Knowledge, attitude, and behaviours on diet, physical activity, and tobacco use among school students: A cross-sectional study in two Indian states

Introduction

The rising epidemic of non-communicable diseases (NCDs), such as cardiovascular diseases, cancers, diabetes and chronic respiratory diseases is recognised as a leading cause of mortality and morbidity across all age groups in India and globally.¹ NCDs are responsible for more deaths in India each year than all other causes of death combined.² In the year 2019, 9.3 million deaths in India were attributed to all-cause mortality, of which 6.1 million (64.9%) were due to NCDs.³

Most NCDs are attributable to potentially modifiable behavioural risk factors, including unhealthy diets, physical inactivity, tobacco and alcohol use.⁴ Synergistic effects of demographic transition, globalisation, and economic growth have resulted in an environment where more children and adolescents are exposed to and/or engage in these behaviours than ever before.⁵ It is a well-known fact that lifestyle-related behaviours are often formed early and persist throughout life.^6,7 Evidence has shown that 70% of premature deaths in adults due to NCDs are associated with risky behaviours that began in childhood.⁸ Primordial prevention, including community-based intervention to promote healthier lifestyles, is extremely important for national development and to achieve the Sustainable Development Goals by 2030. Investment at an early age can yield a triple dividend of benefits, i.e., improving health later during adolescence, enhancing health throughout the course of life, and eventually contributing to the health of the next generation of children.⁹ By 2030, India is expected to be the first country in the world to become home to more than 1.5 billion people, and its population is on target to reach 1.7 billion by 2050.¹⁰ Thus, protecting and supporting child and adolescent health in this country is paramount not only to India’s overall well-being, but also to global health and economy.

Schools have been widely recognised as an important location for promoting healthy behaviours among children and adolescents.^11,12 Incorporating health-based programmes into the school curriculum can substantially influence both health promoting behaviours and educational achievements. The above outcomes can be achieved by providing children and adolescents with adequate knowledge and skills, allowing them to establish healthy attitudes and social norms through such a curriculum.¹³ Understanding their current knowledge, attitudes and lifestyle-related behaviours would immensely help both the health and education sectors in developing and implementing effective and efficient school-based health lifestyle programmes and policies.

We have developed Project PaTHWay, a three-year, school-based programme (2018-2021), to promote healthier lifestyle practices among children.^14,15 The overall objective of the programme is to prevent and control the risk factors of NCDs by delivering a school-based health lifestyle programme to students in two cities of India. Specifically, the Project PaTHWay aims to address key behavioural NCD risk factors, such as unhealthy diet, physical inactivity, and tobacco use among school children of grade 6^th followed for three years (till grade 8^th). Recruitment of sixth graders was done as the World Health Organization defines that adolescent age begins at 10 years. When a child enters adolescence, there is a change in explorative and emotive behaviours due to the shift from parental dependence to independence.¹⁶ Adolescents are vulnerable as they gain more control of what, when, how, and where they eat; moreover, their preferences and personal choices may gain priority over eating habits that are nurtured within the family setting.¹⁷

The first year of the programme included baseline knowledge, attitude, and behaviour (KAB) assessment and development of a health education programme based on the KAB assessment. Subsequently, school-based health lifestyle programme is being implemented for two years, followed by endline evaluation. Baseline analysis of the KAB of the target population would provide better insight to the ‘on-ground’ situation and can guide the development of the intervention programme. In this paper, we present the baseline KAB of students relevant to these NCD behavioural risk factors, which have helped us develop the Project PaTHWay school intervention.

Methods

Results

82.8% of the recruited sample participated in the baseline questionnaire (n = 1026 out of 1238). The reasons for non-participation included absenteeism (n = 112; boys: 67, girls: 45) and parent refusal (n = 100, boys: 54, girls: 46). The final sample size was 1026 (Private: 518 and Public: 508) consisting of 61.1% boys and 55.1% of the sample was from private schools. The mean age of the students recruited for the study was 12.5 ± 0.75 years. The full, de-identified dataset of student responses is available in Underlying data.⁶⁴

Discussion

This is one of the few studies on NCD risk factors that has comprehensively assessed KAB of school going children from two major metropolitan areas of India. During recruitment, it was ensured that the schools included in the study had similar characteristics, as differences in school characteristics could have influenced the results. Given the wide geographic variability in NCDs in this country,^18,30,31 it is important to assess students’ KAB in a myriad of contexts before designing an intervention for them.

The findings of our study revealed low dietary knowledge among students. Knowledge was better among girls and private school students. Similar differences were reported in school going students of Haryana (North India).³² The students’ knowledge of physical activity was better than their knowledge of diet and 66%-69% of students were aware of association between NCDs and physical inactivity. In contrast to our study findings, a better knowledge about physical activity (88%) was reported in students of Gujarat,³³ and Delhi-India.³⁴ Similarly, adolescents from the eighth and ninth grade in other low-and-middle-income countries (LMICs) such as Nepal, knew that physical activity is imperative for disease prevention and for staying healthy.³⁵

In our study, students’ knowledge about the harms of tobacco use was much higher in comparison to their knowledge about diet and physical activity. This increase in knowledge could be attributed to the Government of India’s efforts to combat rising burden of tobacco use and its associate health impact, including comprehensive national tobacco control law i.e., COTPA-2003,³⁶ National Tobacco Control Programme³⁷ as well as tobacco-free educational institutional guidelines.³⁸

With regard to behaviours, only 8.7% of students were missing their breakfast daily. This is similar to the findings of a study conducted among Indian school students³⁹ and Kenya.⁴⁰ In our study, more students from public schools reported missing their daily breakfast than students in private schools. This could be attributed to a low level of knowledge and the presence of students from lower middle-income families in these schools. Students from lower income families are more likely to experience scarcity of good quality food, meaning they may lack a wholesome breakfast as well as other meals of the day.⁴¹ An additional factor could be the availability of a mid-day meal scheme (i.e., school meal) in public schools,⁴² which may preclude the importance of their first meal at home (i.e., breakfast).

Other protective dietary factors include fruit consumption, and only 11.3% of students did not eat fruits daily. The Comprehensive National Nutrition Survey (2019) showed that among adolescents (10-14 years), 59% in Maharashtra and 74% in Karnataka ate whole fruits only once a week.³⁰ Though fruits are “price elastic” (connection between price and the demand of a product),^43,44 no difference in consumption was seen by school type. Results from other LMICs were poorer, with only 9% of adolescents (8-11 years) consuming fruits four to seven times a week.⁴⁰ On other hand, in a cross-country comparison among 49 LMICs, India had highest percentage (29.5%) of adolescents (13-17 years old) who met WHO’s recommendation for fruit and vegetable consumption.⁴⁵

Another worrisome behaviour observed among students was the habit of eating “outside food” (i.e., takeout) every day (95%). Contributing factors to its popularity could be ease of access, taste, parent’s occupation, and fast-food companies marketing strategies.⁴⁶ Fast food consumption data from 153,496 young adolescents (12-15 years) from 54 LMICs showed that 55.2% (51.3–59.1%) of the adolescents consumed fast food at least once per week, and 10.3% (8.3–12.4%) consumed fast food between four to seven days per week. The prevalence of fast-food consumption for four to seven days per week was lowest in the Americas (8.3%; 95% CI: 6.7–9.9) and highest in Southeast Asia (17.7%; 95% CI: 2.3–33.2%).⁴⁷ Our study found that only 33% students not reading nutritional labels while making food choices. Students in public schools were practicing this behaviour more often than students in private schools. In contrast to this trend, 88% of students in Kolkata reported reading nutritional labels, and this was most common among girls.⁴⁸

Lack of physical activity among adolescents is a major NCD risk factor. More than half of the students (57.5%) in this study reported engaging in moderate-to-vigorous physical activity for at least 60 minutes, daily, with no significant differences by gender or school type. One recent publication showed that 73.9% of adolescents in India are insufficiently physically active.⁴⁹ However, a global study of 49 LMICs with 164,771 adolescents found that India had the highest percentage (29.5%) of adolescents who met WHO’s recommendations for physical activity.⁴⁵ On an encouraging note, in the same study, few adolescents (3%) reported screen time of more than two hours a day. This is in contrast to 52.5% of school going adolescents in Tamil Nadu (Southmost part of India) who had an average daily screen time of more than two hours a day.⁵⁰

One third of adolescents had ever tried tobacco (smoke, smokeless and e-cigarette). Evidence from 68 LMICs showed that mean prevalence of tobacco use among adolescents (12-15 years) was 13.6%, ranging from 2·8% in Tajikistan to 44·7% in Samoa and in most countries prevalence among boys was higher compared to girls.⁵¹ However, no difference among boys and girls was observed in this study, indicating a narrowing of gender gap for tobacco use which is much wider among adults in India.⁵² In Pune, public school students used more tobacco (all forms) in comparison to private schools. Whereas in Bengaluru, smokeless tobacco was more commonly used among public school students in comparison to smoke forms. Tobacco use (all forms) was found to be more prevalent in public school boys (13.4%) in comparison to private school boys (11.7%).⁵³ This could be due to the students’ lack of compliance with provisions of Indian tobacco control law as well as the availability and ease of access to tobacco products outside of their schools.⁵⁴ Surprisingly, 32.4% of the students also reported that they have tried e-cigarettes in the past. To the best of our knowledge, no other study in India has yet reported the prevalence of e-cigarette use among school going children. The prevalence found in our study was much higher than that found in a study from Mexico.⁵⁵

As the 2030 deadline for Sustainable Development Goals is only a decade away, the low levels of knowledge, particularly about unhealthy diet and physical inactivity, are a matter of concern.⁵⁶ Aiming to reduce the NCD burden and the budding role of education in primary prevention was emphasised at the 2011 United Nations’ Meeting on the Prevention and Control of NCDs.⁵⁷ Lack of healthy behaviours among adolescents has been linked with lack of sufficient knowledge, and research has also indicated a positive relationship between information level and overt behaviour.⁵⁸ Sufficiently designed health promotion programmes⁵⁹ may provide the much needed knowledge that will help to reduce risk behaviours such as unhealthy diet, physical inactivity, and tobacco use, hence providing a pathway for behaviour change.

In India, various education programmes have been designed for school going adolescents but there are only few comprehensive education programs addressing diet, physical activity and tobacco.⁶⁰ In 2018, the Government of India launched the National School Health Programme under Ayushman Bharat or Healthy India. The programme comprehensively addresses the above risk factors, and is delivered by health ambassadors (two teachers per school) only in government and government aided schools across country.⁶¹ The study highlighted the need to co-design an intervention, using participatory action approach, that involves target audience (adolescents in our study) in development and implementation of the intervention. The advantage of involving adolescents is that experiences, barriers, and facilitators faced by them in adopting healthy behaviours can be considered while development of intervention. This also gives the programme a sense of ownership, which boosts the target audience’s interest in the programme. The programme development should also consider engagement of parents and teachers who plays a crucial role in the nurturing the adolescent’s behaviours. Considering these, a two-year intervention programme has been developed for students in the sixth to eighth grades, their parents, and community members. The programme is based on social cognitive theory, explains that learning and acquiring health behaviours occurs within a social context, through an interaction of external and internal factors.⁶² The agents of intervention implementation are trained teachers and peer leaders, as facilitators. This model of delivery has proven successful in India and elsewhere globally for tobacco⁶³ and nutrition¹² education.

The sampling of schools was one of the limitations of this study. The schools were not randomly selected from the population but were representative of the socio-economic spectrum in these two cities. Furthermore, the sample did not include schools from rural areas, hence limiting the generalizability of the findings. The statistical tests used in the study are indicative only, as the sample selection was purposive. The self-reported method utilised (i.e., survey) also may have led to skewed estimates of dietary intake, physical activity and tobacco use patterns among the students due to the fact that adolescents would have wanted to report positive health behaviours (social desirability - reporting bias). Behaviours related to diet, physical activity and tobacco of all students were assessed without understanding the home environment as it plays a vital role in shaping students’ behaviours. The behaviour for all type of tobacco use was evaluated without further investigating the number of times the tobacco was used by the students. Given budgetary constraints, no anthropometric or biochemical (e.g., salivary cotinine) or food frequency questionnaire were used, which may be a drawback of this study.

Conclusion

The results from this study provide insights in to the KAB of school going children with respect to the risk factors of non-communicable diseases. In the two states of India, a higher proportion of school students know the harm of tobacco use than the benefits of a healthy diet and physical activity. Both gender and school type influenced specific KABs but both the magnitude and direction of such influence were variable. There is a need to strengthen the health education activities by developing context-specific health intervention materials by engaging school children, teachers, parents and communities to promote healthy behaviours among adolescents. This study highlights the need to augment school health programmes in India with a differential approach based on the issues which are specific to each school type (public and private) and city (Pune and Bengaluru).

Data availability