health. 2013;2013:215126. 47. World Health Organization, United Nations Development Programme, United 49 Nations Office on Drugs and Crime. Global status report on violence prevention 2014. Geneva, 2014. http://www.who.int/violence_injury_prevention/violence/ status_report/2014/en/ - accessed 1 November 2017. 48. Peltzer K, Pengpid S. Injury and social correlates among in-school adolescents in four Southeast Asian countries. Int J Environ Res Public Health. 2012;9(8):2851–62. 49. World Health Organization. Global estimates of health consequences due to violence against children- background paper to the UN secretary-general’s study on violence against children. Geneva, 2005. 50. Ministry of Health, Royal Government of Bhutan. Annual health bulletin 2016. Thimphu, 2016. http://www.health.gov.bt/wp-content/uploads/ftps/annual-health- bulletins/Annual%20Health%20Bulletin-2016.pdf - accessed 1 November 2017. 51. Norbu K, Mukhia S, Tshokey. Assessment of knowledge on sexually transmitted infections and sexual risk behaviour in two rural districts of Bhutan. BMC Public Health. 2013 Dec 6;13(1):1142. 52. Unicef Bhutan. Exploratory study on HIV/AIDS issues among out-of-school youth in Bhutan. Thimphu, 2006. 53. Peltzer K, Pengpid S. Oral and hand hygiene behaviour and risk factors among in-school adolescents in four Southeast Asian countries. Int J Environ Res Public Health. 2014 Mar 7;11(3):2780–92. 54. Allen H, Sithey G, Padmasiri EA, Montresor A. Epidemiology of soil-transmitted helminths in the western region of Bhutan. Southeast Asian J Trop Med Public Health. 2004 Dec;35(4):777–9.
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Annex 1 Bhutan GSHS 2016 questionnaire
1. How old are you? The next 5 questions ask about your height, weight, and going hungry. A. 11 years old or younger B. 12 years old 5. How tall are you without your shoes on? ON C. 13 years old THE ANSWER SHEET, WRITE YOUR HEIGHT D. 14 years old IN THE SHADED BOXES AT THE TOP OF THE E. 15 years old GRID. THEN FILL IN THE OVAL BELOW EACH F. 16 years old NUMBER. G. 17 years old H. 18 years old or older Example Height (cm) 2. What is your sex? 1 5 3
0 0 0 A. Male 1 1 B. Female 2 2 2
3. In what class are you? 3
4 4
A. Class 7 5
50 B. Class 8 6 6 C. Class 9 7 7 D. Class 10 8 8 E. Class 11 9 9
4. What type of student are you? 9 I do not know
A. Day student B. Boarding student
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 1 of 13 Bhutan GSHS Questionnaire - 2016 6. How much do you weigh without your shoes on? The next 7 questions ask about what you might ON THE ANSWER SHEET, WRITE YOUR eat and drink. WEIGHT IN THE SHADED BOXES AT THE TOP OF THE GRID. THEN FILL IN THE OVAL 10. During the past 30 days, how many times per day BELOW EACH NUMBER. did you usually eat fruit, such as apples or oranges? Example Weight (kg) A. I did not eat fruit during the past 30 days B. Less than one time per day 0 5 2
0 0 C. 1 time per day D. 2 times per day 1 1 1 E. 3 times per day 2 2 F. 4 times per day 3 3 G. 5 or more times per day
4 4
5 11. During the past 30 days, how many times per day
6 6 did you usually eat vegetables, such as
7 7 cabbage, cauliflower, carrots, or broccoli?
8 8 A. I did not eat vegetables during the past 30 9 9 days I do not know 9 B. Less than one time per day C. 1 time per day D. 2 times per day 7. During the past 12 months, have your weight and E. 3 times per day height been measured at school? F. 4 times per day 51 A. Yes G. 5 or more times per day B. No 12. During the past 30 days, how many times per day 8. How do you describe your weight? did you usually drink carbonated soft drinks, such as Coca Cola, Pepsi, Fanta, or Sprite? (Do A. Very underweight not include diet soft drinks.) B. Slightly underweight A. I did not drink carbonated soft drinks during C. About the right weight the past 30 days D. Slightly overweight B. Less than one time per day E. Very overweight C. 1 time per day D. 2 times per day 9. During the past 30 days, how often did you go E. 3 times per day hungry because there was not enough food in F. 4 times per day your home or boarding school? G. 5 or more times per day
A. Never B. Rarely C. Sometimes D. Most of the time E. Always
2 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 13. During the past 7 days, on how many days did 16. During this school year, were you taught in any of you eat fast food such as samosas, instant your classes the benefits of healthy eating? noodles (maggi, wai wai, or chowmein), pizzas, potato chips, alu chops, chili chops, fish fries, A. Yes juma, or papad from restaurants, hotels, road B. No side food sellers, or canteens? C. I do not know A. 0 days B. 1 day The next 7 questions ask about cleaning your C. 2 days teeth and washing your hands. D. 3 days E. 4 days 17. During the past 30 days, how many times per F. 5 days day did you usually clean or brush your teeth? G. 6 days H. 7 days A. I did not clean or brush my teeth during the past 30 days 14. During the past 30 days, how many times per day B. Less than 1 time per day did you usually eat high protein foods from C. 1 time per day animals, such as beef, chicken, pork, fish, or D. 2 times per day eggs? E. 3 times per day F. 4 or more times per day A. I did not eat high protein foods from animals during the past 30 days 18. During the past 30 days, how often did you wash B. Less than one time per week your hands before eating? C. 1 time per week D. 2 times per week A. Never E. 3 times per week B. Rarely 52 F. 4 times per week C. Sometimes G. 5 or more times per week D. Most of the time E. Always 15. During the past 30 days, how often did you eat breakfast? 19. During the past 30 days, how often did you wash your hands after using the toilet or latrine? A. Never B. Rarely A. Never C. Sometimes B. Rarely D. Most of the time C. Sometimes E. Always D. Most of the time E. Always
20. Is there a place for you to wash your hands after using the toilet or latrine at school?
A. There are no toilets or latrines at school B. Yes C. No
3 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 21. During the past 30 days, how often were the The next question asks about sexual violence. toilets or latrines clean at your school? 25. Have you ever been forced to have sexual A. Never intercourse when you did not want to? B. Rarely C. Sometimes A. Yes D. Most of the time B. No E. Always The next question asks about physical fights. A 22. During the past 30 days, how often did you use physical fight occurs when two students of about soap when washing your hands? the same strength or power choose to fight each other. A. Never B. Rarely 26. During the past 12 months, how many times were C. Sometimes you in a physical fight? D. Most of the time E. Always A. 0 times B. 1 time 23. Is there a source of safe water for drinking at C. 2 or 3 times school such as filtered or boiled water? D. 4 or 5 times E. 6 or 7 times A. Yes F. 8 or 9 times B. No G. 10 or 11 times H. 12 or more times The next question asks about physical attacks. A physical attack occurs when one or more people hit or strike someone, or when one or more The next 3 questions ask about serious injuries 53 people hurt another person with a weapon (such that happened to you. An injury is serious when it as a stick, knife, or gun). It is not a physical attack makes you miss at least one full day of usual when two students of about the same strength or activities (such as school, sports, or a job) or power choose to fight each other. requires treatment by a doctor or nurse.
24. During the past 12 months, how many times were 27. During the past 12 months, how many times were you physically attacked? you seriously injured?
A. 0 times A. 0 times B. 1 time B. 1 time C. 2 or 3 times C. 2 or 3 times D. 4 or 5 times D. 4 or 5 times E. 6 or 7 times E. 6 or 7 times F. 8 or 9 times F. 8 or 9 times G. 10 or 11 times G. 10 or 11 times H. 12 or more times H. 12 or more times
4 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 28. During the past 12 months, what was the most 30. During the past 30 days, on how many days were serious injury that happened to you? you bullied?
A. I was not seriously injured during the past 12 A. 0 days months B. 1 or 2 days B. I had a broken bone or a dislocated joint C. 3 to 5 days C. I had a cut or stab wound D. 6 to 9 days D. I had a concussion or other head or neck E. 10 to 19 days injury, was knocked out, or could not breathe F. 20 to 29 days E. I had a gunshot wound G. All 30 days F. I had a bad burn G. I was poisoned or took too much of a drug 31. During the past 30 days, how were you bullied H. Something else happened to me most often?
29. During the past 12 months, what was the major A. I was not bullied during the past 30 days cause of the most serious injury that happened B. I was hit, kicked, pushed, shoved around, or to you? locked indoors C. I was made fun of because of my race, A. I was not seriously injured during the past 12 nationality, or color months D. I was made fun of because of my religion B. I was in a motor vehicle accident or hit by a E. I was made fun of with sexual jokes, motor vehicle comments, or gestures C. I fell F. I was left out of activities on purpose or D. Something fell on me or hit me completely ignored E. I was attacked or abused or was fighting with G. I was made fun of because of how my body someone or face looks 54 F. I was in a fire or too near a flame or H. I was bullied in some other way something hot G. I inhaled or swallowed something bad for me The next 7 questions ask about your feelings and H. Something else caused my injury friendships.
The next 2 questions ask about bullying. Bullying 32. During the past 12 months, how often have you occurs when a student or group of students say felt lonely? or do bad and unpleasant things to another student. It is also bullying when a student is A. Never teased a lot in an unpleasant way or when a B. Rarely student is left out of things on purpose. It is not C. Sometimes bullying when two students of about the same D. Most of the time strength or power argue or fight or when teasing E. Always is done in a friendly and fun way.
5 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 33. During the past 12 months, how often have you 38. How many close friends do you have? been so worried about something that you could not sleep at night? A. 0 B. 1 A. Never C. 2 B. Rarely D. 3 or more C. Sometimes D. Most of the time The next 10 questions ask about cigarette and E. Always other tobacco use.
34. During the past 12 months, how often have you 39. How old were you when you first tried a cigarette? been so worried about something that you wanted to use alcohol or other drugs to feel A. I have never smoked cigarettes better? B. 7 years old or younger C. 8 or 9 years old A. Never D. 10 or 11 years old B. Rarely E. 12 or 13 years old C. Sometimes F. 14 or 15 years old D. Most of the time G. 16 or 17 years old E. Always H. 18 years old or older
35. During the past 12 months, did you ever 40. During the past 30 days, on how many days did seriously consider attempting suicide? you smoke cigarettes?
A. Yes A. 0 days B. No B. 1 or 2 days C. 3 to 5 days 55 36. During the past 12 months, did you make a plan D. 6 to 9 days about how you would attempt suicide? E. 10 to 19 days F. 20 to 29 days A. Yes G. All 30 days B. No 41. During the past 12 months, have you ever tried to 37. During the past 12 months, how many times did stop smoking cigarettes? you actually attempt suicide? A. I have never smoked cigarettes A. 0 times B. I did not smoke cigarettes during the past 12 B. 1 time months C. 2 or 3 times C. Yes D. 4 or 5 times D. No E. 6 or more times
6 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 42. During the past 7 days, on how many days have 46. During the past 30 days, on how many days did people smoked in your presence? you eat rajnigandha, dildar, wiz or sakila?
A. 0 days A. 0 days B. 1 or 2 days B. 1 or 2 days C. 3 or 4 days C. 3 to 5 days D. 5 or 6 days D. 6 to 9 days E. All 7 days E. 10 to 19 days F. 20 to 29 days 43. At any time during the next 12 months, do you G. All 30 days think you will smoke a cigarette? 47. During the past 30 days, on how many days did A. Definitely not you eat Doma khamtog (areca nut, lime, and B. Probably not betel leaves) or meetha paan? C. Probably yes D. Definitely yes A. 0 days B. 1 or 2 days 44. If one of your best friends offered you a cigarette, C. 3 to 5 days would you smoke it? D. 6 to 9 days E. 10 to 19 days A. Definitely not F. 20 to 29 days B. Probably not G. All 30 days C. Probably yes D. Definitely yes 48. Which of your parents or guardians use any form of tobacco? 45. During the past 30 days, on how many days did 56 you use any tobacco products other than A. Neither cigarettes, such as baba, khaine, or raja? B. My father or male guardian C. My mother or female guardian A. 0 days D. Both B. 1 or 2 days E. I do not know C. 3 to 5 days D. 6 to 9 days E. 10 to 19 days F. 20 to 29 days G. All 30 days
7 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 The next 10 questions ask about drinking alcohol. 52. During the past 30 days, how did you usually get This includes drinking Ara, Bangchhang, the alcohol you drank? SELECT ONLY ONE Singchang, Changkoe, beer, whiskey, tongpa, or RESPONSE. wine. Drinking alcohol does not include drinking a few sips of wine for religious purposes. A A. I did not drink alcohol during the past 30 “drink” is a glass of wine, a bottle of beer, a small days glass of liquor, or a mixed drink. B. I bought it in a store, shop, or from a street vendor 49. How old were you when you had your first drink of C. I gave someone else money to buy it for me alcohol other than a few sips? D. I got it from my friends E. I got it from my family A. I have never had a drink of alcohol other F. I stole it or got it without permission than a few sips G. I got it some other way B. 7 years old or younger C. 8 or 9 years old 53. What type of alcohol do you usually drink? D. 10 or 11 years old SELECT ONLY ONE RESPONSE. E. 12 or 13 years old F. 14 or 15 years old A. I do not drink alcohol G. 16 or 17 years old B. Beer H. 18 years old or older C. Wine D. Spirits, such as whiskey, rum, or vodka 50. During the past 30 days, on how many days did E. Local alcoholic beverages like Ara, you have at least one drink containing alcohol? Bangchhang, or Sinchhang F. Tongpa A. 0 days G. Some other type B. 1 or 2 days C. 3 to 5 days 54. With whom do you usually drink alcohol? 57 D. 6 to 9 days E. 10 to 19 days A. I do not drink alcohol F. 20 to 29 days B. With my friends G. All 30 days C. With my family D. With persons I have just met 51. During the past 30 days, on the days you drank E. I usually drink alone alcohol, how many drinks did you usually drink per day? 55. Do your parents or guardians know that you drink alcohol? A. I did not drink alcohol during the past 30 days A. I do not drink alcohol B. Less than one drink B. Yes C. 1 drink C. No D. 2 drinks D. I do not know E. 3 drinks F. 4 drinks G. 5 or more drinks
8 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 56. Which of your parents or guardians drink 60. During your life, how many times have you used alcohol? marijuana (also called ganja, black, kayna, or weed)? A. Neither B. My father or male guardian A. 0 times C. My mother or female guardian B. 1 or 2 times D. Both C. 3 to 9 times E. I do not know D. 10 to 19 times E. 20 or more times Staggering when walking, not being able to speak right, and throwing up are some signs of being really drunk. 61. During the past 30 days, how many times have you used marijuana (also called ganja, black, 57. During your life, how many times did you drink so kayna, or weed)? much alcohol that you were really drunk? A. 0 times A. 0 times B. 1 or 2 times B. 1 or 2 times C. 3 to 9 times C. 3 to 9 times D. 10 to 19 times D. 10 or more times E. 20 or more times
58. During your life, how many times have you got 62. During the past 30 days, how many times have into trouble with your family or friends, missed you used drugs such as N10, RP, SP, or school, or got into fights, as a result of drinking dendrite? alcohol? A. 0 times 58 A. 0 times B. 1 or 2 times B. 1 or 2 times C. 3 to 9 times C. 3 to 9 times D. 10 to 19 times D. 10 or more times E. 20 or more times
The next 4 questions ask about drug use. This The next 6 questions ask about sexual includes using marijuana (also called ganja, intercourse. kayna, black, or weed) cocaine, inhalants, SP, N10, or dendrite. 63. Have you ever had sexual intercourse?
59. How old were you when you first used drugs? A. Yes B. No A. I have never used drugs B. 7 years old or younger C. 8 or 9 years old D. 10 or 11 years old E. 12 or 13 years old F. 14 or 15 years old G. 16 or 17 years old H. 18 years old or older
9 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 64. How old were you when you had sexual 68. If you wanted to get a condom, how would you intercourse for the first time? most likely get it?
A. I have never had sexual intercourse A. I would get it from a shop, pharmacy, or B. 11 years old or younger medical shop C. 12 years old B. I would get it from a hospital or Basic Health D. 13 years old Unit E. 14 years old C. I would get it from a hotel, lodge, or drayang F. 15 years old D. I would give someone else money to buy it G. 16 or 17 years old for me H. 18 year old or older E. I would get it some other way F. I do not know 65. During your life, with how many people have you had sexual intercourse? The next 3 questions ask about physical activity. Physical activity is any activity that increases A. I have never had sexual intercourse your heart rate and makes you get out of breath B. 1 person some of the time. Physical activity can be done in C. 2 people sports, playing with friends, or walking to school. D. 3 people Some examples of physical activity are running, E. 4 people fast walking, biking, dancing, football, and F. 5 people jogging. G. 6 or more people 69. During the past 7 days, on how many days were 66. The last time you had sexual intercourse, did you physically active for a total of at least 60 you or your partner use a condom? minutes per day? ADD UP ALL THE TIME YOU 59 SPENT IN ANY KIND OF PHYSICAL ACTIVITY A. I have never had sexual intercourse EACH DAY. B. Yes C. No A. 0 days B. 1 day 67. The last time you had sexual intercourse, did C. 2 days you or your partner use any other method of birth D. 3 days control, such as withdrawal, rhythm (safe time), E. 4 days birth control pills, or any other method to prevent F. 5 days pregnancy? G. 6 days H. 7 days A. I have never had sexual intercourse B. Yes C. No D. I do not know
10 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 70. During the past 7 days, on how many days did The next question asks about your sleep. you walk or ride a bicycle to or from school? 73. On an average school night, how many hours of A. 0 days sleep do you get? B. 1 day C. 2 days A. 4 or less hours D. 3 days B. 5 hours E. 4 days C. 6 hours F. 5 days D. 7 hours G. 6 days E. 8 hours H. 7 days F. 9 hours G. 10 or more hours 71. During this school year, on how many days did you go to physical education (PE) class each The next 6 questions ask about your experiences week? at school and at home.
A. 0 days 74. During the past 30 days, on how many days did B. 1 day you miss classes or school without permission? C. 2 days D. 3 days A. 0 days E. 4 days B. 1 or 2 days F. 5 or more days C. 3 to 5 days D. 6 to 9 days The next question asks about the time you spend E. 10 or more days mostly sitting when you are not in school or doing homework, self-study, or evening prayer. 75. During the past 30 days, how often were most of 60 the students in your school kind and helpful? 72. How much time do you spend during a typical or usual day sitting and watching television, playing A. Never computer games, talking with friends, or doing B. Rarely other sitting activities, such as listening to music? C. Sometimes D. Most of the time A. Less than 1 hour per day E. Always B. 1 to 2 hours per day C. 3 to 4 hours per day 76. During the past 30 days, how often did your D. 5 to 6 hours per day parents or guardians check to see if your E. 7 to 8 hours per day homework was done? F. More than 8 hours per day A. Never B. Rarely C. Sometimes D. Most of the time E. Always
11 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 77. During the past 30 days, how often did your 82. Have you ever talked about HIV infection or AIDS parents or guardians understand your problems with your parents or guardians? and worries? A. Yes A. Never B. No B. Rarely C. Sometimes 83. Would you be willing to help, become friends D. Most of the time with, or care for a person with HIV infection or E. Always AIDS?
78. During the past 30 days, how often did your A. Yes parents or guardians really know what you were B. No doing with your free time? 84. During this school year, were you taught in any of A. Never your classes the importance of being kind and B. Rarely supportive to persons with HIV infection or AIDS? C. Sometimes D. Most of the time A. Yes E. Always B. No C. I do not know 79. During the past 30 days, how often did your parents or guardians go through your things without your approval?
A. Never B. Rarely C. Sometimes 61 D. Most of the time E. Always
The next 5 questions ask about HIV infection or AIDS.
80. Have you ever heard of HIV infection or the disease called AIDS?
A. Yes B. No
81. During this school year, were you taught in any of your classes about HIV infection or AIDS?
A. Yes B. No C. I do not know
12 of 13 Bhutan GSHS Questionnaire - 2016
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 1.3 2.1 2.9 14.5 34.3 3255 %(CI) Females (0.9–1.8) (1.6–2.7) (2.4–3.5) (13.1–16.2) (31.2–37.4)
3.1 7.9 1.9 3.3 29.4 2515 %(CI) Males (2.5–4.0) (6.3–9.8) (1.2–2.8) (2.7–4.0) (25.8–33.2)
Students Aged 13-17 Years 2.1 2.0 3.1 11.4 32.1 5809 Total %(CI) (1.7–2.7) (1.5–2.6) (2.7–3.5) (10.3–12.6) (29.1–35.4) 1.0 1.6 3.2 13.2 29.1 1520 %(CI) Females (0.6–1.8) (0.9–2.7) (2.4–4.2) (11.5–15.0) (25.9–32.5) 3.4 5.9 1.2 3.8 23.7 1242 %(CI) Males (2.5–4.8) (4.3–8.1) (0.7–2.1) (2.8–5.2) (19.9–28.1)
Students Aged 16-17 Years 2.2 9.7 1.4 3.5 26.8 2782 Total %(CI) (1.6–2.9) (0.9–2.2) (2.8–4.3) (8.4–11.3) (23.7–30.1) 62 Annex 2 1.5 2.5 2.7 15.7 38.7 1735 %(CI) Females (1.0–2.1) (1.9–3.2) (2.0–3.6) (13.8–17.9) (35.2–42.4) 2.9 9.7 2.5 2.8 34.7 1273 %(CI) Males (1.9–4.3) (1.6–3.9) (2.1–3.8) (7.7–12.0) (31.1–38.5) Students Aged 13-15 Years 2.1 2.5 2.8 13.0 36.9 3027 Total %(CI) (1.5–2.9) (1.9–3.3) (2.2–3.4) (11.6–14.4) (33.8–40.2) Bhutan GSHS 2016 key findings factsheet
a most of the time b c fruit two or more times Nutritional status Life style behaviours Number of students in this subgroup 1. Underweight Overweight Obese went hungry or always because there was not enough food during the last 30 days 2. 2.1 Dietary behaviour Ate per day during the last 30 days
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 42.2 17.0 39.5 92.5 29.6 13.2 3255 %(CI) Females (39.2–45.2) (14.8–19.4) (36.7–42.4) (91.2–93.7) (26.5–32.9) (11.7–14.8) 40.5 12.3 40.5 23.5 15.8 2515 87.9( %(CI) Males 86.0–89.6) (37.9–43.3) (10.5–14.2) (36.3–44.9) (20.3–26.9) (13.6–18.3) Students Aged 13-17 Years 41.5 14.7 40.1 90.4 26.8 14.4 5809 Total %(CI) (39.0–44.0) (12.9–16.7) (37.0–43.2) (89.0–91.6) (24.1–29.6) (13.0–15.9) 39.7 17.5 35.6 92.6 28.9 12.4 1520 %(CI) Females (36.3–43.2) (14.8–20.5) (32.3–39.0) (90.8–94.1) (25.0–33.1) (10.7–14.3) 37.6 12.6 36.3 86.5 19.0 14.8 1242 %(CI) Males (34.5–40.8) (10.8–14.7) (32.9–40.0) (84.3–88.3) (15.9–22.6) (11.7–18.5) Students Aged 16-17 Years 38.7 15.1 35.9 89.7 24.2 13.5 2782 Total %(CI) (36.0–41.5) (13.1–17.5) (32.9–39.0) (88.0–91.2) (21.5–27.2) (11.6–15.7) 63 44.3 16.5 42.9 92.4 30.2 13.9 1735 %(CI) Females (40.7–47.9) (14.5–18.8) (40.0–45.9) (90.7–93.9) (26.8–33.7) (11.6–16.7) 43.3 11.9 44.4 89.2 27.6 16.7 1273 %(CI) Males (9.8–14.4) (40.4–46.3) (39.2–49.7) (86.9–91.2) (23.8–31.7) (14.4–19.4) Students Aged 13-15 Years 43.9 14.3 43.8 91.0 29.0 15.2 3027 Total %(CI) (41.3–46.5) (12.6–16.3) (40.7–46.9) (89.4–92.5) (26.0–32.2) (13.5–17.1) at least drank at least carbonated per day(during
per day during the during the last 30 vegetables three or Number of students in this subgroup Ate more times last 30 days Did not drank soft drinks days Students who usually carbonated soft drinks one or more times the 30 days before survey) Food from a fast food restaurant one or more days during the last 7 days 2.2 Physical activity Not Physically active 60 minutes per day on all 7 the last 7 days days during Physically active 60 minutes per day on all 7 days(during the 7 days before the survey)
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 55.7 30.9 13.9 19.9 17.6 3255 %(CI) Females (52.4–58.9) (26.6–35.5) (12.0–16.1) (17.6–22.4) (15.2–20.2) 55.0 28.7 15.5 29.9 42.9 2515 %(CI) Males (51.9–58.0) (25.7–31.9) (12.7–18.8) (27.5–32.5) (39.6–46.2) Students Aged 13-17 Years 55.4 29.9 14.7 24.6 29.4 5809 Total %(CI) (52.5–58.1) (26.4–33.7) (12.5–17.1) (22.6–26.7) (26.8–32.0) 58.0 32.0 11.7 20.6 21.9 1520 %(CI) Females (9.9–13.8) (53.4–62.4) (26.4–38.1) (17.9–23.6) (18.5–25.7) 55.7 31.0 14.4 31.6 49.6 1242 %(CI) Males (51.7–59.6) (27.0–35.4) (11.3–18.2) (28.9–34.5) (45.7–53.5)
Students Aged 16-17 Years 56.8 31.6 12.9 25.9 35.1 2782 Total %(CI) (53.2–60.3) (26.9–36.6) (10.9–15.3) (23.4–28.5) (32.0–38.5) 64 53.7 29.9 15.9 19.3 13.9 1735 %(CI) Females (50.6–56.8) (25.9–34.2) (13.2–19.0) (16.8–22.1) (11.3–17.0) 54.3 26.5 16.5 28.4 36.5 1273 %(CI) Males (50.6–58.0) (23.3–30.0) (13.1–20.6) (25.0–32.1) (31.4–41.9) Students Aged 13-15 Years 54.1 28.5 16.2 23.5 24.2 3027 Total %(CI) (51.2–56.9) (25.2–32.0) (13.4–19.6) (21.3–25.8) (20.8–28.0)
on one during this or school
playing computer , (used any (used tobacco sitting and watching
to or from school Tobacco, alcohol & substance abuse Number of students in this subgroup Did not walk or ride a bicycle during the last 7 days hours Spent three or more per day television games, or talking with or not in school friends, when during a typical or homework usual day doing Attended physical education on three or more classes days each week school year Missed classes without permission or more days during the last 30 days 3. 3.1 Tobacco use Currently used any tobacco products day on at least 1 products the last 30 days) during
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 13.1 51.2 43.0 10.3 48.6 81.7 3255 %(CI) Females (8.8–12.1) (10.9–15.6) (47.1–55.4) (38.9–47.2) (41.6–55.6) (76.2–86.1) 38.0 66.1 55.8 27.6 58.0 83.5 2515 %(CI) Males (35.0–41.1) (62.1–69.8) (52.0–59.5) (24.7–30.6) (54.4–61.6) (80.9–85.9) Students Aged 13-17 Years 24.7 58.1 48.9 18.4 55.2 83.0 5809 Total %(CI) (22.4–27.1) (54.3–61.9) (45.4–52.3) (16.3–20.6) (51.0–59.5) (80.5–85.2) 17.1 54.5 51.4 12.2 38.3 79.3 1520 %(CI) Females (13.9–20.8) (49.4–59.5) (46.7–56.1) (10.2–14.5) (31.2–45.9) (72.3–84.9) 43.8 69.0 62.6 33.0 47.3 81.0 1242 %(CI) Males (40.0–47.8) (64.6–73.1) (58.5–66.5) (29.4–36.8) (42.5–52.0) (77.7–83.8) Students Aged 16-17 Years 29.8 61.3 56.6 22.1 44.5 80.5 2782 Total %(CI) (26.9–32.8) (57.1–65.4) (52.8–60.3) (19.5–24.9) (40.1–48.9) (77.2–83.4) 65 9.6 8.7 48.5 35.7 63.5 85.5 1735 %(CI) Females (7.3–12.7) (6.8–11.2) (43.5–53.5) (31.8–39.9) (55.3–71.1) (78.0–90.7) 32.5 63.3 49.4 22.5 71.7 87.0 1273 %(CI) Males (27.7–37.8) (58.1–68.2) (44.7–54.2) (18.8–26.6) (67.8–75.2) (83.5–89.8) Students Aged 13-15 Years 20.1 55.3 41.9 15.1 69.4 86.6 3027 Total %(CI) (16.9–23.6) (50.6–59.8) (38.4–45.5) (12.6–18.0) (65.6–73.0) (83.6–89.0)
(one or any tobacco
for the first on at least 1 day (among students Number of students in this subgroup Currently smoked cigarettes cigarettes on at least (smoked the last 30 days) during 1 day Currently ate rajnigandha, dildar, wiz, or sakila more days during the 30 before the survey) Currently ate Doma khamtog (one or more days during the 30 days before the survey) Currently used products other than cigarettes( during the last 30 days) Tried a cigarette before age 14 years time(among students who ever smoked cigarettes) Tried to quit smoking cigarettes who smoked cigarettes during the 12 months before survey)
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 41.3 39.2 16.1 14.7 52.4 3255 %(CI) Females (37.6–45.1) (36.0–42.5) (13.9–18.6) (12.7–16.9) (46.1–58.7) 59.3 33.7 33.4 33.3 58.0 2515 %(CI) Males (56.3–62.2) (30.7–36.8) (30.4–36.6) (30.3–36.4) (54.0–62.0) Students Aged 13-17 Years 49.8 36.8 24.2 23.3 55.7 5809 Total %(CI) (46.8–52.7) (33.9–39.7) (22.0–26.5) (21.4–25.4) (51.4–59.9) 43.6 42.5 21.4 20.9 39.7 1520 %(CI) Females (38.9–48.5) (38.2–46.9) (18.2–25.1) (17.5–24.8) (34.1–45.6) 64.2 36.7 41.2 44.6 44.5 1242 %(CI) Males (59.8–68.3) (32.9–40.7) (37.1–45.4) (40.9–48.4) (39.8–49.2) Students Aged 16-17 Years 53.5 39.8 30.9 32.2 42.6 2782 Total %(CI) (49.7–57.3) (36.2–43.6) (27.8–34.1) (29.3–35.2) (39.1–46.1) 66 9.3 39.3 36.5 11.7 70.4 1735 %(CI) Females (9.6–14.1) (7.8–11.0) (35.3–43.5) (33.5–39.6) (63.1–76.8) 54.7 30.9 26.0 22.8 76.8 1273 %(CI) Males (50.0–59.4) (27.3–34.7) (22.3–30.1) (19.4–26.6) (73.0–80.2) Students Aged 13-15 Years 46.4 34.1 18.2 15.5 74.0 3027 Total %(CI) (42.7–50.2) (31.2–37.1) (15.8–20.8) (13.5–17.7) (69.7–77.9)
, at parents really drunk before age on one or more days smoked in their least one day during the last
Number of students in this subgroup Students who reported that people presence the last 7 days during Students who had or guardians who used any form of tobacco 3.2 Alcohol use Currently drank alcohol( of alcohol on least one drink at 30 days) Ever drank so much alcohol that they were their more times during one or life Drank alcohol 14 years for the first time among students who ever had a drink of alcohol other than few sips
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 6.1 4.1 5.3 11.5 44.4 10.2 3255 %(CI) Females (5.2–7.3) (3.2–5.3) (4.1–6.9) (8.5–15.3) (6.9–14.9) (40.0–48.9) 14.5 21.1 37.5 25.8 21.0 28.3 2515 %(CI) Males (13.2–15.9) (18.4–24.0) (34.1–41.1) (22.1–30.0) (18.7–23.6) (25.7–31.1) Students Aged 13-17 Years 10.1 17.4 40.0 19.5 12.0 16.0 5809 Total %(CI) (9.2–11.1) (15.5–19.5) (37.1–43.1) (16.6–22.9) (10.7–13.4) (14.5–17.6) 8.2 5.8 7.4 11.0 49.4 10.9 1520 %(CI) Females (4.6–7.2) (6.1–8.9) (6.6–10.1) (7.6–15.5) (6.4–17.7) (44.4–54.4) 18.9 24.2 38.0 25.7 26.3 35.5 1242 %(CI) Males (16.5–21.7) (21.0–27.7) (32.9–43.2) (20.7–31.4) (22.3–30.7) (31.3–39.9) Students Aged 16-17 Years 13.3 19.1 42.4 19.6 15.5 20.6 2782 Total %(CI) (11.6–15.3) (16.3–22.3) (38.8–46.0) (15.8–24.2) (13.5–17.7) (18.7–22.7) 67 4.4 9.3 2.8 3.6 12.3 36.0 1735 %(CI) Females (3.0–6.3) (1.6–4.6) (2.2–5.9) (8.0–18.4) (6.6–13.1) (29.0–43.6) 10.3 16.3 36.9 26.0 16.2 21.7 1273 %(CI) Males (8.5–12.5) (11.5–22.5) (31.1–43.2) (20.7–32.2) (13.4–19.4) (18.4–25.5) Students Aged 13-15 Years 7.2 8.9 14.8 36.4 19.3 11.9 3027 Total %(CI) (6.0–8.5) (7.2–11.0) (9.7–14.5) (11.2–19.3) (31.9–41.1) (16.1–23.0) (one or (one with (among (on the days two or more obtained the alcohol result of drinking alcohol Number of students in this subgroup Ever got into trouble their family or friends, missed school, or got into fights as a (one or more times during their life) Usually drank drinks per day they drank alcohol among students who drank alcohol during the last 30 days) Usually they drank from friends (among students who drank alcohol during the last 30 days) Usually drank beer students who drink alcohol) 3.3 Drug use Currently used marijuana (one or more times during the last 30 days) Ever used marijuana their life) more times during
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.5 9.8 8.8 34.2 14.4 13.1 15.8 3255 %(CI) Females (2.7–4.6) (8.6–11.1) (7.7–10.0) (28.5–40.3) (12.7–16.3) (11.6–14.8) (14.3–17.6) 7.4 6.2 9.8 11.2 42.6 10.0 11.2 2515 %(CI) Males (6.3–8.7) (5.2–7.3) (9.5–13.2) (8.6–11.6) (8.4–11.4) (37.6–47.8) (10.0–12.5) Students Aged 13-17 Years 7.2 8.7 7.6 40.9 12.4 11.6 13.7 5809 Total %(CI) (6.0–8.5) (7.7–9.8) (6.8–8.6) (36.4–45.5) (11.1–13.8) (10.4–12.9) (12.6–14.8) 4.1 9.1 25.9 15.3 10.1 14.4 17.1 1520 %(CI) Females (3.1–5.3) (7.6–10.8) (8.5–11.9) (18.7–34.6) (13.4–17.3) (12.0–17.1) (14.9–19.6) 6.9 6.9 9.1 12.3 26.4 11.9 10.2 1242 %(CI) Males (5.4–8.8) (5.2–9.2) (7.4–11.2) (8.8–11.6) (10.2–14.7) (22.3–31.0) (10.2–14.0) Students Aged 16-17 Years 8.0 8.0 8.6 26.3 13.7 11.8 13.7 2782 Total %(CI) (6.7–9.6) (6.8–9.5) (7.3–10.1) (22.5–30.4) (12.1–15.3) (10.1–13.7) (12.4–15.2) 68 * 3.0 7.6 13.7 10.3 12.1 14.7 1735 %(CI) Females (2.0–4.6) (6.3–9.2) (8.7–12.3) (11.5–16.2) (10.2–14.2) (12.9–16.8) 8.2 7.8 5.5 10.3 64.8 10.4 12.1 1273 %(CI) Males (6.5–9.4) (4.3–7.0) (8.2–12.8) (6.7–10.1) (8.6–12.5) (58.8–70.3) (10.2–14.4) Students Aged 13-15 Years 6.4 9.2 6.7 60.5 11.2 11.4 13.6 3027 Total %(CI) (5.0–8.1) (5.8–7.8) (9.8–12.8) (8.0–10.6) (55.5–65.3) (10.1–12.8) (12.2–15.2) (one during could not during the about drugs such as during the last about how they during the last 12 considered not have any close not have worried attempt suicide for the first time, among Mental health Number of students in this subgroup Currently used N10, RP, SP or dendrite or more times during the last 30 days) Used drugs before age 14 years students who ever used drugs 4. Most of the time or always felt lonely months Who did friends Most of the time or always were so something that they sleep at night 12 months Seriously attempting suicide last 12 months Made a plan would the last 12 months
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 12.1 26.1 46.6 54.1 38.4 3255 44.7) %(CI) Females 42.2(39.8– (10.5–13.7) (23.9–28.4) (43.8–49.3) (51.2–57.0) (35.3–41.6) 10.3 27.5 54.4 35.8 39.8 2515 44.1) %(CI) Males (8.8–12.0) 41.4(38.8– (25.3–29.9) (37.5–42.1) (51.6–57.2) (32.2–39.6) Students Aged 13-17 Years 11.3 41.8 26.7 43.3 54.2 37.2 5809 Total %(CI) (10.0–12.7) (39.6–44.0) (24.8–28.8) (41.1–45.6) (51.5–56.8) (34.1–40.3) 14.0 44.0 23.5 48.1 59.7 36.1 1520 %(CI) Females (11.9–16.5) (40.6–47.4) (20.5–26.7) (56.4–63.0) (31.9–40.5) (44.9–51.5) 9.7 42.5 23.6 41.0 56.8 33.6 1242 %(CI) Males (7.9–11.7) (39.1–46.0) (19.9–27.7) (52.8–60.8) (29.7–37.7) (37.6–44.4) Students Aged 16-17 Years 11.9 43.3 23.5 58.3 34.9 44.6 2782 Total %(CI) (10.3–13.8) (40.5–46.2) (20.7–26.6) (41.6–47.7) (55.1–61.4) (31.3–38.7) 69 10.3 40.7 28.3 49.4 40.4 45.2 1735 %(CI) Females (8.8–12.2) (37.9–43.6) (26.4–30.2) (41.9–48.6) (46.6–52.2) (36.1–44.8) 10.9 40.4 31.2 38.7 52.1 37.9 1273 %(CI) Males (8.8–13.4) (37.1–43.8) (28.1–34.4) (36.2–41.3) (48.8–55.4) (33.8–42.2) Students Aged 13-15 Years 10.7 40.4 29.6 50.5 39.2 42.2 3027 Total %(CI) (9.3–12.2) (37.9–42.9) (27.9–31.4) (47.8–53.2) (35.5–42.9) (39.9–44.5)
during the one or understood always really most of the time homework was free time without their approval what they were doing what they were during the last 30 days Social and parental relationships Number of students in this subgroup Attempted suicide the last 12 more times during months 5. Most of the students in their school were or always kind and helpful during the last 30 days Parents or guardians most of the time or always checked to see if their done Parents or guardians most of or always the time their problems and worries Parents or guardians never or rarely went through their things during the last 30 days Parents or guardians most of the time or knew with their last 30 days during the last 30 days during
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 9.1 33.2 32.2 26.3 42.2 39.0 3255 %(CI) Females (7.0–11.8) (29.4–37.3) (28.4–36.2) (22.7–30.2) (35.9–48.7) (35.4–42.7) 45.4 49.2 26.3 37.6 48.8 15.2 2515 %(CI) Males (41.6–49.2) (45.7–52.8) (22.8–30.2) (26.4–50.4) (45.7–52.0) (13.3–17.4) Students Aged 13-17 Years 39.0 40.2 26.5 40.6 43.7 12.3 5809 Total %(CI) (35.3–42.7) (36.6–44.0) (23.1–30.1) (33.5–48.2) (40.5–46.9) (10.7–14.2) 9.7 32.3 23.2 38.3 39.1 1520 34.6) %(CI) Females (6.8–13.7) 29.6(25.0– (27.4–37.5) (19.0–28.1) (31.7–45.5) (34.4–43.9) * 42.1 46.6 21.2 46.7 14.4 1242 %(CI) Males (38.1–46.2) (42.7–50.6) (17.3–25.8) (43.2–50.2) (11.3–18.3) Students Aged 16-17 Years 37.0 37.7 22.4 36.5 42.9 12.1 2782 Total %(CI) (33.0–41.2) (33.6–42.0) (18.6–26.7) (29.0–44.8) (39.1–46.8) (10.1–14.5) 70 8.5 34.0 34.4 28.9 46.7 38.9 1735 %(CI) Females (6.3–11.5) (30.5–37.8) (30.7–38.4) (25.0–33.0) (36.4–57.2) (34.7–43.2) * 48.5 51.7 31.2 50.8 15.9 1273 %(CI) Males (44.1–52.9) (47.5–55.9) (27.8–34.9) (46.8–54.8) (13.3–18.9) Students Aged 13-15 Years 40.7 42.5 30.1 45.4 44.4 12.5 3027 Total %(CI) 38.7–46.3) (37.1–44.3) (26.7–33.6) (36.7–54.3) (40.9–47.9) (10.3–15.0) (one or (among one or on one or
during the last 30 during bullied and could seriously injured bullied physical fight
Violence and injury Number of students in this subgroup 6. Physically attacked more times during the last 12 months) In a the last 12 more times during months Who were more days days Who were not sleep at night students who most of the time or always had been so worried during 12 months before the survey, on one or more days during the last 30 days Who were (one or more times during the 12 months before the survey) Reported that their most serious injury was a broken bone or dislocated joint (among students who were seriously injured during the 12 months before the survey)
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 2.0 8.8 1.6 11.6 46.9 3255 %(CI) Females (1.3–3.2) (1.2–2.2) (9.4–14.3) (7.5–10.3) (37.5–56.6) 3.4 23.2 22.5 10.0 49.5 2515 %(CI) Males (2.3–5.1) (8.6–11.6) (18.9–28.0) (20.1–25.0) (43.5–55.6) Students Aged 13-17 Years 2.8 5.5 17.0 15.1 49.3 5809 Total %(CI) (2.0–4.0) (4.8–6.3) (14.3–20.2) (13.5–16.8) (43.7–55.0) * 2.5 2.7 10.8 10.0 1520 %(CI) Females (1.3–4.5) (2.0–3.6) (7.6–15.1) (8.5–11.8) 1.1 21.3 27.0 13.4 34.3 1242 %(CI) Males (0.4–2.8) (16.0–27.7) (23.7–30.5) (10.9–16.3) (29.1–40.0) Students Aged 16-17 Years 1.8 7.7 15.5 17.9 35.2 2782 Total %(CI) (1.1–2.8) (6.3–9.3) (11.8–20.1) (15.8–20.2) (30.4–40.3) 71 * 1.6 7.8 0.7 12.2 1735 %(CI) Females (0.8–3.2) (6.2–9.8) (0.4–1.2) (8.7–17.0) 5.4 6.9 24.4 18.4 72.6 1273 %(CI) Males (3.6–8.1) (5.3–8.9) (18.4–31.6) (15.7–21.4) (64.7–79.3) Students Aged 13-15 Years 3.8 3.5 18.0 12.6 73.1 3027 Total %(CI) (2.4–5.8) (2.9–4.3) (13.7–23.3) (10.9–14.5) (66.6–78.8) (for the sexual intercourse injury was caused by Sexual behaviors & knowledge of HIV/AIDS Sexual Number of students in this subgroup Reported that their most serious a motor vehicle accident or being hit by a motor vehicle (among students who were seriously injured during the 12 months before the survey) Bullied most often by being hit, kicked, pushed, shoved around, or locked indoors (among students who were bullied during the last30 days) 7. Ever had sexual intercourse Who had with two or more persons (during their life) Had sexual intercourse before age 14 years first time among students who ever had sexual intercourse)
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 6.7 58.5 15.0 88.3 67.4 52.2 3255 %(CI) Females (5.7–8.0) (46.0–70.0) (11.3–19.6) (86.6–89.7) (64.4–70.4) (49.6–54.7) 7.6 60.0 33.3 84.1 65.0 37.7 2515 %(CI) Males (5.8–9.8) (55.0–64.8) (29.0–37.8) (82.2–85.8) (62.2–67.8) (35.0–40.4) Students Aged 13-17 Years 7.1 59.3 26.9 86.3 66.2 45.4 5809 Total %(CI) (6.0–8.5) (54.9–63.5) (23.5–30.7) (84.7–87.7) (63.6–68.7) (43.1–47.8) * 8.7 15.5 87.7 69.8 55.7 1520 %(CI) Females (6.8–11.1) (11.9–20.1) (85.1–89.9) (66.0–73.3) (52.8–58.6) 7.0 65.7 36.6 85.1 68.3 40.0 1242 %(CI) Males (5.3–9.1) (61.1–70.1) (31.4–42.2) (82.6–87.4) (64.5–71.8) (36.6–43.5) Students Aged 16-17 Years 7.9 64.5 29.1 86.3 68.9 48.3 2782 Total %(CI) (6.4–9.5) (60.3–68.5) (25.2–33.5) (84.1–88.3) (65.9–71.8) (45.6–50.9) 72 * 5.0 14.0 88.7 65.4 49.1 1735 %(CI) Females (4.1–6.2) (7.7–24.2) (87.0–90.3) (62.1–68.6) (46.0–52.2) 8.2 51.1 27.1 83.1 62.0 35.5 1273 %(CI) Males (5.7–11.5) (41.9–60.1) (21.0–34.2) (80.6–85.4) (58.8–65.1) (32.0–39.1) Students Aged 13-15 Years 6.5 50.3 22.9 86.2 63.8 42.9 3027 Total %(CI) (5.0–8.3) (41.5–59.1) (17.8–28.9) (84.5–87.8) (60.9–66.6) (40.3–45.5) HIV among when they , had sexual with their during last
about HIV among students that they were really Number of students in this subgroup Used a condom sexual intercourse sexual ever had students who intercourse Students who ever intercourse who had drank so much alcohol drunk (one or more times during their life) Ever heard of HIV infection or AIDS Who were taught in any of their classes infection or AIDS during this school year Who ever talked about infection or AIDS parents or guardians Ever been forced to have sexual intercourse did not want to
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 3.5 4.0 4.6 93.7 33.8 3255 %(CI) Females (2.8–4.4) (3.3–4.8) (3.8–5.6) (92.9–94.5) (25.1–43.8) 3.9 4.5 7.2 90.9 33.3 2515 %(CI) Males (2.8–5.3) (3.6–5.5) (5.8–8.8) (89.6–92.1) (25.1–42.7) Students Aged 13-17 Years 3.7 4.2 5.8 92.4 33.6 5809 Total %(CI) (3.0–4.7) (3.6–4.8) (5.0–6.8) (91.5–93.2) (25.2–43.1) 3.5 3.8 4.9 93.9 29.2 1520 %(CI) Females (2.7–4.6) (2.7–5.3) (3.8–6.3) (92.5–95.0) (19.8–40.9) 3.8 4.8 8.4 91.2 30.2 1242 %(CI) Males (2.7–5.3) (3.8–6.2) (6.6–10.6) (89.0–93.1) (22.1–39.8) Students Aged 16-17 Years 3.7 4.3 6.6 92.5 29.7 2782 Total %(CI) (2.9–4.7) (3.5–5.2) (5.5–8.0) (91.2–93.7) (21.1–40.0) 73
3.5 4.1 4.3 93.6 37.8 1735 %(CI) Females (2.5–5.0) (3.4–5.1) (3.3–5.7) (92.3–94.7) (28.5–48.0) 4.0 4.2 6.0 90.7 36.3 1273 %(CI) Males (2.7–6.0) (3.2–5.4) (4.5–8.0) (88.9–92.2) (27.1–46.5) Students Aged 13-15 Years 3.7 5.1 4.1 92.3 37.1 3027 Total %(CI) (2.7–5.2) (3.4–5.0) (4.1–6.3) (91.1–93.3) (28.0–47.2) or
during at school brushed their one or more times per one Hygiene habits Number of students in this subgroup 8. Cleaned or teeth the last 30 days during day Never or rarely washed their hands before eating the last 30 days their or rarely washed Never hands after using the toilet the last 30 days during latrine Never or rarely used soap when washing their hands during the last 30 days Did not have a safe source of water for drinking a (<-2SD from median for BMI by age and sex); b (>+1SD from median for BMI by age and sex); c (>+2SD from median for BMI by age and sex) * Fewer than 100 students in this subgroup;
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Annex 4 Bhutan GSHS 2016 – List of steering committee members
SN Name Designation Address 1 Dr Pandup Tshering Former Director Department of Public Health, MoH 2 Dr Karma Lhazeen Director Department of Public Health, MoH 3 Dorji Phub Chief Health Promotion Division 4 Ms. Deki Tshomo Deputy Chief School Health and Nutrition Division, MoE 5 Ms. Karma Dechen Deputy Chief School Health and Nutrition Division, MoE 6 Ms. Srijana Ghallay Program Officer Youth Development Fund, CSO 7 Mr. Dorji Phuntsho Statistical Officer National Statistical Bureau 74 8 Ms. Yeshay Lhaden Engineer (Focal for Public Health and Engineering School WASH) Division, DoPH, MoH 9 Mr. Laigdhen Dzed Sr. Program Officer Nutrition Health Program, DoPH, MoH 10 Mr. Ugyen Wangdi Lecturer Faculty of Nursing and Public Health, KGUMSB 11 Ms. Roma Karki Program Officer Disability Prevention and Rehabilitation Program, DoPH, MoH 12 Ms. Yangchen Dolkar Program Officer National HIV/AIDS Control Program, DoPH, MoH 13 Mr. Tshering Dhendup National WHO CO, Bhutan Professional Officer
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Annex 5 Bhutan GSHS 2016 – List of survey administrators
SN Name Designation Address 1 Kinley Wangmo Program Officer Nutrition Health Program, DoPH, MoH 2 Tshering Dhendup National Professional WHO CO, Bhutan (Also Supervisor) Officer 3 Tashi Chozom Planning Officer PPD, MoH 4 Karma Tenzin Program Officer DMS, MoH 5 Dil Kumar Program Officer Mental Health Program, DoPH, MoH 6 Samten Lhendup Human Resource MoH Officer 7 Tshultrim Zangpo Human Resource MoH Officer 75 8 Rada Dukpa Program Officer Environmental Health Program, DoPH, MoH 9 Sangay Phuntsho Program Officer EPI Program, DoPH, MoH 10 Loday Zangpo Program Officer Life Style Related Disease Program, DoPH, MoH 11 Pempa Program Officer DMS, MoH 12 Ugyen Norbu Information and Media Health Promotion Division, Officer DoPH, MoH 13 Tashi Tshering Information and Media Health Promotion Division, Officer DoPH, MoH 14 Pema Wangdi Adminitrative Officer MoH 15 Tashi Dema Research Officer MoH 16 Gyem Tshering Lecturer Faculty of Nursing and Public Health, KGUMSB 17 Sangay Thinley GSHS Coordinator Comprehensive School Health Program, DoPH, MoH
Report on Bhutan Global School-Based Student Health Survey (GSHS) 2016 Report on Bhutan Global School-Based Student Health Survey 2016 Report on Bhutan Global School-Based Student Health Survey 2016
World Health House Ministry of Health Indraprastha Estate Mahatma Gandhi Marg Royal Government of Bhutan New Delhi-110002, India 2017 www.searo.who.int 9 789290 226208