Indicators of urban health in the youth population of Kuwait City and Jahra, Kuwait Fayez Alzarban A thesis submitted to the University of Liverpool for the degree of Doctor of Philosophy (Public Health) at the Faculty of Health and Life Sciences March: 2018 Declaration No portion of the work in this thesis has been submitted in support of an application for any degree or qualification of the University of Liverpool or any other University or institute of learning. Signature Acknowledgements I would like to start by thanking my outstanding supervisors at the University of Liverpool: Dr. Daniel Pope and Dr. Debbi Stanistreet, for their constant support, dedication, and encouragement throughout my study period. I am also grateful for all the help I have received from my academic advisors allocated by the Postgraduate team: Prof. Dame Margaret Whitehead, Prof. Sally Sheard, Prof. David Taylor- Robinson, and Prof. Martin O’Flaherty, for all the advice and guidance they have given me. I would also like to thank Prof. Susan Higham for tremendous support at a very difficult period during my studies. In Kuwait, I would like to extend my thanks to Dr. Jafaar Dawood, the head of the Department of Public Health at the Ministry of Health (Kuwait), for his support in every step of this research in Kuwait. Without his exceptional efforts, this project would have not been possible. I would also like to thank the health inspectors at the Department of Health (Kuwait) for their generosity and dedication in conducting the survey with me: Basim Awkal, MS. Allimby, Ala’a Jaad, Saleh Mohammed, Michelle Asaad, Sarah Alazmi, and Hesa Alali. Also in Kuwait, I would like to thank all the school principals in both Jahra and Kuwait City that have agreed to participate and showed interest in this research, as well as the school teachers for providing all the help needed in the classrooms while conducting the survey. Moreover, I would like to thank all the students that participated in this study. Finally, I would like to thank my family: my mother, my sister and nephew, and the love of my life and soulmate, Anfal, for all their support and encouragement throughout the years. List of Abbreviations ADHD Attention Deficit Hyperactivity Disorder AIDS Acquired immune deficiency syndrome BMI Body Mass Index CDC Centres for Disease Control COPD Chronic obstructive pulmonary disease CSDH Commission on the Social Determinants of Health DEFRA Department for Environment, Food and Rural Affairs ECHI European Community Health Indicators ECRHS European Community Respiratory Health Survey EHIS European Health Interview Survey Questionnaire EMRO Eastern Mediterranean Region ESPAD European School Survey Project on Alcohol and Other Drugs FAS Family Affluence Scale GCC Gulf Co-operation Council Countries GDI Gender Development Index GIP Global Influenza Programme GYTS Global Youth Tobacco Survey(s) GSHS Global School-Based Student Health Survey HBSC Health Behaviour in School-Aged Children study HDI Human Development Index HEART Health Equity Assessment and Response Tool HIV Human immunodeficiency virus HRBQ Health Related Behaviour Questionnaire IMR Infant Mortality Rate ISAAC International Study of Asthma and Allergies in Childhood LDAC Least developed Arab States List of Abbreviations (contd.) LUZ Larger Urban Zone MDG Millennium Development Goals NHS National Health Service PNM Perinatal Mortality RTA Road Traffic Accident SDQ Strengths and Difficulties Questionnaire. SES Socio-economic status SILC Survey on Income and Living Conditions Questionnaire TB Tuberculosis TFI Tobacco Free Initiative UA Urbanised Areas UC Urban Clusters UK United Kingdom UHI Urban Health Indicator UMP Urban Management Programme UN United Nations UN HABITAT United Nations Human Settlements Programme UNESCO United Nations Educational, Scientific and Cultural Organisation UNICEF United Nations International Children’s Emergency Fund UNFPA United Nations Populations Fund URHIS Urban Health Indicator System URHIS-2 Urban Health Indicator System (Part 2) US United States WHO World Health Organisation WP Work Package Abstract Introduction: Kuwait, a country situated in the Middle East, is one of the most urbanised countries in the world and with a large proportion of young people. The government of Kuwait has acknowledged the importance of understanding the needs of its youth population in its current healthcare policy focusing on three main health issues: overweight/obesity, tobacco and cannabis use, and general mental and psychological health. However, little is currently known about the health status of its young people due to the limited epidemiological data at a national and city level. As Kuwait is considered part of the Arab States, it is essential to understand the cultural and social dynamics shared by young people living in the region. Objectives: To describe, compare and summarise the urban health profile of the youth population in the State of Kuwait, aged 14-16 years, in two Kuwaiti cities: Kuwait City (an affluent city with high economic activity) and Jahra (a less affluent, more deprived city), with a focus on the three urban health topics highlighted in the current Kuwaiti healthcare policy: overweight/obesity, tobacco smoking and cannabis use, and general psychological health. The urban health issues found in young people in Kuwait City and Jahra, Kuwait were compared to the findings in European cities in the EURO-URHIS2 study in 15 youth urban health indicators. Methods: Validated and standardised urban health indicator (UHI) questionnaires, specifically designed for young people, were adopted from a large European Health Survey (EURO-URHIS2 project) developed to collect relevant and comparable data on the health and its determinants in young people residing in cities. The EURO-URHIS2 youth questionnaire was translated to the Arabic language and piloted in schools in Kuwait prior to conducting the survey. Data were collected in a classroom setting in Kuwait City and Jahra, Kuwait. Results: Comparisons of urban health profiles for young people in Kuwait City and Jahra: 530 students were surveyed in Kuwait City and 527 in Jahra. Significant socio-economic status differences (measured by Family Affluence Scale) were observed between the two cities, with students in Kuwait City reporting higher family affluence scores than in Jahra. Compared to Kuwait City, young people in Jahra reported an overall poorer urban health profile and significant differences were observed in health status, lifestyle factors and environmental factors. The poor health situation, both in terms of health and determinants of health, was more apparent in girls in Jahra compared to girls in Kuwait City. Priority Urban Health Indicators for Kuwaiti public health policy: Overall, a very high proportion of students from both cities (approximately 60%) were found to be overweight and obese, and approximately one third of students in both cities were obese. Unhealthy dietary factors were widespread in both cities, particularly in the high consumption of sugar-rich products and fizzy drinks and the low consumption of fruit and vegetables. In both cities, only 1 in 3 students reported regular consumption of fruit and less than half of all students reported regular consumption of salads and vegetables. Consumption of fizzy drinks and sugar-rich food products was significantly higher in Jahra than in Kuwait City. Low engagement in physical activity was widely reported in both cities, with less than 1 in 10 students engaging in the WHO recommended daily physical activity. In Kuwait City, students that engaged in weekly vigorous or 60 minutes of daily physical activity were significantly less likely to be obese. Additionally, obese students in Kuwait City were significantly more likely to perceive their health as poor. Smoking appeared to be predominantly an issue for boys rather than girls in both Jahra (OR=11.05) and Kuwait City (OR=9.80). Half of the boys in both cities reported smoking tobacco in the past and approximately 1 in 5 were daily tobacco smokers. In both cities, students that self-reported living in an area with crime, violence and vandalism were approximately 90% more likely to have ever smoked tobacco. In Jahra, elevated risk of psychological distress (measured by SDQ scores) was independently associated with (ever) smoking. While cannabis use was highlighted as a Kuwaiti government public health priority, only 3% of students reported using cannabis in the past in both cities. In terms of mental health, self-reported psychosomatic symptoms were significantly more common in Jahra compared to Kuwait City. Elevated risk of psychological distress was reported two-fold higher in Jahra than in Kuwait City, with the highest proportion reported in girls in Jahra (27%). Girls were 66% more likely than boys to be at an elevated risk of psychological distress in Jahra. Students that were victims of bullying were more likely to report an elevated risk of psychological distress in both cities. Environmental indicators, such as living in an area with crime and violence and exposure to severe noise, were independently associated with psychological distress in Jahra. An extremely high proportion of youths in both cities reported suffering from low back pain (LBP) in the past month and this was significantly more pronounced in Jahra (75%) compared to Kuwait City (64%). Gender was independently associated with LBP in Jahra, with girls twice as likely than boys to report suffering from it. In both cities, elevated risk of psychological distress was independently associated with LBP. The presence of other psychosomatic symptoms was significantly associated with LBP in Kuwait City. In Jahra, environmental indicators continued to carry an importance with students that lived in an area with crime/violence were significantly more likely to suffer from low back pain. Comparing the findings in Kuwait City and Jahra with the EURO-URHIS2 project: In terms of health status UHIs (self-perceived health, psychological distress, psychosomatic symptoms), Kuwait City appeared to show a similar picture to that of the EURO-URHIS2 project average for young people, with the exception of LBP where it was reported higher than in Europe.