Attachment 13- GSHS_Country_Report_Jordan_2007.pdf

Prepared by:

Dr. Basheer M.Al Qaseer Dr.. Samar Batarseh

Supervised by:

Dr. Ali Asa'ad

Jordan Global School-based Student Health Survey

Table of Contents

Acknowledgment

Executive Summary

Part 1: Introduction

Methods……………………………………………………………………………………………9

Part 2: Results

Overview Demographics Dietary Behaviours Hygiene Mental Health Physical Activity Protective Factors Sexual Behaviours that Contribute to HIV Infection Tobacco Use Violence and Unintentional Injury Bar graphics illustrating the main findings per health risk behaviours, protective factors and gender………………………….…………………………………………………………………..25

Part 3: Conclusions and Recommendations.......................................................................................…..28 Conclusions………………………………………………………………………………………29 Recommendations ........................………………………………………………… 30

Comparison between 2004 GSHS and 2007 GSHS………………………………………… 32

- Table……………………………………………………………………….… 32

- Graphs ……………………………………………………………..……………. 33

Part 4: Appendices……………………………………………………………………………….37 GSHS Questionnaire References………………………………………………………………………………………...57

Jordan GSHS Questionnaire - 2007 2

Acknowledgements

First of all, thanks to Almighty God, and to persons who contributed to the success of our

GSHS.

• Husein Al Jaza'eri, EMRO/ WHO Regional Officer,

• His Excellency Minister of Health Dr Sallah Moajdeh,

• His Excellency Minister of Education DrTaiseer Naemy,

• Dr Hashem Al Zain WHO Representative in Jordan,

• Dr. Ali Asaad General Secretary of Technical affairs, MOH,

• Dr Adel Belbisi Under Secretary General ,MOE

• Me Moh,Al okur, Director of Public Education Directorate for Students Affair

• Dr. Basheer Al Qaseer, GSHS Survey Coordinator and Director, and his staff,

• Dr. Samar Batarseh, GSHS Survey administrator

• Dr. Hesham Mrian

• Dr. Abdel Fattah Abu Sweilem

• Dr. Naela Al Jawhari

• Fairouz Al Abbadi, dietition

• Dr. Muna Al-khateeb

• Dr. Abeer shehadeh

• Sawsan Basheer Al-Qaseer/pharmacist

• School health supervisors of the participating health directorates of Amman, East

Amman, Irbid, Zarqa, Ajlon Mafraq,Ramtha,Bany Kenanh , Ma'an and Dear Alla and UNRWA schoolls' supervisors

• Students and principals of the participating sampled schools who assisted in making this study possible

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Executive Summary

Back ground

Since 2003, the GSHS has been used to periodically monitor the prevalence of important health risk behaviours and protective factors related to the leading causes of mortality and morbidity among students aged 13-15 years: dietary behaviours, hygiene, mental health, physical activity, protective factors, sexual behaviours that contribute to HIV infection, tobacco use, and violence and unintentional injuries.

Jordan has been repeated the GSHS for the second time in 2007 in order to see trend of the health risk behaviour and protective factors among students 13-15 years old. Jordan has another few studies like tobacco use among students and the GYTS. Repeated GSHS which conducted by MOH/School health directorate in 2007 to provide accurate base line data on health risk behaviours and protective factors to help in developing priorities, establish programmes, and advocate for resources for school health and youth health programmes and policies; establish trends in the prevalence of health risk behaviours and protective factors for use in evaluation of school health and youth health promotion; allow countries, international agencies, and others to make comparisons across countries and within countries regarding the prevalence of health risk behaviours and protective factors, and establish surveillance systems for health risk behaviours and protective factors.

Methodology

A two-stage cluster sample design was employed to produce a representative sample of students in 8th through 10th grades. 25 schools were selected with probability proportional to school enrolment size. 70 classrooms were randomly selected intact from each school to participate. The sample of students eligible to participate was 2243 students. 2197 questionnaires were completed for the 2007 Jordan GSHS. The school response rate was 100%, the student response rate was 99.8%, and the overall response rate was 99.8%. Data collection occurred from 22rd to 24th May 2007. Students privacy was protected by allowing for anonymous and voluntary participation, The questionnaires, answer sheets, school level forms and class level forms were gathered and sent to CDC/Atlanta on 7/6/2007, for data entry, processing, and analysis and the envelopes were returned to Jordan as agreed on.

Results:

Results show that the sample was 2197 students, females constituted 49.5% of the sample.

Dietary behaviours: 14.3% of students were at risk of becoming overweight and 3.9% were overweight. 34.9% of students were trying to lose weight. 14.1% of students went hungry because there was not enough food in their home. 14.6% of students ate at a fast food restaurant, 38.1% of students usually drink carbonated soft drinks and 35.8% drink milk or eat milk products.

Hygiene: 25.3% of students did not clean or brush their teeth. 7.4% of students never or rarely washed their hands before eating. 7.4% of students never or rarely washed their hands after using the toilet or latrine. 9.1% of students never or rarely used soap when washing their hands. 58.6%

Jordan GSHS Questionnaire - 2007 4 of students do not have a source of clean water for drinking at school, 33.3% of students do not have a place to wash their hands before eating at school. 72.2% of students have not clean toilets or latrines at school.

Mental Health: 15.7% of students felt lonely most of the time. 18.4% of students felt so worried about something that they could not sleep at night. 18.0% of students seriously considered attempting suicide. 18.1% of students made a plan about they would attempt suicide. 8.2% of students have no close friends.

Physical Activity: 14.3% of students were physically active for a total of at least 60 minutes daily for 7 days. 83.5% of students participated in insufficient physical activity. 39.3% of students spent three or more hours per day doing sitting activities. 76.6% of students usually took less than 30 minutes to get to and from school each day during the past 7 days.

Protective Factors: 39.1% of students missed classes or school without permission, 36.5% of students reported that most of the students in school were kind and helpful. 34.3%of students were been never or rarely checked by their parents or guardians for their homework 43.4% of students reported their parents or guardians never or rarely understood their problems and worries. 37.2% of students reported their parents or guardians never or rarely really know what they were doing with their free time.

Sexual Behaviours that Contribute to HIV Infection : 84.9% of students had ever heard of HIV/ AIDS. 56.1% of students had been taught in their classes about HIV or AIDS, 54.8% how to avoid HIV or AIDS, and 75.2% of students knew that people can protect themselves from HIV by not having sexual intercourse outside the bond of marriage.

Tobacco Use : During the past 30 days, 24.9% of students used any form of tobacco one or more times, 15.6% of students smoked cigarettes and 68.3% of them tried to stop smoking cigarettes.

75.3% of students reported that people smoked in their presence during the past seven days.

50.2% of students had a parent or guardian who uses any form of tobacco.

Violence and Unintentional Injury : During the past 12 months, 46.7% of students were in a physical fight one or more times. 43.7% of students were seriously injured one or more times.

Among students who were seriously injured, 24.6% were playing sports, 18.8% had injury by a fall, 38.8% had injury as a result of accident, and 20.5% experienced a broken bone or dislocated joint as their most serious injury. 41.6% of students were bullied on one or more days, 13.3% out of them were bullied most often by being hit, kicked, pushed, shoved around, or locked indoors.

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Recommendations:

1. Evaluate, modify the present educational programs, develop and design up to date programs, and developing guidelines and training for teaching staff, students, parents, and health providers that promote health of students and surrounding communities through improving their level of knowledge and awareness, attitudes, behaviors, gaining skills and healthy practices.

2. Reviewing and updating school curriculum regarding health issues and present it in a simple easy understood way.

3. Improving the learning and social environments through improving and building communication skills between students, teachers, and parents.

4. Improve coordination and cooperation with officials such as MOY, MOH, MOE, and MOD&SA to help students' participation in productive activities

5. Stress on the role of the social counsellors in building better social relations between students, teachers and parents.

6. Activation of councils of students' parents and improve communication skills and interaction between school staff and councils of students' parents.

7 Stressing the school legislations regarding school attendance for students, prevention of smoking, bullying and violence at schools.

8. GSHS is considered a base of surveillance system for heath risk behaviours and protective factors at schools and need to be conducted periodically 2-3 years.

9. Adopt health initiatives to support school health programmes related to (nutrition, physical activity, hygiene tobacco use and sexual behaviours).

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Part 1: Introduction

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Background

In 2001, WHO, in collaboration with UNAIDS, UNESCO, and UNICEF, and with technical assistance from the US Centres for Disease Control and Prevention (CDC), initiated development of the Global School-based Student Health Survey (GSHS).

Since 2003, Ministries of Health and Education around the world have been using the GSHS to periodically monitor the prevalence of important health risk behaviours and protective factors among students.

Jordan was the first country in EMRO region who conducted GSHS in May 2004 and was the first country who repeated the GSHS in May 2007.

Purpose

The purpose of the GSHS is to provide accurate data on health behaviours and protective factors among students to:

• Help countries develop priorities, establish programmes, and advocate for resources for school health and youth health programmes and policies;

• Establish trends in the prevalence of health behaviours and protective factors by country for use in evaluation of school health and youth health promotion; and

• Allow countries, international agencies, and others to make comparisons across countries and within countries regarding the prevalence of health behaviours and protective factors.

• Establish base line data on health behaviours and protective factors

• Establish surveillance systems for health behaviours and protective factors

About GSHS

The GSHS is a school-based survey conducted primarily among students aged 13-15 years. It measures behaviours and protective factors related to the leading causes of mortality and morbidity among youth and adults in Jordan:

• Alcohol and other drug use

• Dietary behaviours

• Hygiene

• Mental health

• Physical activity

• Protective factors

• Sexual behaviours that contribute to HIV infection.

• Tobacco use

• Violence and unintentional injury Jordan has a total area of 89000 square km. The average annual current income per capita is

1515.6 JD. The annual population growth rate is 2.6%. The estimated population was 5,600000 for the year 2006. Most of population of Jordan are literate 91%; the total number of students from all educational sectors was more than one and a half million for the scholastic year

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2003/2004, females constitute 49.3% and the percent of schoolchildren enrolled in schools was 98.2% in schools of all educational sectors since basic education till the 10th grade is mandatory by low. (Department of statistics, 2004) There is political commitment from Jordan government through MOH and MOE towards the health status of students to reach the Gemini Goal of Health for All and Education for All students. The national strategy of school health was developed in order to achieve objectives of school health. Comprehensive school health program include the eight components: medical & dental examination, vaccination according to EPI at schools, school environment, health education, mental and psychosocial health, food and nutrition, physical and recreational activities, programs for school staffs (principals, teachers and custodians) and programs for communities surrounding schools. School health services are implemented by physicians, dentists and paramedics of the health centre that cover a number of schools in an area and offered free of charge only to students in public schools at primary level of care and only poor students are covered by medical insurance according to school administration coverage letter that the student is poor for secondary and tertiary levels in addition to primary care levels.

Data about school visits, medical & dental examination and referral of students, vaccination, laboratory investigation, school environment and drinking water laboratory testing (routine, chlorine residue, and microbiological), health education, infectious and chronic diseases are gathered on monthly and annual bases but no data are collected regarding risk factors and behaviours of students. there is previous study Jordan GSHS/2004 about the magnitude of problems related to such risk factors and behaviours we have in Jordan also few studies about tobacco use among students and the GYTS where overall 21% of students smoked cigarettes on one or more days during the past 30 days and male students (25%) were significantly more likely than female students (14.8%) to have smoked cigarettes. Overall 33% of students used any other form of tobacco and male students ( 36.5%) were significantly more likely than female students (27.7%) used any other form of tobacco. Overall 61.8% tried to stop smoking cigarettes. This study will be conducted to explore the magnitude of health risk behaviours and protective factors among students aged 13-15 years in order to provide baseline data for policy makers to help in setting priorities and planning programs that improve quality of life as students now and fathers tomorrow.

Jordan GSHS Questionnaire - 2007 9

Methods

Sampling

The 2007 Jordan GSHS employed a two-stage cluster sample design to produce a representative sample of students in 8th through 10th grades. The first-stage sampling frame consisted of all schools containing any of 8th through 10th grades. Schools were selected with probability proportional to school enrolment size. 25 schools were selected to participate in the Jordan GSHS, 14 of them were male schools, and distributed as follow: 20 public schools, 2 private schools in Greater Amman, and 3 UNRWA school. Public schools are geographically distributed as follow: 13 in Greater Amman, other governorates:, 4 in Zarqa, 2 in Dear Alla and 1 in each of Irbid , Maan, Ramtha,Mafraq,Bane Kenanh andAjlon.

The second stage of sampling consisted of randomly selecting intact classrooms (using a random start) from each school to participate. All classrooms in each selected school were included in the sampling frame. All students in the sampled classrooms were eligible to participate in the

GSHS.

The sample of students was 2243 students from the sampled 70 classrooms.(Annex 2).

Weighting

A weighting factor was applied to each student record to adjust for non-response and for the varying probabilities of selection.

W= W1*W2*f1*f2*f3 where:

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 non response adjustment factor calculated by school size category (small, medium, large). The factor was calculated in terms of school enrolment instead of numbers of schools.

f2 = a school- level non response adjustment factor calculated by class.

f3 = a post stratification adjustment factor calculated by grade.

Response rates

For the 2007 Jordan GSHS, 2197 questionnaires were completed in 25 schools. The school response rate was 100%, the student response rate was 99.8%, and the overall response rate was 99.8%. The data set was cleaned and edited for inconsistencies. Missing data were not statistically imputed. Software that takes into consideration the complex sample design was used to compute prevalence estimates and 95% confidence intervals. GSHS data are representative of all students attending 8th through 10th grades in Jordan.

Jordan GSHS Questionnaire - 2007 10

Administering the survey

Survey Administration.

• Approval and permission to conduct the study were obtained from both MOH &

MOE.(Annex1) The 2004 GSHS questionnaire was the same tool used in 2007 GSHS. 43 questions were used from the GSHS global core modules and 44 additional questions were added from the GSHS core expanded set of questions .

• A total of 87 questions in 11pages were selected for Jordan

• Print out & copying of the accredited and translated questionnaire was done and

3000 copies were prepared. (Annex3)

• Preparing special forms at school level for the selected sample of schools (School level form) and forms at class level (Class level form).

• Translating & printout of all the instructions relevant to field survey implementation activities: (Student instructions ،School message, and Instructions for field workers).

• A one day workshop was held on for training field workers on how to implement survey activities in the field. Trainers illustrated practically the implementation activities. Copies of questionnaires & answer sheets, pencils, instructions, envelops of different sizes were delivered to them.

Data collection occurred from 22rd to 24th May 2007 Survey procedures were designed to protect student privacy by allowing for anonymous and voluntary participation. Students completed the self-administered questionnaire during one classroom period and recorded their responses directly on a computer-scanable answer sheet. Approximately, twenty Survey Administrators were specially trained to conduct the GSHS.

The answer sheets, questionnaires, school level forms and class level forms were gathered and put in the envelops according to survey protocol and CDC instructions and sent via FedEx company to CDC/Atlanta on 7/6/2007, for data entry, processing, and analysis and the tapulated data were returned to Jordan in order to prepare the final report.

GSHS Questionnaire

The Jordan GSHS questionnaire contained 87 questions addressing the following topics:

1. Respondents demography.

2. Dietary behaviours

3. Personal hygiene.

4. Mental health.

5. Physical activity.

6. Protective factors.

7. Tobacco use.

8. Violence and unintentional injury

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Part 2: Results

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Overview

Data results were tabulated for frequency descriptions and relevant variable description:

demographic characteristics of participating students mainly age, sex, and grade, dietary behaviours, personal hygiene, mental health, physical activity, protective factors, sexual behaviours that contribute to HIV, AIDS, and other STIs, tobacco use, violence and unintentional injuries.

Demographics

The demographic characteristics of the sample are described in the following table.

Table 1. Demographic characteristics of the sample for Jordan, 2007

Sex Grade Age in years

Males Females 8th 9th 10th ≤12 13-15 ≥16 Jordan 50.5% 49.5% 34.8% 32.7% 29.7% 1.4% 73.9% 24.6%

Dietary Behaviours

During adolescence, overweight is associated with hyperlipidemia, raised blood pressure (hypertension), abnormal glucose tolerance, and adverse psychological and social consequences.

Overweight acquired during childhood or adolescence may persist into adulthood and increase risk later in life for coronary heart disease, diabetes, gallbladder disease, some types of cancer, and osteoarthritis of the weight-bearing joints. Nutritional deficiencies as a result of food insecurity (protein-energy malnutrition, iron, Vitamin A, and iodine deficiency) affect school participation and learning.i

Fruits and vegetables are good sources of complex carbohydrates, vitamins, minerals, and other substances important for good health. Dietary patterns that include higher intakes of fruits and vegetables are associated with several health benefits, including a decreased risk for some types of cancer.ii

Jordan GSHS Questionnaire - 2007 13

Results

Table 2. Body Mass Index (BMI) and dietary behaviours, by sex, Jordan, 2007.

Sex Question Total % (CI)* Male % (CI) Female % (CI)

At risk for becoming overweight1 14.3 (11.3 – 17.4) 18.1 (14.4 – 21.8) 9.8 (7.5 – 12.2) Overweight2 3.9 (2.3 – 5.6) 5.5 (3.4 – 7.5) 2.1 (0.7 – 3.4) Try to lose weight. 34.9 (29.3 – 40.6) 26.4 (23.3 – 29.5) 43.6 (37.2 – 50.1) Went hungry most of the time or always because there was not enough food in their home during the past 30 days

14.1 (12.1 – 16.2) 14.2 (11.4 – 17.0) 13.5 (10.2 – 16.8)

Usually ate fruit, such as apples, bananas, citrus fruits, one or more times per day during the past 30 days

69.2 (65.1 – 73.4) 67.6 (62.2 – 73.1) 70.9 (64.6 – 77.1)

Usually ate vegetables, such as tomato, cucumber, spinach or eggplant, one or more times per day during the past 30 days

77.5 (74.7 – 80.4) 78.6 (75.0 – 82.1) 76.5 (72.2 – 80.7)

Ate five or more fruits and vegetables per day during the past 30 days

25.2 (22.4 – 27.9) 26.9 (23.9 – 29.9) 23.6 (18.8 – 28.4)

Ate at a fast food restaurant, such as McDonalds, Boston Fried Chicken, or Burger King on three or more days during the past seven days.

14.6 (11.8 – 17.3) 15.8 (12.9 – 18.6) 13.0 (9.2 – 16.8)

Usually drink carbonated soft drinks, such as Coke, Pepsi, Coca cola, 7-up or Fanta two or more times per day during past 30 days.

38.1 (34.5 – 41.8) 40.5 (36.3 – 44.7) 35.6 (28.9 – 42.4)

Drink milk or eat milk products such as yogurt, cheddar cheese, or cream cheese two or more times per day during the past 30 days

35.8(33.3 –38.3) 37.3 (33.2 –41.4) 34.4 (30.8 -38.0)

*95% confidence interval.

1Students who were at or above the 85th percentile, but below the 95th percentile for body mass index by age and sex based on reference data from Cole, Bellizzi, Flegal, and Dietz, BMJ, May 2000.

2Students who were at or above the 95th percentile for body mass index by age and sex based on reference data from Cole, Bellizzi, Flegal, and Dietz, BMJ, May 2000.

Prevalence of overweight

In Jordan, 14.3% of students were at risk for becoming overweight (i.e., at or above the 85th percentile, but below the 95th percentile for body mass index by age and sex) and 3.9% were overweight (i.e., at or above the 95th percentile for body mass index by age and sex). Male students (18.1%) are significantly more likely than female students (9.8%) to be at risk for becoming overweight.

Trying to lose weight

Overall, 34.9% of students were trying to lose weight. Female students (43.6%) are significantly more likely than male students (26.4%) to be trying to lose weight.

Jordan GSHS Questionnaire - 2007 14

Prevalence of hunger

Overall, 14.1% of students went hungry most of the time or always because there was not enough food in their home during the past 30 days

Fruit and vegetable intake

Overall, 69.2% of students usually ate fruit, such as apples, bananas and citrus fruits, one or more times per day during the past 30 days. Overall, 77.5% of students usually ate vegetables, such as tomato, cucumber, spinach or eggplant, one or more times per day during the past 30 days. Overall, 25.2% of students usually ate fruits and vegetables five or more times per day during the past 30 days.

Fast food and soft drink consumption and milk & milk products intake

Overall, 14.6% of students ate at a fast food restaurant, such as McDonalds, Boston Fried Chicken, or Burger King on three or more days during the past seven days. 38.1% of students usually drink carbonated soft drinks, such as Coke, Pepsi , Coca cola, 7-up or Fanta two or more times per day during past 30 days. 35.8% of students drink milk or eat milk products such as yogurt, cheddar cheese, or cream cheese three or more times per day during the past 30 days

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Hygiene

Background

Dental caries affect between 60-90% of children in developing countries and is the most prevalent oral disease among children in several Asian and Latin American countries. In Africa, the incidence of dental caries is expected to rise drastically in the near future due to increased sugar consumption and inadequate fluoride exposure.iii In addition to causing pain and discomfort, poor oral health can affect children's ability to communicate and learn. More than 50 million school hours are lost annually because of oral health problems.iv In both developed and developing countries, many children do not have access to water fluoridation or professional dental care. Daily tooth cleaning or brushing can help prevent some dental disease.v

Diarrhoeal diseases kill nearly 2 million children every year. Hygiene education and the promotion of hand-washing can reduce the number of diarrhoeal cases by 45%. vi About 400 million school-aged children are infected with worms worldwide. These parasites consume nutrients from children they infect, cause abdominal pain and malfunction, and can impair learning by slowing cognitive development.vii

Table3. Hygiene-related behaviours, by sex, Jordan, 2007.

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Did not clean or brush their teeth during the past 30 days

25.3 (21.5 – 29.1) 30.6 (26.4 – 34.7) 19.3 (16.1 – 22.5)

Never or rarely washed their hands before eating during the past 30 days

7.4 (5.6 – 9.2) 9.7 (6.8 – 12.5) 4.9 (3.4 – 6.4)

Never or rarely washed their hands after using the toilet or latrine

7.4 (5.1 – 9.7) 9.1 (6.3 – 11.9) 5.3 (3.6 – 7.0)

Never or rarely used soap when washing their hands

9.1 (7.3 – 11.0) 11.2 (9.1 – 13.2) 6.8 (4.7 – 8.9)

Do not have a source of clean water for drinking at school.

58.6 (50.6 – 66.6) 50.8 (42.3 –59.3) 66.3 (57.5 – 75.2)

Do not have a place to wash their hands before eating at school.

33.3 (26.8 – 39.8) 35.0 (27.3 – 42.6) 31.6 (22.1 – 41.2)

Whose toilets or latrines at school are not clean.

72.2 (66.5 – 78.0) 70.0 (64.3 – 75.7) 74.4 (66.0 – 82.8)

*95% confidence interval.

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Personal Hygiene:

In Jordan, the percentage of students who did not clean or brush their teeth during the past 30 days was 25.3%. Male students (30.6%) are significantly more likely than female students (19.3%) to not clean or brush their teeth. the percentage of students who Never or rarely washed their hands before eating during the past 30 days(7.4%). Male students( 9.7%) are significantly more likely than female students(4.9%) to never or rarely washed their hands before eating during the past 30 days. Overall, 7.4% of students never or rarely washed their hands after using the toilet or latrine during the past 30 days. the percentage of students who Never or rarely used soap when washing their hands(9.1%). Male students( 11.2%) are significantly more likely than female students(6.8%) to never or rarely used soap when washing their hands during the past 30 days.

In Jordan, 58.6% of students do not have a source of clean water for drinking at school. 33.3% of students do not have a place to wash their hands before eating at school. Overall, 72.2% of students have toilets or latrines which are not clean at school.

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Mental Health

World-wide, approximately 20% of children and adolescents suffer from a disabling mental illness.viii Anxiety disorders, depression and other mood disorders, and behavioural and cognitive disorders are among the most common mental health problems among adolescents.

Half of all lifetime cases of mental disorders start by age 14.ix

Every country and culture has children and adolescents struggling with mental health problems.

Most of these young people suffer needlessly, unable to access appropriate resources for recognition, support, and treatment. Ignored, these young people are at high risk for abuse and neglect, suicide, alcohol and other drug use, school failure, violent and criminal activities, mental illness in adulthood, and health-jeopardizing impulsive behaviours. World-wide, about 4 million adolescents attempt suicide each year. Suicide is the third leading cause of death among adolescents. x, xi

Results

Table 4. Mental health issues among students, by sex, Jordan, 2007 .

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Most of the time or always felt lonely during the past 12 months

15.7 (12.8 – 18.6) 12.2 (9.1 – 15.4) 19.3 (15.2 – 23.4)

Most of the time or always felt so worried about something that they could not sleep at night during the past 12 months

18.4 (15.6 – 21.1) 13.5 (10.6 – 16.3) 23.4 (20.9 – 25.8)

Seriously considered attempting suicide during the past 12months

18.0 (16.1 – 19.9) 16.8 (14.4 – 19.1) 18.8 (15.9 – 21.6)

Made a plan about how they would attempt suicide during the past 12 months

18.1 (16.1 – 20.1) 17.0 (13.8 – 20.1) 18.9 (16.9 – 20.9)

Have no close friends 8.2 (6.5 – 9.8) 8.9 (6.6 – 11.1) 7.4 (5.2– 9.6) *95% confidence interval.

Loneliness/depression

In Jordan, 15.7% of students most of the time or always felt lonely during the past 12 months.

Overall, 18.4% of students most of the time or always felt so worried about something that they could not sleep at night during the past 12 months . Male students (13.5%) are significantly less likely than female students (23.4%) to most of the time or always feel so worried about something they can not sleep at night.

Suicidal behaviour

Overall, 18.0% of students seriously considered attempting suicide during the past 12 months.

Overall, 18.1% of students made a plan about how they would attempt suicide during the past 12 months. Overall 8.2% of students have no close friends.

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Physical Activity

Background

Participating in adequate physical activity throughout the life span and maintaining normal weight are the most effective ways of preventing many chronic diseases, including cardiovascular disease and diabetes.xii

The prevalence of type 2 diabetes is increasing globally and now is occurring during adolescence and childhood.xiii Participating in adequate physical activity also helps build and maintain healthy bones and muscles, control weight, reduce blood pressure, ensure a healthy blood profile, reduce fat, and promote psychological well-being.xiv

Roughly 60% of the world's population is estimated to not get enough physical activity. Patterns of physical activity acquired during childhood and adolescence are more likely to be maintained throughout the life span, thus sedentary behaviour adopted at a young age is likely to persist.xv

Results

Table 5. Physical activity among students, by sex, Jordan, 2007.

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Physically active all seven days for a total of at least 60 minutes per day during the past seven days

14.3 (12.2 – 16.5) 17.5 (14.7 – 20.2) 11.3 (9.7 – 13.0)

Physically active seven days for a total of at least 60 minutes per day during a typical or usual week

11.2 (9.6 – 12.8) 14.7 (12.8 – 16.6) 7.9 (6.6 – 9.2)

Participated in physical activity for a total of at least 60 minutes per day on five or fewer days on average

83.5 (81.3 – 85.6) 79.1 (76.7 – 81.6) 87.8 (86.2 – 89.3)

Spent three or more hours per day doing sitting activities during a typical or usual day

39.3 (35.5 – 43.2) 37.8 (33.2 – 42.4) 41.2 (34.5 – 47.8)

Did not walk or bicycle to and from school during the past seven days

44.4 (40.5 – 48.3) 42.4 (38.7 – 46.1) 46.5 (39.6 – 53.4)

Usually took less than 30 minutes to get to and from school each day during the past seven days

76.6 (74.7 – 78.4) 74.6 (72.9 – 76.4) 78.4 (75.5 – 81.2)

*95% confidence interval.

Physical activity

In Jordan, 14.3% of students were physically active all 7 days during the past 7 days for a total of at least 60 minutes per day. Male students(17.5%) are significantly more likely than female students(11.3%) to be physical active all 7 days for a total of at least 60 minutes per day than .

11.2% of students were physically active 7 days during a typical or usual week for a total of at least 60 minutes per day. Male students(14.7%) are significantly more likely than female students(7.9%) to be physically active 7 days during a typical or usual week for a total of at

Jordan GSHS Questionnaire - 2007 19 least60 minutes per day. 83.5% of students participated in insufficient physical activity (i.e., participated in physical activity for a total of at least 60 minutes per day on five or fewer days on average). Male students(79.1%) are significantly less likely than female students(87.8%) to participate in insufficient physical activity (i.e., participated in physical activity for a total of at least 60 minutes per day on five or fewer days on average.

Sedentary behaviour

Overall, 39.3% of students spent three or more hours per day doing sitting activities during a typical or usual day.

Walk or bicycle to and from school

Overall, 44.4% of students did not walk or bicycle to and from school during the past 7 days.

Overall, 76.6% of students usually took less than 30 minutes to get to and from school each day during the past 7 days.

Protective Factors

For most adolescents, school is the most important setting outside of the family. School attendance is related to the prevalence of several health risk behaviours including violence and sexual risk behaviours.xvi

Adolescents who have a positive relationship with teachers, and who have positive attitudes towards school are less likely to initiate sexual activity early, less likely to use substances, and less likely to experience depression. Adolescents who live in a social environment which provides meaningful relationships, encourages self-expression, and also provides structure and boundaries, are less likely to initiate sex at a young age, less likely to experience depression, and less likely to use substances.xvii

Being liked and accepted by peers is crucial to young people’s health development, and those who are not socially integrated are far more likely to exhibit difficulties with their physical and emotional health. Isolation from peers in adolescence can lead to feelings of loneliness and psychological symptoms. Interaction with friends tends to improve social skills and strengthen the ability to cope with stressful events.xviii

Parental bonding and connection is associated with lower levels of depression and suicidal ideation, alcohol use, sexual risk behaviours, and violence.xix

Jordan GSHS Questionnaire - 2007 20

Table 6. Protective factors among students, by sex, Jordan, 2007.

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Missed classes or school without permission on one or more of the past 30 days

39.1 (34.4 – 43.9) 42.9 (37.1 – 48.8) 35.1 (28.7 – 41.6)

Most of the students in their school were never or rarely kind and helpful most of the time or always during the past 30 days

36.5 (32.5 – 40.4) 42.9 (39.7 – 46.1) 29.9 (26.2 – 33.6)

Parents or guardians never or rarely checked to see if their homework was done most of the time or always during the past 30 days

34.3 (31.2 – 37.4) 31.7 (28.5 – 34.8) 36.8 (31.7 – 42.0)

Parents or guardians never or rarely understood their problems and worries most of the time or always during the past 30 days

43.4 (40.8 – 46.0) 42.3 (39.0 – 45.7) 44.4 (40.1 – 48.8)

Parents or guardians never or rarely really knew what they were doing with their free time most of the time or always during the past 30 days

37.2 (34.2 – 40.2) 38.3 (34.8 – 41.8) 36.1 (32.1 – 40.2)

*95% confidence interval.

Missing classes

In Jordan, overall 39.1% of students missed classes or school without permission on one or more of the past 30 days.

Being kind and helpful

36.5% of students reported that most of the students in their school were never or rarely kind and helpful most of the time or always during the past 30 days. Male students (42.9%) are significantly more likely than female students (29.9%) reported that most of the students in their school were never or rarely kind and helpful most of the time or always during the past 30 days.

Parents or guardians

Overall, 34.3% of students reported their parents or guardians never or rarely checked to see if their homework was done most of the time or always during the past 30 days. Overall, 43.4% of students reported their parents or guardians never or rarely understood their problems and worries most of the time or always during the past 30 days. Overall, 37.2% of students reported their parents or guardians never or rarely really know what they were doing with their free time most of the time or always during the past 30 days.

Jordan GSHS Questionnaire - 2007 21

Sexual Behaviours that Contribute to HIV Infection, and Other STI.

AIDS has killed more than 25 million people since 1981. As of 2005, an estimated 40.3 million people were living with HIV. In that year alone, roughly 3.1 million people died of HIV and another 4.9 million people became infected with HIV.xx Young people between the ages of 15 and 24 are the most threatened group, accounting for more than half of those newly infected with HIV. At the end of 2003, an estimated 10 million young people aged 15 to 24 were living 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 is reducing average life expectancy, threatening food security and nutrition, dissolving households, overloading the health care system, reducing economic growth and development, and reducing school enrolment and the availability of teachers.xxi STIs are among the most common causes of illness in the world and have far-reaching health consequences. They facilitate the transmission of HIV and, if left untreated, can lead to cervical cancer, pelvic inflammatory diseases, and ectopic pregnancies.xxii Worldwide, the highest reported rates of STIs are found among people between 15 and 24 years; up to 60% of the new infections and half of all people living with HIV globally are in this age group.xxiii

Results

Table 7. HIV-related knowledge, by sex, Jordan 2007.

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Ever heard of HIV or the disease called

AIDS

84.9 (81.5 – 88.4) 81.1 (77.2 – 85.1) 88.6 (85.2 – 92.0)

Taught in any of their classes about HIV or AIDS during this school year

56.1 (51.1 – 61.0) 51.2 (44.4 – 57.9) 60.7 (53.7 – 67.8)

Taught in any of their classes how to avoid HIV or AIDS during this school year

54.8 (50.6 – 59.0) 52.9 (46.4 – 59.4) 56.7 (49.5 – 63.9)

Know that people can protect themselves from HIV by not having sexual intercourse

75.2 (72.2 – 78.2) 72.9 (70.4 – 75.3) 77.5 (74.0 – 81.0)

*95% confidence interval

Awareness of HIV or AIDS

In Jordan, 84.9% of students had ever heard of HIV or the disease called AIDS. Male students (81.1%) are significantly less likely than female students (88.6%) had ever heard of HIV or the disease called AIDS. Overall, 56.1% of students had been taught in any of their classes about HIV or AIDS during this school year. Overall, 54.8% of students had been taught in any of their classes how to avoid HIV or AIDS during this school year. Overall, 75.2% of students knew that people can protect themselves from HIV by not having sexual intercourse.

Jordan GSHS Questionnaire - 2007 22

Tobacco Use

Background About 1.1 billion people worldwide smoke and the number of smokers continue to increase.

Among these, about 84% live in developing and transitional economy countries. Currently 5 million people die each year from tobacco consumption, the second leading cause of death worldwide. If present consumption patterns continue, it is estimated that deaths from tobacco consumption will be 10 million people per year by 2020.xxiv The overwhelming majority of smokers begin tobacco use before they reach adulthood. Among those young people who smoke, nearly one-quarter smoked their first cigarette before they reached the age of ten.

Smokers have markedly increased risks of multiple cancers, particularly lung cancer, and are at far greater risk of heart disease, strokes, emphysema and many other fatal and non-fatal diseases.

If they chew tobacco, they risk cancer of the lip, tongue and mouth. Children are at particular risk from adults’ smoking. Adverse health effects include pneumonia and bronchitis, coughing and wheezing, worsening of asthma, middle ear disease, and possibly neuro-behavioural impairment and cardiovascular disease in adulthood. Many studies show that parental smoking is associated with higher youth smoking.xxv

Results Table 8. Tobacco use among students, by sex, Jordan, 2007.

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Smoked cigarettes on one or more days during the past 30 days

15.6 (11.0 – 20.2) 22.7 (18.1 – 27.2) 8.7 (6.1 – 11.2)

Used any other form of tobacco, such as argela or pipe, on one or more days during the past 30 days

20.8 (16.3 – 25.3) 26.6 (23.3 – 29.9) 14.6 (9.6 – 19.6)

Used any form of tobacco on one or more of the past 30 days

24.9 (19.4 – 30.3) 33.5 (29.2 – 37.9) 16.5 (11.6 – 21.5)

Among students who smoked cigarettes during the past 12 months, those who tried to stop smoking cigarettes

68.3 (63.4 – 73.3) 71.0 (66.9 – 75.2) 62.1(51.5– 72.7)

People smoked in their presence on one or more days during the past seven days

75.3 (72.3 – 78.3) 75.0 (71.2 – 78.8) 75.8 (71.8 – 79.7)

Have a parent or guardian who uses any form of tobacco

50.2 (46.8 – 53.6) 50.2 (46.7 – 53.8) 50.1 (44.6 – 55.7)

*95% confidence interval.

**fewer than 100 students Prevalence of tobacco use In Jordan 15.6% of students smoked cigarettes on one or more days during the past 30 days.

Male students (22.7%) are significantly more likely than female students (8.7%) to have smoked cigarettes on one or more days. Overall, 20.8% of students used any other form of tobacco on one or more days during the past 30 days. Male students (26.6%) are significantly more likely than female students (14.6%) to use any other form of tobacco on one or more days. Overall, 24.9% of students used any form of tobacco on one or more of the past 30 days. Male students (33.5%) were significantly more likely than female students (16.5%) to use any form of tobacco.

Among students who smoked cigarettes during the past 12 months, 68.3% tried to stop smoking cigarettes.

Jordan GSHS Questionnaire - 2007 23

Parents or guardian tobacco use Overall, 75.3% of students reported that people smoked in their presence on one or more days during the past seven days. Overall, 50.2% of students had a parent or guardian who uses any form of tobacco.

Violence and Unintentional Injury

Unintentional injuries are a major cause of death and disability among young children.xxvi Each year, about 875,000 children under the age of 18 die from injuries and 10 to 30 million have their lives affected by injury. Injury is highly associated with age and gender. Males aged 10-14 have 60% higher injury death rates than females. Teenagers aged 15-19 have higher rates than those aged 10-14 years (64 compared to 29 per 100,000).

Estimated global homicide death rate for males aged 15-17 is 9 per 100,000xxvii. For every youth homicide, approximately 20 to 40 victims of non-fatal youth violence receive hospital treatment.xxviii Many unintentional injuries lead to permanent disability and brain damage, depression, substance abuse, suicide attempts, and the adoption of health risk behaviours.

Victims of bullying have increased stress and a reduced ability to concentrate and are at increased risk for substance abuse, aggressive behaviour, and suicide attempts.xxix

Results Table 9. Violence and unintentional injury among students, by sex, Jordan,, 2007

Sex Question Total % (CI)* Male % (CI) Female % (CI)

Were in a physical fight one or more times during the past 12 months

46.7 (37.9 – 55.5) 63.9 (59.3 – 68.5) 29.4 (23.7 – 35.1)

Were seriously injured one or more times during the past 12 months

43.7 (37.7 – 49.7) 52.3 (47.9 – 56.7) 34.7 (29.5 – 39.9)

Among students who were seriously injured during the past 12 months, those whose most serious injury happened to them while they were playing or training for a sport

24.6(18.0 – 31.2) 33.7 (28.8 – 38.6) 11.1 (6.2 – 16.0)

Among students who were seriously injured during the past 12 months, those whose most serious injury was the result of a fall

18.8 (15.9 – 21.7) 20.4 (17.1 – 23.7) 15.7 (11.9- 19.6)

Among students who were seriously injured during the past 12 months, those who most serious injury was the result of them hurting themselves by accident

38.8 (34.4 – 43.1) 33.8 (29.5 – 38.0) 46.7 (38.6 – 54.8)

Among students who were seriously injured during the past 12 months, those who had a broken bone or dislocated joint as their most serious injury

20.5 (16.9 – 24.0) 24.6 (21.8 – 27.4) 14.1 (8.5 – 19.7)

Were bullied on one or more days during the past 30 days

41.6 (36.9 – 46.3) 46.6 (43.4 – 49.7) 36.5 (29.6 – 43.5)

Among students who were bullied during the past 30 days, those who were bullied most often by being hit, kicked, pushed, shoved around, or locked indoors

13.3 (9.6 – 17.0) 16.9 (13.4 – 20.4) 8.5 (5.4 – 11.6)

*95% confidence interval.

Jordan GSHS Questionnaire - 2007 24

Serious Injury

In Jordan 46.7% of students were in a physical fight one or more times during the past 12 months. Male students (63.9%) are significantly more likely than female students (29.4%) to have been in a physical fight. Overall, 43.7% of students were seriously injured one or more times during the past 12 months. Male students (52.3%) are significantly more likely than female students (34.7%) to have been seriously injured. Among students who were seriously injured during the past 12 months, 24.6% were playing or training for a sport when their most serious injury happened to them, 18.8% had their most serious injury caused by a fall, 38.8% had their most serious injury occur as a result of hurting themselves by accident. Male students (33.8%) are significantly less likely than female students (46.7%) had their most serious injury occur as a result of hurting themselves by accident. and 20.5% who had a broken bone or dislocated joint as their most serious injury. Male students (24.6%) are significantly more likely than female students (14.1%) who had a broken bone or dislocated joint as their most serious injury.

Bullying

Overall, 41.6% of students were bullied on one or more days during the past 30 days. Among students who were bullied during the past 30 days, 13.3% were bullied most often by being hit, kicked, pushed, shoved around, or locked indoors. Male students (16.9%) are significantly more likely than female students (8.5%) to be bullied most often by being hit, kicked, pushed, shoved around, or locked indoors.

Jordan GSHS Questionnaire - 2007 25

Bar graphics illustrating the main findings per health risk behaviours, protective factors and gender

Dietary Behavior: Percentage of students (13-15 years) by sex who are at risk of becoming overweight or are overweight (JORDAN GSHS 2007)

23.6

18.1

5.5

11.9 9.8

2.1

BMI above 85th percentile

Risk of overweight

Overweight

Pe rc en t

Boys Girls

Hygiene: Percentage of students (13-15 years) who during the past 30 days did not brush their teeth, never or rarely washed their hands before eating or after using the toilet or latrine

(JORDAN GSHS 2007)

30.6

9.7 9.1

19.3

4.9 5.3

Did not brush their teeth

Never washed hands before eating

Never washed hands after toilet

Pe rc en t

Jordan GSHS Questionnaire - 2007 26

Mental health issues among students (13-15 years) by sex (Jordan GSHS 2007)

12.2 13.5 16.8

19.3 23.4

18.8

Felt lonely most time past 12 months

Felt worried most time could not sleep past 12 months

Seriously considered attempting suicide past 12 months

Pe rc en t

Physical activity among students (13-15 years) by sex (Jordan GSHS 2007)

17.5

37.8 42.4

11.3

41.2 46.5

Physically active all 7days for a total 60 minutes per day last 7 days

Spent 3 hours at least per day doing sedentary activity per typical day

Did not walk or bicycle to and from school during past 7 days

Pe rc en t

Jordan GSHS Questionnaire - 2007 27

Violence and unintentional injury issues among students (13-15 years by sex) Jordan GSHS 2007

63.9 52.3

46.6

29.4 34.7 36.5

Were in Physical fight one or more times during past

12 months

Were seriously injured one or more times during the past 12 months

Were bullied on one or more days during the past 30 days

Pe rc en t

Tobacco use issues among students (13-15 years) by sex JORDAN GSHS 2007

22.7 26.6

50.2

8.7 14.6

75.8

50.1

Smoked cigarettes on one or more days during past 30 days

Used any form of tobacco during past 30 days

People smoked in their presence on one or more days during past 30 days

Have a parent or guardian who uses any form of tobacco

Jordan GSHS Questionnaire - 2007 28

Part 3: Conclusions and Recommendations

Jordan GSHS Questionnaire - 2007 29

Conclusions

Dietary behaviour: boys were not aware about the problem of overweight or the risk of becoming over weight and they didn't try to lose weight as females did. The prevalence of hunger among students reflects the low socio economic status of their families. 70% - 78% of students ate fruits and vegetables which is a protective factor. There is tendency to eat at a fast restaurant three or more days a week, and drink carbonated soft drinks which inhibit calcium absorption and at the same time the percent of students who take milk or milk products is low.

Hygiene: Results also indicate that female students were taking care about themselves better than males and despite there are good healthy practices regarding personal hygiene such as brushing or cleaning teeth, washing hands before eating and after using the toilet or latrines, and using soap when washing their…