Behavioral Risk Factors of Non-Communicable Diseases Among School Adolescents in Nepal

Table of Contents

Contents

Acknowledgement

Summary

Table of Contents

List of Figures

List of Tables

Abbreviations

Chapter I
Introduction
1.1 General background
1.2 Statement of Problem
1.3 Rationale of the Study
1.4 Objectives
1.4.1 General Objective
1.4.2 Specific Objectives
1.5 Research Questions
1.6 Study variables
1.7 Conceptual Framework
1.8 Operational definition

Chapter II
Literature Review
2.1 Overview of literature
2.2 Theoretical Literature Review
2.3 Empirical Literature Review

Chapter III
Methodology
3.1 Study design
3.2 Study area
3.3 Study population
3.4 Sample size
3.5 Sampling technique
3.6 Sampling unit
3.7 Criteria for sample selection
3.8 Data collection technique
3.9 Data collection tools
3.10 Reliability and validity
3.11 Data processing and analysis
3.12 Ethical considerations
3.13 Limitations of the study

Chapter IV
Results
4.1. Socio-demographic Characteristics of Participants
4.2. Health Service-Related Information of the participants
4.3 Information about exposure to behavioral risk factors in family and environment
4.3.1 Exposure of participants with tobacco
4.3.2 Alcohol use in participants’ family and close circle
4.4 Tobacco Use
4.4.1 Tobacco use among participants
4.5. Alcohol Consumption
4.5.1 Standard alcohol consumption by participants
4.6 Diet
4.7. Physical Activity
4.7.1 Level of physical activity of the participants
4.8 Magnitude of risk factors of NCDs among participants
4.9 Combined Risk Factors of the participants
4.10 Association between behavioral risk factors and independent variables (Inferential Analysis)
4.10.1. Association between tobacco use and socio demographic characteristics of participants
4.10.2 Association between tobacco use and other explanatory variables
4.10.3 Association between alcohol consumption and socio demo characteristics of the participants
4.10.4 Association between alcohol consumption and health service related variables
4.10.5 Association between fruit and vegetable consumption and socio demographic characteristics of respondents
4.10.6 Association between fruit and vegetable consumption and health service related variables
4.10.7 Association between level of physical activity and socio demo characteristics of the participants
5.10.8 Association between physical activity and health service related variables

Chapter V
Discussion
5.1 Discussion

Chapter VI
Conclusion and Recommendation
6.1 Conclusion
6.2 Recommendation

References

Annexes
Annex I: Informed Consent Form in English
Annex II: Informed Consent Form in Nepali
Annex III: Research Questionnaire in English
Annex IV: Research Questionnaire in Nepali

Acknowledgement

This research report is the result of continuous efforts, ideas, contribution and collaboration of several people and organizations. Through this acknowledgement, I would like to extend my heartfelt and profound gratitude to all the institutions and individuals who in one or another way have contributed effort and support to make this endeavor a reality.

First of all, I would like to express my profound gratitude to School of Public Health Research Committee for providing a favorable academic environment for the successful completion of this research report. I would also like to express my sincere gratitude to Institutional Review Board of Chitwan Medical College for the approval of my research proposal and providing me an opportunity to carry out this research in partial fulfillment of requirement of BPH fourth year course.

I am very grateful to my research supervisor Lecturer Ms. Shakuntala Chapagain for all her continuous inspiration, precious suggestion and valuable direction through the course as well as during the time of doing this research.

I would like to express my special thanks to Lecturer Subash Koirala for his guidance and valuable suggestion in analysis part of my research. I would like to express my sincere gratitude to Vice-Principal Of School of Public Health, Associate Professor Mr. Harish Chandra Ghimire, Associate Professor Dr. Kishor Adhikari, CBL Coordinator Mr. Eak Narayan Poudel, 4th Year Coordinator, Ms. Amrita Paudel, Assistant Professor Dr. Mamata Chhetri, Lecturer Ms. Gayatri Khanal, and Lecturer Ms. Sumnima Shrestha including all family members of School of Public Health for their untiring efforts.

Most importantly, I would like to express my heartfelt acknowledgement to the teachers and participants of Myagde Rural Municipality for their cooperation.

The existence of this report owes much to the continuous support from the library department and its staffs for the research supporting resources generously supplied. I am also obliged to the authors who enriched the stream of literatures.

I would like to thank Kailash Pandey for his consistent support and motivation to work hard and successfully complete the research. I would like to thank and dedicate this research work to my parents Indra Prasad Khanal and Bishnu Adhikari Khanal and my brother Sarthak Khanal for their eternal support, guidance and inspiration to work hard for universal betterment.

Ganga Khanal

BPH IV Year

CMC

Summary

Non Communicable Diseases are the leading cause of death worldwide. World Health Organization has identified certain risk factors that are associated with an increase in the occurrence of Non Communicable Diseases. Among them, tobacco use, alcohol use, unhealthy diets and physical inactivity are main behavioral risk factors. The general objective of this study was to assess the magnitude of behavioral risk factors of non-communicable diseases among adolescents. A descriptive cross sectional study was conducted with sample size 230 using probability sampling technique. It was conducted on students of secondary schools of Myagde Rural Muncipality, Tanahun. A semi-structured questionnaire was used and self-administered technique was done to collect the data from 20th to 29th of Baisakh. The analysis was done by using descriptive statistics (frequency, percentage, mean, standard deviation) and inferential statistics (Chi Square test). The prevalence of current tobacco consumption was 9.13%, current alcohol consumption was 30.87%, inadequate fruit and vegetable consumption was 75.22% and low level physical activity was 4.78%. There was significant association between tobacco use and sex (p<0.001), anyone smoked in the family (p=0.006), smokeless tobacco use in the family (0.032) and smokeless tobacco use in the close circle (<0.001). Significant association was found between alcohol consumption and sex (<0.001), age (p=0.001) education of mother (p<0.044), distance to the nearest health center (p=0.001), alcohol use in the family (p<0.001) and alcohol use in the close circle (p<0.001). There was significant association between fruit and vegetable consumption and sex (p=0.003, ethnicity (p=0.001), religion (p=0.001), frequency of visit to health care center (p=0.003). Significant association was found between level of physical activity and sex (p<0.01).The study showed that one third of adolescents consumed alcohol. Majority of the adolescents have poor dietary habit which may lead to non-communicable diseases. The adolescents were active as they involved in both high and moderate level of physical activity. Likewise the use of tobacco and alcohol is affected by the family history of tobacco and alcohol use. So the provision of health education regarding behavioral risk factors focusing to both parents and adolescents might be fruitful in order to prevent NCDs.

List of Figures

Figure 1: Conceptual framework showing relationship between dependent and independent characteristics

Figure 2: Magnitude of risk factors of NCDs

Figure 3: Combined risk factors of NCDs among participants

List of Tables

Table 1: Sampling units with respective sample size

Table 2: Socio-demographic characteristics of the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 3: Description of Health Service-Related Information of the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 4: Description of exposure of participants with tobacco in Myagde Rural Muncipality, Tanahun, 2019

Table 5: Alcohol use in participants' family and close circle in Myagde Rural Muncipality, Tanahun, 2019

Table 6: Description of the Tobacco Use by the Participants in Myagde Rural Muncipality, Tanahun, 2019

Table 7: Description of the smoking and smokeless tobacco by the participants in Myagde rural Muncipality, Tanahun, 2019

Table 8: Description of Alcohol Consumption by the Participants in Myagde Rural Muncipality, Tanahun, 2019

Table 9: Description of the Standard Alcohol Consumption by the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 10: Description of diet related behaviors of the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 11: Description of Physical Activity of the Participants in Myagde Rural Muncipality, Tanahun, 2019

Table 12: Description of level of physical activity of the participants in Myagde rural Muncipality, Tanahun, 2019

Table 13: Description of magnitude of risk factors of NCDs among participants in Myagde rural Muncipality, Tanahun, 2019

Table 14: Combined risk factors of the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 15: Association between tobacco use and socio demographic variables of participants in Myagde Rural Muncipality, Tanahun, 2019

Table 16: Association between tobacco use and other explanatory variables in Myagde Rural Muncipality, Tanahun, 2019

Table 17: Association between alcohol consumption and socio demo characteristics of the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 18: Association between alcohol Consumption and other explanatory variables in Myagde Rural Muncipality, Tanahun, 2019

Table 19: Association between fruit and vegetable consumption and socio demographic characteristics of participants in Myagde Rural Muncipality, Tanahun, 2019

Table 20: Association between fruit and vegetable consumption and health service related variables in Myagde rural Muncipality, Tanahun, 2019

Table 21: Association between level physical activity and socio demographic characteristics of the participants in Myagde Rural Muncipality, Tanahun, 2019

Table 22: Association between level of physical activity and health service related variables in Myagde Rural Muncipality, Tanahun, 2019

Abbreviations

CMC Chitwan Medical College

CVD Cardiovascular Diseases

IRC Institutional Review Board of CMC

NCD Non communicable disease

SPSS Statistical Package for Social Science

WHO World Health Organization

Chapter I

Introduction

1.1 General background

Non communicable disease can be defined as disease or conditions that occur in, or are known to affect, individuals over extensive period of time and for which there are no known causative agents that are transmitted from one affected individual to another. They are of long duration and generally slow progression. The 4 main types of non-communicable diseases are cardiovascular diseases (like heart attacks and stroke), cancers, chronic respiratory diseases (such as chronic obstructed pulmonary diseases and asthma) and diabetes.¹

There are eight major risk factors of NCDs, out of which four of them are behavioral risk factors and four of them are biological risk factors. The main behavioral risk factors of NCDs include tobacco use, harmful alcohol consumption, unhealthy diets and physical inactivity.²

The four main NCDs are driven by four modifiable risk factors: tobacco use, excessive use of alcohol, unhealthy diet, and insufficient physical activity. These behaviors can lead to overweight, obesity, high blood pressure and high cholesterol-all directly related to NCDs.³

Among all the risk factor, tobacco use remains as an important risk factor. Excessive consumption of alcohol and exposure of cigarette smoking may directly cause cirrhosis of liver, cancer of the mouth, pharynx, pancreas, and esophageal cancer.⁴ Unhealthy diets and physical inactivity are two of the main risk factors for raised blood pressure, raised blood glucose, abnormal blood lipids, overweight/obesity, and for the major NCDs such as CVD, cancer, and diabetes.⁵

Adolescence is a time of risk taking and experimentation and many studies have found a co-occurrence of several health risk behaviors among young people from different countries.⁶ -⁹ Several researchers also underlined that an early age at onset of health risk behaviors is associated with an increased likelihood that adolescents will engage in multiple risk behaviors as they progress through adolescence.⁷, ¹⁰, ¹¹

It is seen that NCDs has its birth in childhood and most of them are due to one’s lifestyle.² The prevalence of NCDs is related to unhealthy behaviors and practices that are typically initiated in adolescence.¹²

An analysis of the distribution of health behaviors among adolescents (i.e. those 11–15 years old) from more than 100 countries found that approximately 80.0% of them performed daily physical activities (for at least 60 minutes), 6.0% smoked cigarettes daily, 7.6% consumed beer weekly and 25.0% had an unhealthy diet.¹³

In Nepal, among adolescence, the main risk behavior related to NCDs found to be high like tobacco (smoking) consumption (17.2%), smokeless tobacco consumption (8.1%), Current alcohol consumption (14.4%), inadequate vigorous intensity activity (58.3%), and moderate intensity activity (50.5%). The prevalence of fruit and vegetables consumption 21.2% and 60.4% respectively.¹²

1.2 Statement of Problem

Unhealthy diet, physical inactivity and substance use like tobacco, alcohol, drugs, etc. are recognized as the global determinants of NCDs.¹⁴ The morbidity and mortality due to the NCDs is ever increasing.² CVD and other chronic diseases are becoming the major causes of morbidity and mortality in most of the third world countries including Nepal.¹⁵

Non communicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally. Each year, 15 million people die from NCD between the ages of 30 and 69 years; over 85% of these premature deaths occur in low- and middle-income countries.¹⁶

It was estimated that about 5 million premature deaths in the world was attributed to smoking and 4 million of these deaths were in men.¹⁷ Inadequate levels of physical activity increases the risk of cancer, diabetes, heart disease and stroke by 20-30% and shortens lifespan by 3-5 years.¹⁸ Alcohol consumption is estimated to cause more than 10% of burden of non-communicable diseases, including cirrhosis of liver, pancreatitis, cancers (oral and pharynx, larynx, esophagus, liver, colorectal), hemorrhagic stroke and hypertension.¹⁹

The World Health Organization estimates that 70 percent of premature deaths in adults are the result of behaviors begun during adolescence and youth.¹²

The STEPS survey Nepal (2013) showed that average age for the starting of smoking is 18.2 years.²⁰ A study conducted by Karki KB (2008) revealed that the overall smoking prevalence in Nepal for the population aged fifteen or more is 37.4 %.²¹ A study conducted by Adhikari et.al (2012) for the behavioral risk factors for NCDs among adolescents revealed that nearly 40% of male respondents and 23% of female respondents were using tobacco in one or other forms. It was found that only 14% of respondents were doing satisfactory level of physical activities.¹⁵

Young and adolescents are susceptible to unhealthy lifestyle and have been shown to have various risk factors that may predispose them to development of NCDs. The world health organization has already earned of increasing NCDs among adolescents as a major public health problem.²²

This study aims to dissect the magnitude and factors determining the behavioral risk factors for NCDs as the in the study area such that the conclusions generated can be used to draw planning and policy strategies to combat this alarming public health problem.

1.3 Rationale of the Study

NCDs are significantly growing burden on global health. NCDs are one of the major development challenges of the 21st century, in terms of both the human suffering they cause and the harm they inflict on the socioeconomic fabric of countries, particularly low and middle-income countries.²³

Non-communicable diseases (NCDs) are increasingly becoming a major cause of morbidity, mortality and disability in the developing country like Nepal .Rapid changes in the economic, social, and demographic determinants of health as well as adoption of unhealthy lifestyles by large segments of population are contributing factors for NCDs.²⁴

Alcoholism, tobacco smoking, unhealthy diet , physical inactivity are highly prevalent among adolescents and almost 80% of deaths due to NCDs can be prevented by eliminating those risk factors. Nevertheless, those risk behaviors are initiated usually in the adolescent’s age groups which are continued to adult. Therefore, this group is important target for primordial prevention.¹²

For example, the earlier in life that tobacco and alcohol use are initiated, the greater the risk of addiction. In contrast, when positive health behaviors such as healthy eating and regular exercise are established at a young age, they are more likely to be carried through to adulthood. Thus, working with young people to mitigate risks and establish positive health behaviors early in life can foster a healthier adult population, and substantially decrease the burden of NCDs.

Till the date, there is no evidence that such study on the magnitude of behavioral risk factors of NCDS among adolescents has been conducted in the Myagde rural municipality of Tanahun, district. So, this study might be helpful for formulating preventive strategies and policies regarding NCDs risk factors among adolescents in the study area.

1.4 Objectives

1.4.1 General Objective

- To assess the magnitude of behavioral risk factors of Non-communicable Diseases among school adolescents of Myagde rural municipality of Tanahun district.

1.4.2 Specific Objectives

- To determine the magnitude of tobacco use, alcohol consumption, unhealthy diet and physical inactivity among school adolescents.
- To identify the association of behavioral risk factors with different explanatory variables.

1.5 Research Questions

1. What is the magnitude of behavioral risk factors of Non-communicable Diseases among school adolescents?
2. Is there any association of behavioral risk factors with different explanatory variables?

1.6 Study variables

Dependent Variables

- Tobacco use
- Alcohol consumption
- Dietary habits
- Physical inactivity

Independent Variables

- Sex
- Age
- Education of father
- Education of mother
- Occupation of father
- Occupation of mother
- Ethnicity
- Religion
- Family Income
- Distance to the nearest health center
- Frequency of visit to health center
- Visit health care professional for counseling
- Visit to heath center in past 12 months
- Exposure to risky behaviors in family and close circle

1.7 Conceptual Framework

Abbildung in dieser Leseprobe nicht enthalten

Figure 1: Conceptual framework showing relationship between dependent and independent characteristics

1.8 Operational definition

- Behavioral risk factors: The behavioral risk factors include current tobacco use, current alcohol consumption, unhealthy diets and physical inactivity.
- Tobacco use: Current consumption of both smoking products (manufactured cigarettes, hand rolled cigarettes, cigars, etc) and smokeless tobacco products ( betel nuts, bidi, khaini, etc)
- Current tobacco use: Use of any smoking and smokeless tobacco products in past 30 days
- Alcohol consumption: Respondents taking any form of alcohol such as beer, jaand, tongba, local raksi, whisky, vodka (spirits), rum, wine (red and white).
- Current alcohol consumption: Consumption of any form of alcohol within past 12 months
- Inadequate Fruit and vegetable consumption: Participants consuming ≤3 servings/day of fruits and vegetables and those consuming fruits and vegetables for ≤4 days/week were considered as persons not meeting dietary recommendations.
- One serving of vegetable: One cup of raw, leafy green vegetables (spinach, salad, etc.), one half cup of other vegetables, cooked or raw (tomatoes, pumpkin, beans etc.), or half cup of vegetable juice
- One serving of fruit: One medium-sized piece of fruit (banana, apple, etc.) or half cup of raw, cooked or canned fruit, or a half cup of juice from a fruit (not artificially flavored.
- Level of physical activity: It is categorized on high, moderate and low level based on WHO MET Guidelines.

1 .High: A person meeting any of the following criteria:

i. Vigorous-intensity activity on at least 3 days achieving a minimum of at least 1,500 MET(metabolic equivalents of task) -minutes/week; or
ii. 7 or more days of any combination of walking, moderate- or vigorous-intensity activities achieving a minimum of at least 3,000 MET-minutes per week.

2. Moderate: A person not meeting the criteria for ‘high’ level of activity, but meeting any of the following criteria:

i. 3 or more days of vigorous-intensity activity of at least 20 minutes per day; or
ii. 5 or more days of moderate-intensity activity or walking of at least 30 minutes per day; or
iii. 5 or more days of any combination of walking, moderate- or vigorous-intensity activity achieving a minimum of at least 600 MET-minutes per week.

3. Low: A person not meeting any of the above mentioned criteria for high or moderate activity

- Person performing low level of physical activity was considered in risk factor
- Vigorous intensity work: Defined as any activity that causes a significant rise in heart rate and breathing rate, for example digging or plugging fields, lifting heavy weights, etc. Continuous engagement in such activity for at least 10 minutes was considered as involvement in vigorous activity.
- Moderate intensity work: Defined as any activity that causes a moderate increment in heart rate and breathing rate (examples include domestic chores, gardening, lifting light weights, etc.). Continuously engaging in such activity for at least 10 minutes was considered involvement in moderate activity.
- Vigorous recreational activity: Defined as any recreational activity that causes a large increase in heart rate and breathing; for example, games such as football, fast swimming and rapid cycling. Ten minutes of such activity was considered as involvement in vigorous recreational activity.
- Moderate recreational activity: Defined as any kind of recreational activity that causes a moderate increase in heart rate and breathing; examples include yoga and playing basketball. Ten minutes of such activity was considered as involvement in moderate recreational activity.
- Sedentary behavior: Defined as a behavior where an individual spends time sitting at a desk, sitting with friends, , reading a book and watching TV, mobile , so on.
- Adolescents: Those students both boys and girls studying in grade 9, 10 of those selected schools who belong to age group (10-19).
- Age: It includes the age of the participants in completed years. Date of birth was asked to confirm the completed age.
- Education: It includes the state of literacy of participants' father and mother. For the study, it was classified as:

i. Illiterate
ii. Primary education: Formal education up to eight classes
iii. Secondary education: Formal education up to 12 classes
iv. Bachelor and above bachelor: Formal education up to bachelor level and above

- Religion: Religion was classified as: Hindu, Buddhist, Christian, Muslim and Others.
- Close circle: Close circle in this study includes friends, relatives and both.
- Family income: It refers to the estimated annual household income of the participants. The annual household income of participants was categorized into three categories based on the value of mean and standard deviation as; <200000, 200000-350000, >350000.
- Occupation: It includes the occupation of both parents of participants. Occupation was classified as: agriculture, business, foreign employment, service, homemaker and others.
- Combined risk factor: Presence of more than one behavioral risk factor

Chapter II

Literature Review

2.1 Overview of literature

One of the most important and early step of any research project is conducting the literature review. Literature review is the systematic search of the published work to gain more details and information about the research topic. Literature review helps in finding past results conducted on the research topic and helps to find out whether the research topic is feasible for the study or not. On the basis of findings from literature review we can generalize our research and also have a depth knowledge regarding the aspects used for research.

Many journals, books, bulletins, articles, papers were searched for the purpose of literature review. Literatures were searched by entering key words “Adolescents”, “Behavioral risk factors”, “Non-communicable Diseases”, in various search engines like Google Scholar, Pub Med, BMC and Google.

2.2 Theoretical Literature Review

Non communicable disease is a disease that is not transmissible directly from one person to another. They are those conditions that are usually not passed on from one affected person to others, but are caused as a direct result of lifestyle and environmental factors. The four main NCDs are driven by four modifiable risk behaviors: tobacco use, excessive use of alcohol, unhealthy diet, and insufficient physical activity.³ These behaviors can lead to overweight and obesity, high blood pressure, and high cholesterol—all directly related to NCDs.¹²

Non communicable diseases are the leading cause of death, causing more deaths than all other causes combined, and they strike hardest at the world's low and middle income populations. These diseases have reached epidemic proportions, yet they could be significantly reduced, with millions of live saved and untold suffering avoided, through reduction of their risk factors, early detection and timely treatments.³

Research on the global burden of diseases during recent years has demonstrated how the world’s health situation is changing rapidly. The relative role of infectious diseases is diminishing and that of some major non-communicable diseases (NCDs) is increasing. NCDs are increasing rapidly in the developing world.²⁴

The World Health Organization (WHO) has identified the eight major behavioral and biological risk factors for NCDs. The main behavioral risk factors of NCDs are tobacco use, harmful alcohol consumption, unhealthy diet (low fruit and veg­etable consumption), and physical inactivity.¹⁴

Cardiovascular and other chronic diseases are becoming the major causes of morbidity and mortality in most of the third world countries, including Nepal. Unhealthy diet, physical inactivity and consumption of tobacco and alcohol are major global determinants of non-communicable diseases and contribute to the excess death and disability among the poor in terms of mortality.¹⁵

The prevalence of NCDs is related to unhealthy behaviors and practices typically initiated in adolescence. Research indicates that behaviors associated with two of the key risk factors for NCDs—tobacco and alcohol use—are likely to start or become established during adolescence. Other risk factors related to poor diet and insufficient physical activity may begin during childhood, but adolescence is an opportunity to reinforce the benefits of positive behaviors through appropriate messages and programs.¹²

The World Health Organization has already warned of increasing NCDs among adolescents as a major public health problem. The importance of this age group also lies in the fact that many serious diseases in adulthood have their roots in adolescence.²²

2.3 Empirical Literature Review

A school based study conducted by Khuwaja et.al (2011) among 414 adolescents of Pakistan found that 80% adolescents had unhealthy diets, 54% were physically inactive, and 14% were current smokers. More girls were physically inactive and greater proportions of boys were current smokers.²⁵

A cross sectional study conducted by Ahikari et.al (2012) in Chitwan District of Nepal found that about 50% male and 30% female respondents were currently abusing one or other forms of substance. Male (39%) and female (26%) were using tobacco products. It was found that only 14% of respondents were doing satisfactory level of physical activities.¹²

A cross sectional study conducted by Jain et.al (2012) among 413 students in Mangalore, India revealed that one tenth of the students had adequate dietary habits. Though most students were physically active, the type and duration of activity was inadequate.²⁶

A cross-sectional conducted by Sograwal et.al (2014)on the risk factors of non-communicable diseases among 4339 students of 10-19 years age group in selected districts of India showed that, the prevalence of tobacco use in any form was 31.5% and the use of alcohol was 7.9% among the study subjects. Significant association was found between the use of tobacco/alcohol with age, family/friends habit of tobacco/alcohol use and duration of watching television.²²

A cross sectional study, done among 241 students by Adhikari et.al (2014) in Ratnanagar Municipality of Chitwan District of Nepal found that nearly half of male respondents and also 1/5th of female respondents were using any type of addiction.²⁴

A cross sectional study conducted by Goud et.al (2014) in Bellary, Karnataka among 100 adolescents revealed that adequate physical activity was seen among only 60%. It was observed that 6% of the study subjects consumed tobacco and 5% consumed alcohol.²⁷

A cross sectional study conducted by Pareskar et.al (2015) among 838 adolescents in Udupi Talak found that Current smoking was found in 1.67% of the participants. Nearly 16.94% participants were exposed to second hand smokers. About 2.15% of the participants were current alcohol drinkers. About 89.86% of the participants were physically inactive. Nearly 31.98% of the participants reported adding extra salt to the diet . ²⁸

A cross sectional study conducted by Mahmood et.al (2017 ) among 250 school going adolescents of Uttar Paradesh, India found that 4.8% currently use tobacco., 3.2% consumed alcohol in last 30 days , 22.4% involved in moderate intensity while 20.4% involved in vigorous intensity sports. Only 64% consumed fruits and 75.6% consumed vegetables.²⁹

A descriptive cross-sectional study conducted by Shrestha et.al (2017) among the adolescents of higher secondary of Lalitpur district in Nepal found that the prevalence of current tobacco (smoking) consumption was 17.2% and the prevalence of smokeless tobacco consumption was 8.1%. Current alcohol consumption was 14.4%. The prevalence of inadequate vigorous intensity activity was 58.3% and moderate intensity activity was 50.5%. The prevalence of fruit and vegetables consumption was 21.2% and 60.4%.¹²

A study was conducted Nagendra et.al (2018) in urban and rural field practice areas of Shivamogga institute of medical sciences; Shivamogga found that in rural 2.5% adolescents smoke tobacco and 1.25% consume alcohol.³⁰

A cross-sectional study conducted by Yadav et.al (2018) among 640 higher secondary students of grade 11 and 12 of Kaski district in Nepal revealed that the prevalence of smoking was 6.1% which was high in male (11.9%) than female (0.6%). Alcohol consumption practice among the adolescents was 18.9%.²³

A community-based cross-sectional study was conducted by Pitchai et.al (2018)in Maharashtra. A total of 483 males and 417 females participated in this study. Among males, 34.8% consumed smoked tobacco whereas 21.8% of females consumed smokeless tobacco. Only 9.32% of male participants were current alcohol drinkers. Both the genders did not meet the recommended amount of fruit consumption. Insufficient physical activity amongst males was 45.21% and females 60.49.³¹ A Cross-sectional study conducted by Peltzer et.al (2019)among adolescents in Seychelles found that the prevalence rates for risky behaviors were: tobacco use –23.4%, alcohol consumption - 47.6%, inadequate consumption of fruits and vegetables -60.9% and physical inactivity- 82.7%.³²

Chapter III

Methodology

3.1 Study design

The study design was descriptive cross sectional study.

3.2 Study area

The study area was Myagde rural municipality, Tanahun.

3.3 Study population

Study population was the students of grade 9 and 10 of public school of Myagde rural municipality, Tanahun.

3.4 Sample size

The sample size was calculated based on the Cochran’s Formula (1977):

Abbildung in dieser Leseprobe nicht enthalten

Where,

d= margin of error = 0.05

Z= 1.96 for 95% Confidence Interval

p= prevalence = = 60.4%= 0.604

q=1-p=0.396 (prevalence of vegetable consumption=60.4%) ¹²

So, 368

Now, for the finite population, N=483

Abbildung in dieser Leseprobe nicht enthalten

Hence, n=209

Adding 10% non-response rate, the sample size is 230.

3.5 Sampling technique

Myagde Rural Municipality was selected purposively (Total number of Public school -6).Number of Sample from each school was taken proportionately. Number of sample from 9 and 10 classes was taken proportionately. Sampling unit was selected by using simple random sampling from each class.

Table 1: Sampling units with respective sample size

Abbildung in dieser Leseprobe nicht enthalten

3.6 Sampling unit

The sampling unit of the study was individual.

3.7 Criteria for sample selection

Inclusion criteria

The participants who were willing to participate were included in the study.

Exclusion criteria

The students who were absent during the study will be excluded from the study The participant who couldn't hear, speak properly and have mental illness was excluded from study.

3.8 Data collection technique

The participants were the students of grade 9 and 10. Consent was taken from the principals, teachers and the participants of each school before the data collection. The students of grade 9 and 10 selected for the study were gathered together in a hall. Their seating arrangement was managed so that they were unable to discuss with each other while writing the answer and to avoid the sample contact. Each question was explained briefly to them before starting data collection. Self-administered questionnaire was used for data collection

3.9 Data collection tools

Semi structured questionnaire based on WHO stepwise approach for surveillance of Non-Communicable Diseases (NCDs) risk factors was used for the data collection.

The questionnaire contains four parts.

Part A: Questions related to socio demographic characteristics

Part B: Questions on health related information.

Part C: Questions on exposure to risk behaviors in family and close circle.

Part D: Questions related to behavioral measurement

3.10 Reliability and validity

Validity

- The variables and units of measurements under study were properly operationalized.
- The questionnaire was developed by extensive literature review and reviewed by expertise
- Valid questionnaire based on WHO STEP instrument was used for the data collection process.

Reliability

- The research questionnaire was forth and back translated in Nepali and English and necessary editing was done.
- Consistency and accuracy of collected data was checked on the day of data collection.

3.11 Data processing and analysis

Data processing: Data processing was done through editing, coding, classification and tabulation.

Data analysis: The data was entered, coded, analyzed and interpreted according to the objective of the study using SPSSv20.0 software and MS Excel. The analysis was done by using descriptive statistics (frequency, percentage, mean, standard deviation) and inferential statistics (Chi Square test)

Data presentation: Tabular and graphical forms.

3.12 Ethical considerations

- The study was conducted in compliance with ethical and human right standards.
- Research was started only after the approval from School of Public Health Research Committee.
- Ethical clearance was obtained from Institutional Review Board of Chitwan Medical College.
- Before the study, purpose and process of the study was clearly explained to the participants.
- Verbal informed consent was taken from respondents before starting the survey.
- Privacy and confidentiality of respondents was maintained.

3.13 Limitations of the study

The study was done only on the adolescents of public secondary schools of Myagde Rural Municipality so it might not represent the status of entire country.

Chapter IV

Results

This Chapter deals with analysis and interpretation of the findings of the study. The data was collected among 230 secondary school students of Myagde Rural Municipality. The collected data were analyzed according to the objective of the study and presented in tables.

4.1. Socio-demographic Characteristics of Participants

Among 230 participants, 45.22% were male while 54.78% were female participants. About 36.5% participants were of age 10-14 years and 63.5% of participants were of age 15-19 years. The ethnic composition of the participants included 1.74% Brahmin, 6.52% Chhetri, 26.96% Dalit and 64.78% Janajati. About 92.61% of the respondents were Hindu while 7.39% were Christian. About 11.74% of participants' father was illiterate while 67.39% had primary level education, 20.43% had secondary level education and only 0.43% had bachelor and high level education. About 32.17% of participant's mother were illiterate, 59.57% had primary level education, 8.26% had secondary level education while none of the participants' mother had bachelor and above level education. Majority of participant’s father’s occupation was foreign employment (45.22%) and it was followed by agriculture (24.35%), business (14.35%), home maker(10%) and service (6.09%). Majority of the participant's mother (75.22%) were home maker and it was followed by agriculture (17.83%), business (3.91%), service (2.61%) and foreign employment (0.43%). Majority (41.30% ) of participants had the annual household income below 2 lakhs, 23.48% of participants had between 2 lakhs and 3 lakhs fifty thousand and 35.22% of participants had annual household income more than three lakhs fifty thousand (table 2).

Table 2: Socio-demographic characteristics of the participants in Myagde Rural Muncipality, Tanahun, 2019

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4.2. Health Service-Related Information of the participants

Among 230 participants, 24.80% had to travel about more than 120 minutes to reach to nearest health facility, 30.90% of participants had to travel 60 to 120 minutes to reach nearest health facility and 44.30% of participants had to travel less than 60 minutes in order to reach nearest health facility . Majority of the participants(89.13%) visited the health care center only while ill whereas 3.48% participants visited the health care center once every year and 7.39% participants visited the heath care center once every six months. About 35.22% of the participants visited health care professional for counseling and 64.78% did not visit health care professional for counseling about the risk factors of Non-communicable diseases. Majority of the participants (72.6%) visited health worker in past 12 months and remaining 27.40% of participants did not visit health worker in past 12 months (table 2).

Table 3: Description of Health Service-Related Information of the participants in Myagde Rural Muncipality, Tanahun, 2019

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4.3 Information about exposure to behavioral risk factors in family and environment

4.3.1 Exposure of participants with tobacco

Among 230 participants, 47.83% of the participants said that in past 30 days someone in their family smoked and 52.17% said that someone in their family did not smoke. About 67.83% of the participants said that somebody smoked in their school area or public places and remaining 32.17% said that no one in their close area of school or places smoked. 39.57% of the participants said that their father used smokeless tobacco, 7.83% said that their mother, 19% of the participants said that their grandparents and 9% of the respondents said that their siblings used smokeless tobacco. Likewise 60.43% of the participants said their father did not use smokeless tobacco, 92.17% said their mother, 91.74% said grandparents and 96.09% said their siblings did not use smokeless tobacco. About 47.39% of the participants said that someone in the close circle outside family used tobacco. Among them, 17.43% of the participants reported that their friends used tobacco, 63.30% of the participants reported that their relatives used tobacco while 19.27% of the participants reported that people in both of these circles used tobacco (table 3).

Table 4: Description of exposure of participants with tobacco in Myagde Rural Muncipality, Tanahun, 2019

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4.3.2 Alcohol use in participants’ family and close circle

Among 230 participants, 39.57% said that their father consumed alcohol and 60.43% said that their father did not consume alcohol, 10.4% of them reported that their mother consumed alcohol and 89.60% said that their mother did not consume alcohol. Similarly, 20.4% reported that their grandparents and 10% reported that their siblings consumed alcohol while 79.60% and 90% said that their grandparents and siblings did not consume alcohol respectively. About 69.57% of the participants said that someone in the close circle outside family consumed alcohol. Among them, 31.2% reported that they were relatives, 28.8% reported that they were friends and 27.8% reported the both (table 4).

Table 5: Alcohol use in participants' family and close circle in Myagde Rural Muncipality, Tanahun, 2019

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4.4 Tobacco Use

Among 230 participants, 6.09% of the participants were found to be currently smoking tobacco while 57.14% of the participants among the current smokers were found to be smoking tobacco products daily. 93.91% of participants did not smoke tobacco currently. Only 13.49% of participants were found to smoke in the past while 86.51% did not smoke in the past. Regarding the use of smokeless tobacco products, 4.35% were currently using smokeless tobacco products and 50% of them were using it daily. 12.61% of the participants reported to have used smokeless tobacco products in the past while 87.39% did not use smokeless tobacco in the past (table 5).

Table 6: Description of the Tobacco Use by the Participants in Myagde Rural Muncipality, Tanahun, 2019

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4.4.1 Tobacco use among participants

The age at which the participants started smoking for the first time was minimum age of 9.67 years, the maximum age of 16 years and the average age of 13.52 years. The average number of manufactured cigarettes smoked daily was 2 while the average number of smoking of hand-rolled cigarette was 2. The average number of times of snuff taken by mouth in a day was 1.25, chewing tobacco in a day was 1 time, and using betel nut in a day was 2. Among the respondents who stopped smoking the average age at which smoking was quit was 13.11 years (table 6).

Table 7: Description of the smoking and smokeless tobacco by the participants in Myagde rural Muncipality, Tanahun, 2019

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4.5. Alcohol Consumption

Less than half (40.9%) of the participants reported that they ever consumed alcohol in the past and 59.10% had reported they had not ever used alcohol in the past. Among the alcohol users, 75.53% of the participants reported that they consumed alcohol in past 12 months while 24.47% of participants said they did not consume alcohol in the past 12 months. Among the participants who consumed alcohol in past 12 months, 2.82% consumed daily, 8.45% consumed 1-2 days/week, 2.82% consumed 3-4 days/week, 4.23% consumed 5-6 days/week, 16.90% consumed 1-3 days/ month and 64.79% consumed less than once a month. 65.96% of the participants reported that they were influenced by their friends to consume alcohol for the first time while 19.15% reported that they were influenced by their relatives, 2.13% by siblings and 12.77% by their parent (table 7).

Table 8: Description of Alcohol Consumption by the Participants in Myagde Rural Muncipality, Tanahun, 2019

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4.5.1 Standard alcohol consumption by participants

In past 30 days, the mean number of occasions in which at least one standard drink was consumed was 2.40 and mean number of standard drinks in one occasion was 1.87. In past 7 days, one standard drink was consumed on average 2.22 occasions and in one occasion the average 2.28 standard drink was consumed by participants. The average standard drink consumption of homebrewed spirit, homebrewed beer/wine and alcohol brought from another country were 1.73, 1.29 and 1.60 respectively. The participants consumed average 1.38 standard drinks of alcohol marketed in the country in past 7 days while they consumed 1 standard drink of alcohol not intended for drinking (table 8).

Table 9: Description of the Standard Alcohol Consumption by the participants in Myagde Rural Muncipality, Tanahun, 2019

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4.6 Diet

The mean number of days in a typical week in which the participants ate fruits was 2.62 and they ate average 1.43 servings in those days. Vegetable was consumed in mean 3.94 days and 1.68 means numbers of servings was ate in one of those days. 75.22% of participants had inadequate intake of fruits and vegetables while remaining 24.78% had adequate fruit and vegetable consumption. About 14.3% of participants always/ often added extra salt/ sauce to food while eating. 47% of participants always/ often added salt/ sauce to food while cooking and 17.8% of participants always/ often ate processed food high in salt. About 57% of participants rarely/ sometimes added salt/ sauce to food while eating, 39.10% rarely/ sometimes added salt/ sauce to food while cooking and 39.10% rarely/ sometimes ate processed food high in salt. About 21.30% of participants never added salt/sauce to food while eating, 1.30% of participants never added salt/sauce to food while cooking and 3.90% of participants never ate processed food high in salt. About 7.40% of participants did not know about extra addition of salt/ sauce to food while eating, 12.60% did not did not know about extra addition of salt/ sauce to food while cooking and 12.60% did not know about eating processed food high in salt. About 28.70% and 47.40% of participants had meals and snacks once in a day respectively. Percentage of participants having meal twice and having snacks twice was 64.30% and 42.60% respectively. Similarly, 7% of the participants had meal thrice in day, 9.10% of the respondents had snacks thrice a day and 0.9% of the respondents had snacks more than thrice a day .65.22% of the participants reported that major constituent most commonly available in their meal was rice, 18.70% reported pulses, and 5.22% said meat and 10.87% reported milk and milk products (table 9).

Table 10: Description of diet related behaviors of the participants in Myagde Rural Muncipality, Tanahun, 2019

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4.7. Physical Activity

Majorities (56.5%) of the participants were involved in vigorous intensity work and 43.50% of the participants did not involve in vigorous intensity work. Similarly, 64.80% of participants were involved in moderate intensity work while remaining 35.20% did not involve in moderate intensity work. 97.80% walked or used bicycle for at least 10 mins in a day and only 2.02% did not walk or use bicycle for at least 10 mins in a day. About 60% of participants involved in vigorous intensity recreational activity and 52.6% were involved in moderate intensity recreational activity. Likewise 40% and 47.40% of participants did not involve in vigorous and moderate intensity recreational activity respectively (table 10).

Table 11: Description of Physical Activity of the Participants in Myagde Rural Muncipality, Tanahun, 2019

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4.7.1 Level of physical activity of the participants

Majority (68.3%) of participants were found doing high level of physical activity where as 27% and 4.8% of participants were found doing moderate and low level of physical activity respectively.

Table 12: Description of level of physical activity of the participants in Myagde rural Muncipality, Tanahun, 2019

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4.8 Magnitude of risk factors of NCDs among participants

The prevalence of current tobacco use was 9.13%; current alcohol consumption was 30.87%. The prevalence of inadequate fruit and vegetable consumption was 75.22% and low level physical activity was 4.78% (table 12).

Table 13: Description of magnitude of risk factors of NCDs among participants in Myagde rural Muncipality, Tanahun, 2019

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Figure 3: Combined risk factors of NCDs among participants

4.10 Association between behavioral risk factors and independent variables (Inferential Analysis)

The relationship between independent variables with behavioral risk factors among participants was tested using Chi square test as listed in objective number 2.The level of significance for the relationship was set at P-value= 0.05.

4.10.1. Association between tobacco use and socio demographic characteristics of participants

The present study revealed significant association between tobacco use and sex of the participants (p<0.001). The study did not show any significant association between tobacco use and other socio-demographic variables i.e., age, ethnicity, religion, education of father, education of mother, occupation of father, occupation of mother, household income (table 14).

Table 15: Association between tobacco use and socio demographic variables of participants in Myagde Rural Muncipality, Tanahun, 2019

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* Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance) ** others included service, business and foreign employment,

4.10.2 Association between tobacco use and other explanatory variables

The present study showed significant association between tobacco use and anyone smoked in the family (p=0.006), smokeless tobacco use in the family (0.032), smokeless tobacco use in the close circle (<0.001).The study didn’t show any significant association between tobacco use and other explanatory variables (table 16).

Table 16: Association between tobacco use and other explanatory variables in Myagde Rural Muncipality, Tanahun, 2019

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*Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance)

4.10.3 Association between alcohol consumption and socio demo characteristics of the participants

The present study showed significant association between alcohol consumption and sex of the participants (P-value<0.001), age of the participants (p-value=0.001) and education of mother (P-value=0.004. The study did not show any significant association between alcohol consumption and other socio-demographic variables i.e., ethnicity, religion, education of father, occupation of father, occupation of mother, household income (table 17).

Table 17: Association between alcohol consumption and socio demo characteristics of the participants in Myagde Rural Muncipality, Tanahun, 2019

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*Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance) ** others included service, business and foreign employment

4.10.4 Association between alcohol consumption and health service related variables

The present study illustrated that there was significant association between alcohol consumption and distance to the nearest health center (P-value=0.001).Highly Significant association was seen between the alcohol consumption and alcohol use in the family (P<0.001) and alcohol use in the close circle (P<0.001).

Table 18: Association between alcohol Consumption and other explanatory variables in Myagde Rural Muncipality, Tanahun, 2019

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*Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance)

4.10.5 Association between fruit and vegetable consumption and socio demographic characteristics of respondents

The present study showed there was significant association between adequate fruit and vegetable consumption and sex (P=0.003), ethnicity (P=0.001) and religion of the participants (P=0.001). There was no association of adequate fruit and vegetables consumption with age, education of father and mother, occupation of the participants' father and mother and annual household income (table 18).

Table 19: Association between fruit and vegetable consumption and socio demographic characteristics of participants in Myagde Rural Muncipality, Tanahun, 2019

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* Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance) ** others included service, business and foreign employment

4.10.6 Association between fruit and vegetable consumption and health service related variables

Significant association was found between adequate fruit and vegetable consumption and frequency of visit to health care center (P=0.003). There was no association of adequate fruit and vegetables consumption with other health service related variables i.e. distance to the nearest health center, visit health care professional for counseling, visit health institution in past 12 months (table 20).

Table 20: Association between fruit and vegetable consumption and health service related variables in Myagde rural Muncipality, Tanahun, 2019

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* Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance)

4.10.7 Association between level of physical activity and socio demo characteristics of the participants

The present study showed that the level of physical activity was significantly associated with sex (p=0.001) while there was no significant association found with other socio demographic information (table 21).

Table 21: Association between level physical activity and socio demographic characteristics of the participants in Myagde Rural Muncipality, Tanahun, 2019

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*Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance), ** others included service, business and foreign employment

5.10.8 Association between physical activity and health service related variables

The present study illustrated that no significant association was found between level of physical activity and any health service related variables (table 21).

Table 22: Association between level of physical activity and health service related variables in Myagde Rural Muncipality, Tanahun, 2019

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*Statistically significant at p<0.05, Applying Pearson chi-square test for association at 5% level of significance)

Chapter V

Discussion

This chapter deals with the conclusion, discussion and recommendation of the findings of this study. The conclusions and recommendation are drawn based on the findings and discussion. The collected data are thoroughly analyzed and interpreted in terms of findings and stated objectives.

5.1 Discussion

As the Objective of the study was to assess the prevalence of risk factors among adolescents which are responsible for several non-communicable diseases, information regarding tobacco use, alcohol consumption, dietary intake and physical activity were collected.

In the present study, it was found that the prevalence of tobacco use was 9.13% which is lower than the study conducted in Chitwan, Nepal(26.55%)²⁴, selected District of India (31.5%)²², Lalitpur, Nepal (17.2%)¹², Sychelles (23.4%)²⁹ and higher than the study conducted in Bellary, Karnataka (6%)²⁷. These inconsistent findings might be due to the difference in setting and sample size. The present study revealed 30.9% of the participants consumed alcohol which is similar to the study conducted in Brazil(29.7%).³³ The findings of the study is higher than the study conducted in Chitwan, Nepal(19.91%)²⁴, Lalitpur, Nepal (14.4%)¹², Kaski, Nepal(18.9%)²³, Bellary, Karankata(5%)²⁷, Mangalore, India (4.6%)²⁶. The finding of study is lower than the study conducted in Seychelles (47.6%).²⁹ This inconsistent might be due to the difference in setting. The present study revealed that majority of participants (75.22%) did not meet the recommended level of fruit and vegetable consumption which is lower than the study conducted in Pakistan (80%)²⁵ and higher than the study conducted in Seychelles (60.9%)²⁹ and Brazil (66.7%)³³. This inconsistent might be due to the difference in sample size and settings. The present study revealed that 4.78 % of participants were doing low level of physical activity which is very low than the study conducted in Pakistan (54%)²⁵, Bellary, karankata (40%)²⁷, Sychelles (82.7%)²⁹ and Brazil (41.7%)³³. This inconsistent might be due to the difference in sample size and settings.

The present study revealed that there was significant association between tobacco use and sex of the respondents (p=0.002) which was in line with the findings of the study conducted in Udupi Talak (p<0.001).²⁸ In contrast, another study conducted in Brazil (p=0.22)³³ and Mangalore, India (p=0.894)²⁶ showed that there was no difference with regards to sex for tobacco use. In this study, there was no any significant association of tobacco use and socio demographic variables like ethnicity and family income which is similar to the study conducted in Kathmandu, Nepal.³⁴ The present study shows that there is no any significant association between tobacco use and religion of the respondent with (p= 0.971) which is inconsistent to the findings of the study conducted in Udupi Talak (p<0.001).²⁸ The present study revealed that there was significant association between alcohol consumption and sex of the respondent (p<0.005) which is similar to the findings of the study conducted in Brazil (p<0.001)³³ and Udupi Talak (p=0.001)²⁸. In this study, there is no any association between alcohol consumption and religion of the participants which in contrast to the study conducted in Udupi Talak (P<0.001).²⁸ The present study revealed that there was significant association between fruit and vegetable consumption and sex of the respondent (p=0.003) which is in contrast with the findings of the study conducted in Pakistan (0.47)²⁵ and Brazil (0.68)³³. The present study revealed that there was significant association between the level of physical activity and sex of the respondents (p<0.001) which is similar to the findings of the study conducted in Pakistan (p<0.001)²⁵, Brazil (p<0.001)³³ and Udupi Talak (p<0.05)²⁸.

Chapter VI

Conclusion and Recommendation

6.1 Conclusion

This study was conducted to assess behavioral risk factors of non-communicable diseases among adolescents of Myagde rural municipality. The study showed that one third of adolescents consumed alcohol. Majority of the adolescents have poor dietary habit which may lead to non-communicable diseases. The adolescents were active as they involved in both high and moderate level of physical activity. The use of tobacco products, alcohol and inadequate intake of fruit and vegetable intake were higher in male than in female and low level of physical activity was higher in female than in male. Likewise the use of tobacco and alcohol is highly affected by the family history of tobacco and alcohol use.

6.2 Recommendation

- The provision of health education regarding behavioral risk factors focusing to both parents and adolescents might be fruitful in order to prevent NCDs.
- The findings of the study might be helpful to the community health workers to encourage adolescents as well as family members to adopt healthy lifestyles.
- These finding might be helpful to the concerned Rural Municipality to plan health programs that focus on awareness and preventive approaches like healthy dietary pattern and prevention of tobacco and alcohol use among adolescents.
- The findings might be relevant for local level policy makers as well as NGO and INGO to focus on community awareness program, training program related to identification and reduction of behavioral risk related to non-communicable disease.

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Annexes

Annex I: Informed Consent Form in English

Namaskar!

I am undergraduate student of Bachelor in public Health at Chitwan Medical College, Bharatpur, and Chitwan. I am conducting a research study as a partial requirement of Bachelor in public health program. The information gathered from this study will be used only for study purpose. For this purpose, you have to fill the questionnaire regarding Behavioral Risk Factors of Non-Communicable Diseases which takes about 15- 25 minutes. Any information that you provide during the interview will be kept confidential. Your name and identity will not appear anywhere. I assure you that there are no any risks for you in taking part in this study. Participation in this study is completely voluntary. You are free to withdraw from the interview at any time or to refuse to answer any particular question that you feel uncomfortable. I will be indebted that you agreed to participate in this study and provide your valuable information.

I agree to participate in the study

I do not agree to participate in the study

Thank you for your support and participation!

Annex II: Informed Consent Form in Nepali

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Annex III: Research Questionnaire in English

Part 1: Socio demographic Information

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Part 2: Health service Related Information

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Part 3: Exposure to tobacco and alcohol use in family and close circle

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B. Alcohol consumption

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C. Diet

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D. Physical Activity

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Annex IV: Research Questionnaire in Nepali

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