High Risk Health Behavior among Malaysian Adolescents: A Comparison between Gender

Purpose: The main objective was to study health risk behaviours, knowledge and perception amongst Malaysian adolescents aged between 13-17 years of age. Methods: Modified version of Youth Behaviour Risk Factor Surveillance System (YBRFSS) was used in this nationwide cross-sectional study involving 5,000 students enrolled from 50 selected schools, by adopting multi-stage sampling with randomization of schools and classes from all states in Malaysia. Descriptive data for behaviours, knowledge and perception were also compared between genders. Results: Overall, 72.6% and 21.1% adolescents were found to not perform adequate exercise or did not perform any exercise, respectively. Majority of them also (81.8%) spent time watching TV beyond one hour per day. Although overall compliance to meal timings showed better result for girls (89.2%) than boys (84.8%); non-compliance to breakfast timing was the most frequent (74.7%) compared to other meal timings. Signs of continuous sadness ranked highest (21.3%), followed by signs of depression (9.4%) and suicidal ideation (7.8%). Girls suffered worse than boys for signs of continuous sadness (25.4% vs. 16.2%) and suicidal ideation (10.4% vs. 4.5%). In terms of perception, only 50.1% responded favourably to managing their anger. Boys were more satisfied with their own body weight and body shapes compared with the girls (43.3% vs. 34.7%; 45.3% vs. 37.9%, respectively). Conclusion: Although adolescents in Malaysia had good overall knowledge and perception on the healthy habits, they still practiced risky behaviours which may lead to early morbidity and mortality among adolescence.


Introduction
The Malaysian health care authorities initiated a survey to determine the youth risky behaviour practices. In this regard, the Youth Behaviour Risk Factor Surveillance (YBRFS) was adapted from the Youth Behaviour Risk Factor Surveillance System (YBRFSS) originated by Centre for Disease Control (CDC) Atlanta in 1990. Since then, CDC has collected data on the behaviour trend from over 1.7 million high-school students . In the Malaysian version, knowledge and perception was added to the original YBRFSS.
obtained as the NHMS main coverage is for adults aged 18 and above (Institute of Public Health, 2008). The GSHS covers ten key areas and is performed annually worldwide by presently in 101 nations. However, Malaysia was not part of the group, and both studies (NHMS and GSHS) did not include data on the knowledge and perception of participants involved.
The objective of this study was to elicit health risk behaviours, knowledge and perception amongst adolescence aged 13-17 years that leads to morbidity and mortality, disability and social problems traversing from adolescent to adult life. This study specially emphasised on exercise and physical inactivity, dietary behaviours, smoking behaviour, alcohol intake, drug use, risky sexual behaviour, mental health and road safety. It is expected that the results of the study may be beneficial for future health care planning in the country.

Study Design and Sampling
This cross sectional study with multi-staged sampling involved Malaysian secondary school students from Form 1, 2 and 4 (equivalent to 7th, 8th and 10th grade of the American education system) aged between 13 to 17 years from selected secondary schools nationwide. Nationwide enrolment of the 2,248 public secondary schools in 2010 was 2,344,891 students for all 15 states in Malaysia (MOE, 2010). Therefore, fifty schools were selected via randomization according to the enrolment size and the representativeness of the population ratio and density for each state within the country. Overall, 5000 respondents were recruited; excluding absentees, illiterate adolescents and adolescents who refused to participate. All data collection was carried out between August and December 2010.

Ethical Approval
Consent to conduct the study was obtained from two governing bodies; namely, The National Medical Research Ethics Committee of the Ministry of Health (Project Code: NMRR-09-97-3520) and the Education Research Ethics Division from the Ministry of Education. Written approval was also obtained from the State Health Directors, State Education Directors and the selected schools.

Instrument
The Youth Behaviour Risk Factor Surveillance (YBRFS) questionnaire was adapted from the Youth Behaviour Risk Factor Surveillance System (YBRFSS) originated by Centre for Disease Control (CDC) Atlanta in 1990; and was modified by adding components of knowledge and perception adjusted to the needs of the local setting. The questionnaire was subjected to a series of review via workshops conducted between 2008-2010 involving experts from the various divisions within the Ministry of Health Malaysia and universities. The adapted questionnaire was also subjected to forward-backward translation.
The questionnaire comprises of three main components: (1) behaviour (exercise and inadequate physical inactivity, dietary behaviours, smoking behaviour, alcohol intake, drug use, risky sexual behaviour, mental health and road safety), (2) knowledge (exercise, food pyramid and dietary behaviour, smoking, alcohol, mental health & risky sexual behaviour), and (3) perception (exercise and physical inactivity, dietary behaviour, self-body perception, smoking behaviour, alcohol intake, risky sexual behaviour and mental health that covered two sub-domains; anger management and self-harm). The definitions used for the YBRFS were mostly derived from the original YBRFSS and other sources. They included definitions for exercise (ACSM, 1998), physical inactivity (The Henry J. Kaiser Foundation, 2005), meal timing (Gibney et al., 2005), favourable and unfavourable food intake (Ministry of Health, 2010), Body Mass Index (BMI) for age (WHO, 2007), smoking behaviour, alcohol intake, drug use, mental health and risky sexual behaviour (CDC, 2003).
Cognitive test was conducted involving 24 students from two different schools in Selangor, Malaysia via face-to-face interview and changes were made in the instrument prior to being pilot tested twice on different students in a high-school in Selangor. Subsequent changes were made accordingly to the piloted instrument before data collection. Data collected from the pre-test was analysed to measure the reliability and readability of the instrument. Results were tabulated and appraised to assess individual merits and usability. Some questions were modified to improve comprehension and readability while others were dropped as advised by the technical committee. Composite reliability was assessed for the attitude component and this yielded acceptable results for each domain: exercise and physical inactivity (0.571), dietary behaviour (0.570), self-body perception (0.826), smoking behaviour (0.652), alcohol intake (0.712), risky sexual behaviour (0.697), anger management sub-domain for mental health (0.623) and self-harm sub-domain for mental health (0.736).

Statistical Analysis
Complex sampling analysis extracted descriptive results with 95% Confidence Intervals (CI). Comparison was made between genders and missing values were not excluded from the analysis. Analysis was done using SPSS version 19.

General Findings & Demographics
Overall response rate for the study was 4088 (81.8%) from the 5000 eligible respondents. The socio-demographic characteristics of the respondents (as shown in Table 1) represented the total student population in the country. Half of the respondents had 4 to 6 siblings in their family (50.1%) and the majority had 6 to 10 persons living together (53.4%). Most respondents also had parents who were married (88.8%).

Behaviour
Half of the eight behavioural domains studied showed worrying trends. Smoking behaviour, alcohol intake, drug use and sexual behaviours showed a better overall result in practice as compared to the physical exercise and sedentary habits, dietary behaviours, mental health and road safety ( Within the dietary behaviour domain, the overall non-adherence to meal timing was 87.3%; with breakfast being the most frequently missed meal (74.7%), followed by lunch (57.8%) and dinner (47.5%). Girls showed better adherence to the meal timing as compared to the boys. Late night eating was least frequently reported attribute at 34.3% with no notable gender differences. Non-adherence to the recommended food groups was highest for vegetables (67.1%) and fruits (50.9%) with the girls showing higher non-adherence compared to boys. For risky dietary intake, over half of the respondents declared that they practiced regular intake of fast-food from fast food restaurants (69.0%) and school canteens (57.0%) as well as carbonated drinks (75.2%) beyond the recommended limit. In terms of BMI, most respondents were within the normal range (69.4%) with only 16.9% being overweight and 4.9% being obese.
Smoking behaviour, alcohol intake and drug use domain revealed low proportions of ever and current practices of risky behaviours. Smoking behaviour was the most frequently reported behaviour with 9.1% being ever smokers and 8.7% being current smokers. Boys were more frequently reported as ever smokers (17.6%) and current smokers (14.6%) compared with the girls (ever, 3.9% and current, 2.0%). This was followed by alcohol intake, with 5.7% having ever consumed alcohol and 5.6% still consuming alcohol. Only 0.1% of the respondents admitted to drug use (current drug user) and 0.7% admitted of ever inhaling glue. For both the latter domains, gender difference was extremely spatial.
A total of 61 subjects (1.6%) admitted of past sexual experience. Out of these 61 subjects, 43 adolescents (81.3%) had a single partner. Amongst those who admitted of having had sex, 11.1% were homosexuals, 5.5% were bisexuals, while the remaining were heterosexuals. Proportion of homosexuals and bisexuals were almost equivalent in either sex.
The road safety domain also showed low proportion of favourable behaviours with only 26.2 % of the respondents reported of wearing seatbelts every time they got into a car or taxi while only 30.9% wore a helmet while riding a motorcycle. No gender differences were noted.
in this study and the signs were more prevalent among girls (25.4%) rather than boys (16.2%). Signs of depression ranked second among the respondents with 9.4% reporting it with little difference between gender. Suicidal ideation followed closely to depression with 7.8% reporting it and the behaviour skewed more towards the girls (10.4%) compared to boys (4.5%).

Knowledge
The Knowledge component delved into six domains: exercise, food pyramid and dietary behaviour, smoking, alcohol, mental health & risky sexual behaviour knowledge (Table 3). The findings showed that the respondents had a good overall outlook in terms of knowledge. However, respondents scored low on the item 'to ensure the body gets enough nutrients, students need to eat three of six food groups recommended by the Malaysian Food Pyramid' with only 13.6% providing positive responses. Within the same domain of dietary behaviour knowledge, respondents also scored low on the correct 'servings of fruits to be consumed' (33.5%) and 'servings of vegetables to be consumed' (31.9%).
Respondents also scored low in the risky sexual health behaviour domain for questions asked such as 'having sex with a 16-year old girl is illegal even though it is consensual' (16.9%), 'infection is caused by abortion' (28.5%), 'syphilis is one of the diseases caused by having multiple sexual partners' (15.2%) and 'sexual activities are one of the mode of transmission of HIV/AIDS' (83.4%). Overall, comparison between gender showed that girls scored better for the majority of the questions.

Perception
The Perception component attempted to seek favourable perception from seven domains listed (Table 4). Of the seven domains, four domains (dietary intake, smoking behaviour, alcohol intake and risky sexual behaviour) showed favourable perception and the proportions in general for all items showed better results among girls. For the remaining domains, the respondents provided a mixture of responses with the mental health domain yielding both favourable and unfavourable responses within its two sub-domains.
Exercise and physical inactivity domain showed least favourable responses per item basis. Only 10.5% of the respondents perceived exercise as important to them, whilst 42.1% claiming to possess the energy to perform exercises and 49.0% mentioning that they will exercise even without friends. Albeit, over half of the subjects felt that time was not an issue (56.3%). In terms of gender, overall responses skewed towards girls over boys in terms of favourable responses.
The mental health domain yielded mixed findings. Only half of respondents perceived of having ability to control their anger well (50.1%) and girls seem to perceive less able to manage their anger compared to the boys (45.8% vs. 55.4%). Only less than half of respondents perceived average stress level is good and can be motivating (41.1%). Majority perceived that no one should commit suicide (80.3%) and self-inflicted injury should not be committed (75.9%).
For the self-body perception domain, respondents were unfavourable to both items; with only 38.6% reported of being satisfied with their current weight and only 41.2% were satisfied with their body shape. For both items, boys were more favourable in their responses.

Discussion
The present study is consistent with reports from WHO that 60% of the world's population is not getting enough physical activity (WHO, 2003). This finding is reflective of the Malaysian Adult Nutrition Survey conducted in 2003 where only 15.6% of adults did adequate exercise (Ministry of Health, 2003). This study further reinforced high sedentary lifestyle of excessive TV watching (81.8%) as reported in Spanish adolescent. This association could explain the lack of time for exercise as more time is devoted to sedentary lifestyle among adolescents (Serrano-Sanchez et al., 2011). In previous years, school children performance had always been benchmarked through academic performance thus ignoring the physical education and health. However, of late the National Education Philosophy is reinforced through the 1Student 1Sport Policy to encourage students to take up in sports as an initiative to improve physical activity and education in schools (Ministry of Education, 2011). Although the respondents had fairly good knowledge on exercise, they lacked the physical willpower to do it. Having a negative perception on exercise only strengthens the poor behaviour performance. About half of the respondents preferred to do exercise with the company of friends and a significant minority of them had problem finding time to do exercise. This dependency on social support to do exercise is the nature of humans. Other studies also noted time constraints such as after-school time demand as the similar barriers to physical activities (Romero, 2005); or in this case of exercise.
High non-adherence to meals timing is alarming especially for the first meal (breakfast) at 74.7%; considering that breakfast skipping is associated with dietary behaviours that result in increased unhealthy weight gain from adolescence to adulthood (Niemeier et al., 2006). Many possible factors may have led respondents not taking breakfast during the recommended timing. Some possible reasons include no time for breakfast (Shaw, 1998), living far away from schools (Nicklas, O'Neil, & Berenson, 1998) and that breakfast could not be prepared at home due to parents rushing out to work in the morning (Jackson, 2013). Respondents tended to take their "breakfast" during the morning recess (between 9:40 am and 10:50 am depending on school timing) and this affects the timing for lunch and dinner by pushing these meals to a later time; de-balancing the overall meals timing for the day. Other reasons such as leaving school late or reaching home late due to the standard school time ending between 12:40pm and 1:10pm (depending on schools), also tends to shift the time for lunch further. Added with extracurricular activities, meal timing tends to change for the benefit of these activities. This may have contributed to the high overall meals timing non-adherence (87.3%), even though these adolescents had good knowledge and perception on other aspects of dietary behaviours. The break up for all components between genders seemed to favour more on the boys compared to girls as physiologically boys tend to eat more due to their on-going puberty that ceases near to adulthood compared to the girls in whom it terminates earlier (PAMF, 2001) and who has more consciousness regarding their body shape and weight (Shaw, 1998).
Within the same domain, non-adherence to recommended food types is problematic only for vegetables and fruits. The 67.1% for vegetables and 50.9% for fruits non-adherence is reflective of the Malaysian Adult Nutrition Survey which revealed that only 60.1% of adults are not consuming adequate amounts of vegetables (Ministry of Health-2, 2003). These results are concurrent with low knowledge scores of the respondents on serving size of fruits (33.5%) and vegetables (31.9%). It is common knowledge that children do not like vegetables and fruits but they 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 were associated with several health benefits, including a decreased risk for some type of cancer (CDC, 2006). Thus, the practice of these beneficial food group intakes should be inculcated from young to prevent resistance in consumption. It should be noted however; the respondents have tenacity for taking fast food from either the fast-food restaurant (69.0%) or school canteen (57.0%). This in turn increases the chances of intake for carbonated drinks (75.2%). Studies showed a significant positive association between adolescent and their peer's behaviour in terms of sports, exercise and fast food consumption (Ali, Amialchuk, & Heiland, 2011). The accessibility of the fast food will lead to an increase in prevalence of obesity that is associated with hyperlipidaemia, raised blood pressure (hypertension), abnormal glucose tolerance, and adverse psychological and social consequences (Mohammadbeigi et al., 2019). Although the results of the Body Mass Index (BMI) suggested that the majority is normal, a 21.8% representativeness of the overweight and obesity cannot be overlooked. This linkage is often associated with intake of carbonated soft drink and fast food (Bleich & Vercammen, 2018).
The Smoking Behaviour domain showed contradicting results in regards to the behaviour, knowledge and perception components. Less than 10% declared to be ever smokers and 8.7% are still smoking and this is reflective of their knowledge of knowing smoking to be the cause of cancer (94.2%) and the illegality for selling cigarettes to minors (89.7%). The contradiction occurs in perception where the majority believed that smoking symbolizes adulthood (76.8%) and by smoking will attain more friends (80.0%) which consistent with other study (Oidwai, Ishaque, Shah, & Rahim, 2010). The perception is more skewed towards girls than boys indicating the success of the marketing by tobacco companies to increase smoking in female. If the perception is not changed, the tendency of adolescent to start smoking will be high especially when the majority of smokers begin tobacco use before they reach adulthood (Cantrell et al., 2018).
Alcohol Intake domain yielded similar results to smoking behaviour in every sense. Although yielding lower prevalence of ever (5.7%) and current (5.6%) drinker and also slightly lower knowledge level, the perception component yielded almost similar values to smoking. The majority agreed that drinking during the teenage years does not affect health (75.1%) and intake of alcohol can calm the mind (82.0%). These misperceptions, if not changed can lead to a start of excessive intake at a younger age. Young people who drink are more likely to use tobacco and other drugs and engage in risky sexual behaviours, than those who do not drink (Calvert, Bucholz, & Steger-May, 2010) and study showed early initiation of smoking and alcohol drinking reduced bone mineral density in late adolescence (Lucas, Fraga, Ramos, & Baros, 2012). Recent studies have shown drug and substance use, availability of drug and family history of substance abuse were identified as risk factors for disability and pattern of drinking in adolescent; and as an important marker for future reduced work capacity (Nguyen et al., 2012). In the present study the boys were observed to have higher rate of drug and alcohol intake. This is an agreement with previous studies which showed that adolescent at risk should be counselled and the pattern of risk should be decreased (Sidorchuk, Hemmingsson, Romelsjo, & Allebeck, 2012). There were reports of substance abuse more in boys resulting in deterioration of health in Asian population (Oidwai, Ishaque, Shah, & Rahim, 2010). However, cultural influences were taken into account to avoid misinterpretation thus the data is not affected by those factors.
The Drug Use domain had the least number of negative responses with only 0.1% claimed to have ever used drugs and still a user. However, a slight higher percentage of 0.7% has claimed of ever inhaling gum. This revelation is in line with the United Nations data of 2009 that stated 3.3% to 6.1% of the global population aged 15 years and above used illicit substances at least one in the previous year (UNODC, 2011). The prevalence will likely to increase if control and preventive measures are not taken as early as possible. Existing programmes have stayed the youth from falling prey to drugs but drug taking is more of a moral and social issue rather than a medical one.
World-wide, approximately 20% of children and adolescents suffer from a disabling mental illness (WHO-1, 2005). Anxiety disorders, depression and other mood disorders, and behavioural and cognitive disorders are among the most common mental health problems among adolescents. The Mental Health domain showed worrying results although the prevalence reduces as the magnitude of the problems becomes more serious that is parallel to those mentioned above (signs of continuous sadness -21.3%, signs of depression -9.4% and suicidal ideation -7.8%). The worrying results of suicidal ideation accounted to four million adolescents world-wide that have actually attempted suicide and suicide is the third leading cause of death among adolescents (WHO-2, 2001;WHO-3, 2001).
Risky Sexual Behaviour domain yielded acceptable results with only 1.6% having sexual experience before. Of those who did, 11.1% have claimed to have had same sex (homosexual) experience, 5.5% to have bisexual experience and 18.7% have claimed to have sex with more than one partner. This information, although small in prevalence, can increase over time if no action is taken. In terms of knowledge most of the respondents had poor performance in STI and HIV knowledge, opening the risk to infections in young people between the ages of 12 to 17 years old (Ramirez, et al., 2012); 15 to 24 years old are the most vulnerable group, accounting for 40% to 50% of those newly infected with HIV (UNIAIDS & WHO, 2008) and STI are among the most common causes of illness in the world; having far reaching health consequences and facilitate transmission of HIV and other complications (WHO-4, 2019). By the year 2018 itself, a total of 5.9 million people are living with HIV in Asia and Pacific regions (AVERT, 2019).

Conclusion
Physical exercise and sedentary habits, dietary behaviours, mental health and road safety showed worrying results that require immediate attention. Knowledge and perception showed more amicable results with exceptions of technical jargon that is found to be difficult to comprehend by the participants. Further studies are needed for more in-depth perspective of individual domain. Advance analysis should be carried out on existing data to ascertain factors on the findings for the purpose of future interventions. This study should be continued biennially to obtain the trending of adolescents' health risk behaviour in the country.