Health behaviors among adolescents in Ethiopia

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JEMBERE BERHANU BELIHU

HEALTH BEHAVIORS AMONG ADOLESCENTS

IN ETHIOPIA

Dissertations in Health Sciences

PUBLICATIONS OF

THE UNIVERSITY OF EASTERN FINLAND

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HEALTH BEHAVIORS AMONG ADOLESCENTS IN

ETHIOPIA

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Jembere Berhanu Belihu

HEALTH BEHAVIORS AMONG ADOLESCENTS IN ETHIOPIA

To be presented by permission of the Faculty of Health Sciences, University of Eastern Finland for public online

on February 18^th, 2022, at 12 noon.

Publications of the University of Eastern Finland Dissertations in Health Sciences

No 651

Department of Nursing Sciences, Faculty of Health Sciences University of Eastern Finland

Kuopio 2022

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Series Editors

Professor Tomi Laitinen, M.D., Ph.D.

Institute of Clinical Medicine, Clinical Physiology and Nuclear Medicine Faculty of Health Sciences

Lecturer Tarja Välimäki, Ph.D.

Department of Nursing Science Faculty of Health Sciences

Professor Ville Leinonen, M.D., Ph.D.

Institute of Clinical Medicine, Neurosurgery Faculty of Health Sciences

Professor Tarja Malm, Ph.D.

A.I. Virtanen Institute for Molecular Sciences Faculty of Health Sciences

Lecturer Veli-Pekka Ranta, Ph.D.

School of Pharmacy Faculty of Health Sciences

Distributor:

University of Eastern Finland Kuopio Campus Library

P.O.Box 1627 FI-70211 Kuopio, Finland http://www.uef.fi/kirjasto

PunaMusta Oy 2022 ISBN: 978-952-61-4338-5 (Print)

ISSNL: 1798-5706 ISSN: 1798-5706

ISBN: 978-952-61-4339-2 (PDF) ISSNL: 1798-5706

ISSN: 1798-5714

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Author’s address: Department of Nursing Sciences University of Eastern Finland KUOPIO

FINLAND

Doctoral programme: Doctoral programme in Health Sciences

Supervisors: Docent Päivi Kankkunen Ph.D.

Department of Nursing Sciences University of Eastern Finland KUOPIO

FINLAND

Professor Hannele Turunen Ph.D.

Department of Nursing Sciences University of Eastern Finland KUOPIO

FINLAND

Reviewers: Associate Professor Emily Darlington, Ph.D.

Department of Health Promotion

University of Claude Bernard University Lyon 1 LYON

FRANCE

Docent Satu Elo, Ph.D.

Department of Health Education Lapland University of Applied Sciences OULU

FINLAND

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Opponent: Professor Katja Joronen, Ph.D.

Department of Health Sciences University of Turku

TURKU FINLAND

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Berhanu Belihu, Jembere

Health Behaviors among Adolescents in Ethiopia Kuopio: University of Eastern Finland

Publications of the University of Eastern Finland Dissertations in Health Sciences, 2022, 594 p.

ISBN: 978-952-61-4338-5 (Print) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-4339-2 (PDF) ISSNL: 1798-5706

ISSN: 1798-5714

ABSTRACT

A decline in health-promoting behaviors and an upsurge in health risk behaviors is clearly documented as human age continues to increase.

Health risk behaviors are established during adolescence and often continue into adulthood, gradually impairing health and wellbeing during the life course. The main aim of this study was to describe, explain, and examine and establish the relationships between health-related behaviors and sociodemographic characteristics and add and develop knowledge of health-related behaviors around adolescents in Ethiopia.

A cross-sectional survey of randomly selected 927 adolescents aged 11- 17 years was conducted attending urban and rural high schools in 2010.

The data were collected using the Global School Health Survey (GSHS) questionnaire. The response rate was very high. The data were analyzed using cross-tabulation to determine the distribution of health-related behaviors and a logistic regression model to examine and establish the relationship between sociodemographic factors and health-related behaviors using SPSS version 25.0.

The present study suggested a very large quantity of adolescents engaged in several health risk behaviors. The frequency of health risk behaviors was rife among male adolescents, compared to female

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adolescents. Likewise, higher rates of female adolescents than male adolescents consumed fruit and vegetables the past 30 days. Also, getting into difficulty with family or friends, getting into fights because of alcohol consumptions, having sexual intercourse with many partners, spending their time on sedentary activity, and poor parental understanding of their worries and problems and poor parental monitoring and supervision were widespread among urban adolescents than rural adolescents. The rural adolescents were at higher risk for food insecurity, bullying, feeling loneliness, feeling sad, hopelessness and stopping doing their usual

activities, exposure to secondhand smoking, drinking too much alcohol and really getting drunk, not using condoms during their latest and first sexual intercourse and unhelpful relationships with other students in the schools.

Adolescents who practiced the Islam religion were at high risk for using drugs (Khat).

The male gender, adolescents who had fathers/male guardians and mothers or female guardians who are farmers, daily laborers, and

pensioners were associated with food insecurity the past 30 days. Likewise, the early adolescent period and the higher education of fathers or male guardians and mothers or female guardians increased the likelihood of consumption of fruit and vegetables among adolescents. Also, the higher education of fathers or male guardians enhanced the likelihood of washing hands always after using the latrine for the past 30 days. Adolescents whose parents were farmers were more likely to brush their teeth the past 30 days.

Male gender increased the likelihood of sleep deprivation, cigarette smoking, drug use, alcohol consumption, and risky sexual behavior.

Similarly, the urban areas increased the probability of cigarette smoking, alcohol consumption, and risky sexual behaviors among adolescents.

Likewise living alone enhanced the likelihood of alcohol consumption and risky sexual behavior among adolescents. Also, living with friends

increased the likelihood of people have smoked in their presence among adolescents. Adolescents from urban and in General Secondary and Primary schools are more likely to spend 2 or more hours on a usual day,

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on sedentary activity. Male gender and living in rural areas were associated with the highest levels of physical activity among adolescents.

In conclusion, the distribution of health risk behaviors varies by gender, areas of residence, types of occupations and education levels of parents, religion, living conditions, grade levels, and age. Health risk behaviors difference by the combination of social, economic, and demographic factors suggested tailored public health interventions from public health policymakers and public health interventionists. Culturally competent and geographically oriented research among adolescents is required in

Ethiopia. Ethiopia must invest in adolescent health, education, nutrition, and physical infrastructure to eliminate poverty in its posterity.

Keywords: Adolescents, Ethiopia, Health, Health behavior, Health risk behavior, Health promoting behavior, Lifestyle

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Berhanu Belihu, Jembere

Nuorten terveyskäyttäytyminen Etiopiassa Kuopio: Itä-Suomen yliopisto

Publications of the University of Eastern Finland Dissertations in Health Sciences, 2022, 594 s.

ISBN: 978-952-61-4338-5 ((nid.) ISSNL: 1798-5706

ISSN: 1798-5706

ISBN: 978-952-61-4339-2 (PDF) ISSNL: 1798-5706

ISSN: 1798-5714

TIIVISTELMÄ

Terveyttä edistävä käyttäytyminen saattaa heikentyä merkittävästi elämän aikana, jos terveyttä vaarantava käyttäytyminen lisääntyy lapsuus- ja nuoruusiässä. Terveyttä vaarantava käyttäytyminen kehittyy nuoruusiässä ja se jatkuu usein aikuisuuteen saakka vaikuttaen terveyteen ja

hyvinvointiin elämän aikana. Tämän tutkimuksen päätavoite oli kuvata, selittää ja ennustaa etiopialaisten nuorten terveyskäyttäytymistä.

Kvantitatiivinen aineisto kerättiin käyttäen Global School Health Survey (GSHS) –kyselylomakkeen etiopiankielistä versiota. Aineisto kerättiin kahdesta koulusta 927 nuorelta sekä kaupunki- että

maaseutuympäristössä opiskelevilta nuorilta vuonna 2010. Aineisto analysoitiin ristiintaulukoinnilla kuvaten nuorten terveyskäyttäytymistä sekä logistisella regressioanalyysilla ennustaen nuorten

sosiodemografisten tekijöiden ja terveyskäyttäytymisen välistä yhteyttä käyttäen SPSS-ohjelman versiota 25.0.

Tässä tutkimuksessa todettiin runsaasti nuorten terveyttä vaarantavaa terveyskäyttäytymistä. Nuorilla miehillä oli naispuolisia useammin

epävarmuutta ruuasta, riittämätöntä nukkumista, tupakointia, huumeiden käyttöä, alkoholin liiallista käyttöä, seksuaalista riskikäyttäytymistä ja toissijaisia toimintoja (mm. istuva elämäntapa). Vastaavasti naispuoliset

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nuoret käyttivät miehiä enemmän hedelmiä ja kasviksia viimeisen 30 päivän aikana. Kaupungissa asuvat nuoret olivat maalla asuvia

suuremmassa riskissä joutua vaikeuksiin perheen tai ystävien kanssa, sekä joutua tappeluihin alkoholin käytön vuoksi, sekä käyttäen aikaansa

toissijaisiin toimintoihin ja he kuvasivat etteivät vanhemmat ymmärrä heidän huoliaan ja pitivät vanhempiensa valvontaa ja ohjausta heikkona.

Kaupunkilaisnuorilla oli maalla asuvia suurempi riski epävarmuuteen ruuasta, kiusatuksi tulemiseen ja yksinäisyyteen, surullisuuteen, normaalitoimintojensa lopettamiseen, altistumiseen tupakansavulle, liialliseen alkoholin juontiin, kovaan humalaan juomiseen, kondomin käyttämättäjättämiseen ja apua saamattomiin suhteisiin muiden koulun oppilaiden kanssa. Miespuoliset ja Islamin uskontoa harjoittavat olivat muita suuremmassa riskissä huumeiden (Khat) käytössä.

Epävarmuutta ruuasta viimeisen 30 päivän aikana ennustivat miessukupuoli, miespuolinen huoltaja, maanviljelijänä toimiva äiti tai naispuolinen huoltaja, päivittäin työskentelevä tai eläkkeellä oleva huoltaja.

Hedelmien ja kasvisten suurempaa käyttöä ennustivat puolestaan nuoren matalampi ikä ja huoltajan tai vanhemman korkeampi koulutus.

Vanhemman tai huoltajan korkeampi koulutustaso ennusti myös nuorten käsienpesun todennäköisyyttä wc-käyntien yhteydessä viimeisen 30 päivän aikana.

Miessukupuoli ennusti nuorten liian vähäistä nukkumista, tupakointia, huumeiden ja alkoholin käyttöä ja seksuaalista riskikäyttäytymistä. Myös asuminen kaupungissa ennusti tupakointia, alkoholin käyttöä ja

seksuaalista riskikäyttäytymistä. Yksin asuminen ennusti puolestaan alkoholin käyttöä ja seksuaalista riskikäyttäytymistä. Ystävien kanssa asuminen ennusti todennäköisyyttä sille, että aikuinen oli tupakoinut nuoren läsnäollessa. Miessukupuoli ja ja maalla asuminen ennustivat korkeinta fyysistä aktiivisuutta nuorilla.

Johtopäätöksenä voidaan todeta, että terveyttä vaarantava

käyttäytyminen vaihtelee nuorten sukupuolen, asuinpaikan, vanhemman tai huoltajan työllisyyden ja kouIutustason, uskonnon, elinolosuhteiden, nuoren kouluasteen ja iän perusteella. Nämä erot huomioiden on syytä kehittää nuorille räätälöityjä terveyden edistämisen ohjelmia niin

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poliittisten päättäjien kuin terveyden edistämisen ammattilaistenkin toimesta koulutukseen ja ravitsemukseen tulevien sukupolvien köyhyyden poistamiseksi. Kulttuurisesti kompetenttia ja maantieteellisesti

orientoitunutta tutkimusta etiopialaista nuorista tarvitaan edelleen.

Etiopiassa tulee investoida nuorten terveyteen, koulutukseen ja ravitsemukseen tulevien sukupolvien köyhyyden poistamiseksi.

Avainsanat: Nuoruus, Etiopia, terveys, terveyskäyttäytyminen, terveyttä vaarantava käyttäytyminen, terveyttä edistävä käyttäytyminen,

elämäntapa.

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ACKNOWLEDGEMENTS

This study was done at the University of Eastern Finland, Faculty Health Sciences, Department of Nursing Sciences.

Several people have contributed and made possible this thesis. I am

profoundly appreciative to all those who directly and indirectly contributed and supported me in every step to make possible this study.

I would like to thank the University of Eastern Finland, for giving me the opportunity to pursue my doctoral degree in Health Sciences. Especially, my genuine thanks to Professor Katri Vehviläinen-Julkunen who trusted me and provided me the opportunity to enroll in the doctoral degree program.

My deepest and sincere gratefulness to my supervisors to Docent Päivi Kankkunen, Ph.D., Professor Hannele Turunen, Ph.D., for the continuous encouragement, valuable guidance, kind advice, professional suggestions, beneficial criticism, and supervision in each step of the research process and preparation of this study. Your expert support and assistance have been critical for the accomplishment of this study.

I am grateful to my supervisor Merja Nikkonen Ph.D. who supervised and gave me a lot of encouragement at the beginning of this project. Your support was crucial when I joined the doctoral program. Wish you full of health.

I am thankful to Professor Reija Klementti, Ph.D. for introducing me to the scientific world in public health and health promotion many years ago.

My experience and my practice as your assistance were game-changing and an eye-opener.

I am grateful to the statisticians Reijo Sund, Matti Eskola, Merja-Leena Lamidi for providing me guidance and assistance in research data

management and analysis. Thank you, your support was very important for the data preparation and data analysis.

I would like to express my gratitude to the Education Bureau Officials and schoolteachers in Ethiopia for agreeing, supporting, and assisting me during data collection.

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I am grateful to the participant students in this study and their parents for granting permission to adolescents to participate in this study. Without your cooperation, it would have been impossible to collect the data in this study.

I would like to express my thankfulness to my reviewers Associate Professor Emily Darlington, Ph.D., and Docent Satu Elo, Ph.D. for their careful reading, constructive, thoughtful comments, and suggestions which very much improved this study.

I am very grateful to my opponent Professor Katja Joronen, Ph.D., for agreeing and devoting her time to become my opponent for this

dissertation.

I am grateful to everyone in the editorial team, especially docent Tarja Välimäki, Ph.D., for their editorial support.

I owe to express my uppermost gratefulness to my beloved parents-my mother Tejitu Dersie, your sacrifices, resilience, courage, success, hard work, profound dedication are interwoven into each step of my life and everything I have accomplished. I am always grateful for everything you have given me. You are the greatest Mom and the blessing to our family, and nobody can replace you, you are superior and no better substitute. We love you Mom and wish you long life. My father-Berhanu Belihu who had departed us prematurely-for being my role model for courage,

hardworking and to live life with purpose. I am thankful for the unflagging support and caring my parents have offered us. Our parents’ hard work and scarifies inspired and permitted us to succeed in our livelihoods.

My deepest gratitude goes to my siblings especially to Fetene Berhanu and Simegn for their unconditional love, support, for being always there and assisting me in every aspect of my life.

I would like to express my wishes to the juniors-Patrick, Ermias, and Setna a healthy, productive, and brighter future, it has always been enjoyable and exciting playing and talking with you. May God protect and bless your lives throughout your lifespan.

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ABBREVIATIONS

ACOG American College of Obstetricians and Gynecologists ADHD Attention Deficit

Hyperactivity Disorder AOD Alcohol Outlet Density AUD Alcohol Use Disorder AS Active Smoking

AST Active School Transport AT Active Travel

ATA Active Transport AIDS Acquired

Immunodeficiency Syndrome

BMI Body Mass Index CDC Centers for Disease

Control and Prevention CI Confidence interval CINAHL Cumulative Index to

Nursing & Allied Health Literature

CVD Cardiovascular Disease CSLT Cognitive social learning

theory

CO Carbon Monoxide COPD Chronic Obstructive

Pulmonary Disease CMAJ Canadian Medical

Association Journal CRFA Common Risk Factor

Approach

DALYs Disability-Adjusted Life- Years

ETS Environmental Tobacco Smoke

EHLC External Health Locust of Control

EOLSS Encyclopedia of Life Support System

EDHS Ethiopia Demographic and Health Survey

EBRBs Energy Balance Related Behaviors

FAO Food and agriculture Organization United Nations

FHAPCOE Federal HIV/AIDS Prevention and Control Office Ethiopia

FGM/C Female Genital Mutilation/Cutting FMS Fundamental Movement

Skills

FV Fruit and Vegetable GDPR General Data Protection

Regulation

GSHS Global School children health Survey

GSHS Global School Health Survey

GYTS Global Youth Tobacco Survey

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GHGE Greenhouse Gas Emission HBSC Heath Behavior in School-

Aged Children HEA Health Education

Authority

HEI Health Effects Institute HIV Human Immunodeficiency

Virus

HLC Health Locust of Control HRB Health-Risk Behavior HTPs Harmful Traditional

Practices

IARC International Agency for Research on Cancer IDUs Injecting Drug Users IHLC Internal Health Locust of

Control

IM Institute of Medicine IMS Institute of Medicine Staff IFH International Scientific

Forum on Home Hygiene IQ intellectual quotient IVE International Vehicle

Emission

JAMA Journal of the American Medical Association KAP Knowledge, Attitudes

Practices Kcal Kilocalories

KSOS Korean Sarcopenic Obesity Study LCHD Life Course Health

Development

LMICs Low and Middle-income countries

MCCs Multiple Chronic Conditions

MDD Minimum Dietary Diversity METs Metabolic Equivalent to

Tasks

MOIE Ministry of Information in Ethiopia

MMWR Morbidity and Mortality Weekly Report

MVPA Moderate-to-Vigorous Physical Activity

Natsal National Survey of Sexual Attitudes and Lifestyles NCD Noncommunicable

Disease

NIAAA National Institute on Alcohol Abuse and Alcoholism

NIHD National Institute for Health Development NRIM National Research Council

and Institute of Medicine OR Odd ratio

PA Physical activity PE Physical Education PES Physical Education and

Sport

PST Primary Socialization Theory

PTSD PostTraumatic Stress Disorder

QL Quality of Life

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SEB Sedentary Behavior SEL Social-Emotional Learning SEAs Sedentary Activities SET Sedentary Time

SHS Second Hand Smoking SPSS Statistical Package for the

Social Sciences

SRH Sexual and Reproduction Health

STIs Sexually transmitted infections

SRTS Safe Routes to School SUDs Substance Use Disorders TTM Transtheoretical Model TV Television

UN-ECA United Nations Economic Commission for Africa

UNESCO United Nations Educational Scientific and Cultural Organization UNICEF United Nations

International Children's Emergency Fund

UNICEF United Nations Children’s Fund

UNODC United Nations Office on Drugs and Crime

USDAERS United States

Department of Agriculture Economic Research Service

WHO World Health Organization WSB Walking School Bus

YLD Years Lost because of disability

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1. INTRODUCTION

Health is unlike anything else significantly important in the life of humankind (Kurt 2015, Birol 2004). Decent health is treasured asset for everyone at every step of the way in all areas of life during the lifespan including to learn, work, establish & maintain social and personal

relationships and physical, social and economic growth (Seedhouse 1986).

In other words, good health is strictly associated with academic triumph, strength, creativity, diligence, brilliance, and superior quality of life (Ratnaprabha et al. 2018, WHO 1997). This suggests that health is a precious resource (Dutta-Bergman 2004) that is certainly helpful and health plays a purposeful and significant role to live an active, a productive, an independent life and enjoy successful aging. And health maintenance, promotion, and preventing diseases are essential and fundamental

preconditions (Musavian et al. 2014, Raiyat et al. 2012) to achieve optimum health; that is to say state of reaching exhaustive physical, social,

emotional, intellectual, ecological, spiritual and economical intact (WHO 1986) and then to promote and strengthen the development and growth of individuals, families, communities, and nations (Musavian et al. 2014, Raiyat et al. 2012). An appropriate time for starting healthy and ingenious lifestyles is early years of developmental period (Musavian et al. 2014).

Prudence in resource mobilization to improve adolescent health by society is very crucial (Lee & Loke 2005) because a brighter future of the world (Haj-Ahmad & Sarah Karmin 2019) hinges on the adolescent population (Currie et al. 2004) and the health of the future generation (Haj-Ahmad &

Sarah Karmin 2019, Lee & Loke 2005). Adolescents are a major force in shaping a brighter future through making positive and maximum

contribution to social, economic, and political change. Thus, adolescents can contribute to a vigorous workforce, everlasting economic expansion, better governance, and dynamic societies (Haj-Ahmad & Sarah Karmin 2019). The future of the next generation and society can be endangered when the nation is incapable to invest in the health of adolescents. Poor health during adolescence will dangerously influence the human reservoir

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development and the future economy of the future generations through increasing the size of reliant adolescents and adults on healthcare and social services.Thus, investing in adolescent health promotion in order to ensure a brighter future for successive generations is imperative and unavoidable (Salam et al. 2016). Thus, health promotion will always remain the cornerstone of public health (Madi & Hussain 2007). The best

developmental period for initiating beneficial behavior for health is the early years of life (Musavian et al. 2014, Raiyat et al. 2012). And health habits that are adapted and established in the early years of life, are very unlikely and not easy to change in adulthood since they are not transient and passing phase behaviors (Jackson et al. 2012, Lee & Loke 2005, Lee et al. 1997). Therefore, adolescent health promotion is one of the key

strategies to improve global health, since health risk behaviors in adolescents will contribute to adverse health conditions sooner or later (Lee et al. 2019, WHO 2014).

Health destructive behaviors that comprise smoking, alcohol, drug abuse, unsafe sexual practice, unhealthy eating habits, and sedentary behavior are usually started during adolescence and are maintained throughout the lifespan and are factors of risk for chronic health

conditions in the near and distant future (Azeredo et al. 2016). Moreover, several adolescents are seriously at risk because of insufficient nutritional intake, physical inactivity, smoking, drug abuse and excessive alcohol drinking that can contribute to poor health outcomes (Derlippe et al. 2013, Lee & Loke 2005, Walker & Townsend 1999) all around the lifespan such as injuries, accidents, violence, suicide, unsafe abortion and infection with HIV, cognitive impairment, homicides, cardiovascular diseases, respiratory infections and some cancers (Lee & Loke 2005). The estimates show about 70% of premature deaths in adulthood are attached to health destructive behaviors that are adopted in the early years of life worldwide (Qidwai et al. 2010).

The adolescent period is most of the time considered a healthy period of life because mortality and physical illness is low during adolescence compared with other developmental phases, however, this is misleading (Currie et al 2012, Plianbangchang 2011), because 1.2 million adolescents

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die of curable causes of diseases worldwide each year. The onus of death and disease is whetted by mental health problem, self-inflicted injuries, and self-annihilation, not so much by physical illness during the adolescent period (Mewton et al. 2019). About 67% of deaths happened in lower middle-economies of the world. Growing evidence indicated that traffic accidents, hostile behavior or foul play, underwater suffocation, lower respiratory tracks illnesses, and self-inflicted injuries were the leading causes of mortalities among male adolescents. Equally, the main reasons of mortality among female teenagers were respiratory infections, self- inflicted harm, dysenteric illness, maternal reproductive syndrome such as hemorrhage- bleeding from the genital tract, and sepsis-infection of the genital tract, hypertensive (raised blood pressure with proteinuria), disorders of pregnancy (unsafe abortion and complication of labor) and road traffic injury in 2015 (WHO 2018).

The health of the environment and human health and well-being are inseparable (Marlow et al. 2009, Fowler & Hobbs 2003). Around the world, 23% of all deaths are prompted by environmental risk factors including unsafe drinking water and poor sanitation, and high indoor and outdoor air pollution, climate change, rapid urbanization, poor infrastructures for active travel, lead crystals in soil, pesticide remnants in food (WHO 2019, WHO 2006). Also, environmental pollutants can affect teenagers

excessively because their immunities are not entirely matured and their growing bodies are more easily hurt. And persistent exposure to

contaminated air is the real culprit of respiratory infections among teens (WHO 2010). Thus, environmental management and policy intervention is required for healthy, green, and quality physical environments that supply basic human needs in respect of clean air to breathe and safe water for drinking and sanitation, fertile land for food production, stabilizing climate change and prevent flooding, and providing opportunities for recreation and to have a greater influence on health behavior development and then to improve health (Kuntsche et al. 2017, EEA 2008).

Heath risk behaviors contribute significantly to chronic diseases (Alzahrani et al. 2014, Patton et al. 2009). Also, the initiation of multiple unhealthy behaviors usually occurs simultaneously during the adolescent

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period (Kipping et al. 2012, Connell et al. 2009, van Nieuwenhuijzen 2009) and heightened risk of low academic success, premature disabilities, and deaths (Kipping et al. 2012, Biglan et al. 2004). Destructive behaviors of adolescents are predictive of high social and economic costs now and in the future through injuries, violence, suicide, chronic health conditions, shortened academic accomplishment, and diminished opportunity to access the labor market which can cause direct economic problems to social welfare systems (Health Canada 2001, Benda & Corwin 1998). In other words, health risk behaviors can place adolescents at risk for weak physical, mental, social, and economic outcomes (Behanova et al. 2014, Bambara 1999, McCauley & Salter 1995).

Affectionate support from parents is critical for the development of self- image and mental image the individuals can have for themselves regarding strength, weakness, and status (Mann et al. 2004). The previous study showed that feeling of stable attachment to parents among adolescents was associated with fast adaptation, ability to think and understand quickly, self-respect or self-assurance, and negatively associated with feelings of school disentanglement (Kocayörük & Şimşek 2016). High levels of self-esteem and self-confidence are strongly related to mental wellbeing, adjustment, happiness, subjective well-being, success, satisfaction, and quick recovery after severe sicknesses (Mann et al. 2004). Among others, trust and good communication between adolescents and parents are essential to building excellent parental-child attachment. And trust is felt security that is perceived by adolescents (Ishaka et al. 2010, Armsden &

Greenberg 1987), and is displayed when parents understand and respect adolescents and respond to the adolescents’ questions, needs, desires, and wishes accurately (Ishaka et al. 2010, Erikson 1950). Apparently, when adolescents do trust their parents, they are more willing to share their feelings and ambitions with their parents. Furthermore, trust and confidence between adolescents and parents can be established in part when adolescents can contact their parents and feel that support is at their disposal when it is required (Ishaka et al. 2010). Thus, trust promotes self- disclosure between adolescents and parents and it is a vital component of attachment building (Ishaka et al. 2010, Erikson 1950). Thus, parents are

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immensely important to build up the keystone for their teenagers to stand on and keep on making their own building block to succeed and prevail now and in the future.

Destructive behaviors are exceedingly harmful to individuals’ health and often happen simultaneously (Prochaska et al. 2010, Fine et al. 2004). The existence of multiple health-threatening behaviors either in sequence or simultaneously could heighten the chance of developing chronic ill health, specifically certain cancers, diabetes, and cardiovascular diseases

(Alzahrani et al. 2014).Multiple health risk behaviors multiply the

healthcare burden in connection with health outcomes and costs including, the risk of death, physical, social and cognitive infirmities, jacking up

healthcare cost and hospitalization demands and drug-connected ill effects (Prochaska et al. 2010, Shinton 1997). Also, a study done on Australian adolescents revealed that engaging in road accidents was strongly linked to other health-risk behaviors including tobacco, alcohol and illicit drug use, and unprotected sex (Sanci etal.2018 & Martin et al. 2016). In other words, initiation of one unhealthy behavior would create a favorable condition to engage in other several unhealthy behaviors because of its domino effects.

The world could have saved millions of lives and trillions of dollars had adolescents around the globe made successful transitions to adulthood with positive health behaviors which include health-promoting and risk avoidance behaviors (Boyce et al. 2006, US Department of Health and Human Services 1991) into adulthood. Regrettably millions of adolescents adopt health risk behaviors that are likely to raise the risk of premature morbidity and mortality both today and in the future every year.

Ethiopia has done well in scaling down mortalities associated with lack of nutritional awareness, neonatal & other maternal conditions,

communicable diseases, and injuries by 65%. However, premature death rates due to non-communicable diseases such as cardiovascular disease, diabetes, cancer, and chronic respiratory disease have multiplied and making non-communicable diseases among the top killer diseases in Ethiopia in 2015 (Misganaw et al. 2017). Another study done in Ethiopia revealed that 42% of death caused by non-communicable diseases (NCDs) and among these 27% of death were untimely which is prior to 70 years of

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age. Furthermore, the number of individuals living with Disability Adjusted Life Years (DALYs) has rapidly risen from less than 20% in 1990 to 69% in 2015. This suggests that Ethiopia will suffer from the whopping of before- time deaths and disabilities from NCDs by 2040 if the current development persists unaddressed (Shiferaw et al. 2018). A few studies were conducted on adolescent health behaviors in Ethiopia. Thus, there is an obvious scarcity of information about adolescent health behaviors in Ethiopia.

However, up-to-date research findings around health-related behaviors of adolescents are required to design and deliver the efficient and apposite public health-promoting intervention in Ethiopia. Also, the capacity to accurately delineate, explain and prescient health-related behaviors is vital to varieties of researchers and professionals engaged in developing and pinpointing appropriate interventions to adopt positive health behaviors and to nip the progress of risky health behaviors in the bud (Conner &

Norman 2005). Thus, the overall purpose of this study is to describe, explain, examine and establish the relationships of health-related behaviors to sociodemographic characteristics and then to add and develop knowledge of health-related behaviors among adolescents in Ethiopia and in due course advance preventive healthcare knowledge worldwide.

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2. REVIEW OF THE LITERATURE

In this section, the descriptions and definitions of important concepts and terms used in the present study using previous studies are presented.

Therefore, definitions and comprehensive descriptions of nutrition habits, hygiene, mental health, substance use (alcohol & drug that enhance the risk of injury & violence and tobacco use), sexual behaviors that contribute to HIV infection, other STI, and unintended pregnancy, physical activity, leisure-time sedentary behavior, active travels, and protective factors or school connectedness were presented as health-related behaviors were measured using Ethiopian GSHS questionnaire through 39 questions to address these pertinent themes in the present study. The definitions and comprehensive descriptions of health, adolescent period, and health- related behaviors were critical to broaden and deepen our understanding of the intrinsic and extrinsic determinants and outcomes of these

behaviors, and to propose a useful conceptual framework for the present study. Thus, the various definitions and descriptions of concepts are presented in boxes at the end of each relevant topic. And the definitions used in this study were notably introduced in box 6 with the aim that they could be understood unambiguously. This section began by introducing the literature search strategy used in this study.

2.1 SUBTITLE

Systematic literature search to discover adolescent health behavior studies were conducted on the following databases: CINAHL(Cumulative Index to Nursing & Allied Health Literature), PsycINFO, PubMed, Ovid MEDLINE, Cochrane Library, Google Scholar, and EBSCOhost. Moreover, governments and international organizational websites linked to health, health

promotion, nutrition, food, tobacco, drug abuse, adolescence, and Ethiopia were searched systematically. The information search on these databases and government and international organization websites has been made from 2008 until 2021 (Box 1).

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Box 1. Searching words and phrases used.

Phases of literature search on each database and Google Scholar, governments, and international organizational websites

1st lifestyle, health behavior, health promotion or protection, health risk behavior, nutrition, fruit and vegetable, personal hygiene,

handwashing, dental care, teeth brushing, mental health or disorder, sleeping habits, drug use or khat, tobacco or smoking cigarette, alcohol intakes or consumptions or drinking, sexual behavior or activity, physical activity, sedentary behavior or physical inactivity, active transportation or travel and school attachment, connectedness, school estrangement or alienation.

2nd “health and adolescent or teenager or underage or youth”; “lifestyle and adolescent or teenager or underage or youth”; “health behavior and adolescent or teenager or underage or youth”, “health promotion and adolescent or teenager or underage or youth”; “health risk

behavior and adolescent or teenager or underage or youth“; “nutrition and adolescent or teenager or underage or youth”; “fruit and

adolescent or teenager or underage or youth”; “vegetables and adolescent or teenager or underage or youth”; “personal hygiene and adolescent or teenager or underage or youth”; “handwashing and adolescent or teenager or underage or youth”; “dental care and adolescent or teenager or underage or youth”; “teeth brushing and adolescent or teenager or underage youth”; “mental health or mental disorder and adolescent or teenager or underage or youth”; “sleeping habits and adolescent or teenager or underage or youth”; “drug use or khat and adolescent or teenager or underage or youth”; “tobacco or smoking or cigarette and adolescent or teenage or underage or youth”

“alcohol intakes or consumption or drinking and adolescent or teenager or underage or youth”; sexual behavior or activity and adolescent or teenager or underage or youth”;“physical activity and adolescent or teenager or underage or youth”; sedentary behavior and adolescent or teenager or underage or youth”; “physical inactivity and adolescent or teenager or underage or youth or youth; active transport or travel and adolescent or teenager or underage or youth”; “school connectedness or engagement or attachment and adolescent or teenager or underage or youth”; “school estrangement or alienation and adolescent or teenager or underage or youth”

Cont (continue)

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3rd “health behaviors in adolescents or teenagers or underage or youth”;

“health risk behaviors in adolescent or teenager or underage or youth”; “health promotion or protection behaviors in adolescent or teenager or underage or youth”; “nutrition behavior in adolescent or teenager or underage or youth”; “food insecurity or insufficiency in adolescent or teenager or underage or youth”; “fruit and vegetable consumption in adolescent or teenager or underage or youth”;

personal hygiene behavior in adolescent or teenager or underage or youth”; handwashing behavior in adolescent or teenager or underage or youth; dental care or teethbrushing in adolescent or teenager or underage or youth”; mental health or disorder in adolescent or teenager or underage or youth”; “sleeping habit or behavior in adolescent or teenager or underage or youth”; drug or Khat use behavior in adolescents or teenager or underage or youth”; “tobacco or cigarette smoking in adolescent or teenager or underage or youth”; “alcohol intakes or consumptions or drinking behavior in adolescent or teenager or underage or youth”; “sexual behavior or activity in adolescent or teenager or underage or youth”; “physical activity in adolescent or teenager or underage or youth”; ”sedentary or sedentary behavior or physical inactivity in adolescent or

teenager or underage or youth”; “active transportation or travel in adolescents or teenagers or underage or youth”; “school attachment or connectedness in adolescent or teenager or underage or youth;

“school estrangement or alienation in adolescents or teenagers or underage or youth”

4th “Adolescent and Ethiopia”; “health behaviors among adolescents in Ethiopia”; “adolescent or teenager or underage or youth in

developing countries or Africa”; “health behaviors among adolescent or teenager or underage or youth in developing countries or Africa”

5th Hand searching by checking or scanning the reference lists of collected journal articles was conducted.

The search keywords and phrases were used in the same manner in each database to ensure consistency of systematic searching. The inclusion criteria were (1) publications/journal articles in English at least the

abstracts, (2) the title of the articles that include adolescent and health- related behaviors, and (3) no restrictions were applied on the years of publications. The publications or journal articles were excluded when the articles were not published in English language (minimum the abstract)

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and when the articles did not include adolescent and health-related behavior data.

2.2 DEFINITIONS OF ADOLESCENCE

The word “adolescence” has come from the Latin word “adolescere” which is equivalent to “grow to maturity.” It is the transition phase when

adolescents experience physical, social, and psychological spurt and period of transition from being a child to an adult (Kotecha et al. 2013, Bhave &

Nair 2002). In other words, the Latin word adolescere means growing up- adolescence whereas the Latin word adultus means grown up-adulthood (Sawyer et al. 2012, WHO 2001). It is obvious that the adolescent period begins with puberty naturally and terminates by the sociocultural factor because the time of transition into the phase of adolescence is expressed by the sweeping biological processes change such as sexual maturity and physical growth, whereas entering adulthood is less obviously visible (Arnett 2004 & 2000). Adolescence starts immediately prior to puberty and ends when adulthood roles and tasks are assumed. Puberty indicates the period that marks the growth and the maturation of reproductive,

endocrine, and physical systems (Allender 2002). In the past generations, transition time between adolescence to adulthood is smooth, orderly, and defined sociologically along with the rapid biological change in relations to wedding and family formation, graduation from high school, university, and entering the labor force. However, in the new generations, the transition from adolescence to adulthood happens at later ages and is more complicated because of many years of studies, widespread

unemployment rates, and changes in social structures among adolescents (Arnett 2004 & 2000). Others defined the adolescent period starts with puberty and end when adult height and physical characteristics are accomplished (Scheidt et al. 2000, Dorland’s illustrated medical dictionary 1974). The adolescent period is unique because of its rapid physical, psychological changes, and gradually changing personal relationships (Scheidt et al. 2000). In other words, the adolescent period is a time of extraordinary physiological (body), psychological (mind) social relationships

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(increased demand from school and wider society and increased influence from peers) changes (WHO 1993).

Adolescence is an active period because of the exciting physical, cognitive, and social development. Especially, in the middle adolescence period, adolescents go through considerable physical or biological maturation and social environment change however progress in their cognitive is usually sluggish (Wang et al. 2013, Steinberg 2005).

Characteristics that are distinct during the period of adolescent included risk-tolerance, inventiveness, thrill-seeking, high social interaction &

engage in playing for enjoyment, and doubt or uncertainty. And these unique behaviors boost the process of learning new skills and getting knowledge (erudition) for the achievement of maturation and self-reliance (Crews et al. 2007, Spear 2000, Feldman & Elliott 1990). Moreover, the adolescent period is largely connected with risk-taking behaviors (WHO 1993).

Cultural and social class differences become apparent at the end of the adolescent period (Allender 2002). The distinguishing lines between childhood and adolescence and adolescence and adulthood vary by the cultural traditions and the geographical locations worldwide. Also, the apparent biological, social, and psychological changes during adolescence are not necessarily occurring simultaneously and evenly (Irwin et al. 2002).

Thus, the dividing lines between childhood and adolescence, equally, the dividing lines between adolescence and adulthood, are challenging to define (West 1997). According to WHO (2012), the age range of the

adolescence period is 10-19 years. The adolescent period is broken down into three developmental periods by researchers. Thus, the time between 10 to 13 years old is in the early adolescent period, from 14 to 17 years old is a middle adolescent stage, and 18 to the early twenties years old is a late adolescent phase (Radzik et al. 2002, Smetana et al. 2006). Likewise, others divide the adolescence period into three phases: early adolescence is between 10-13 years of age, middle adolescence is between 14-16 years of age and late adolescence is 17 to 19 years of age (Petersen & Crockett 1993).

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Moreover, growing independence from parents and family is observed during the adolescent period. During the second decade of life adolescents’

bodies, social relations and minds go through an immense transformation or precocious that paves ways for physical maturation and to adopt adult ways of life (Breidablik 2008). Additionally, puberty does cause such radical and visible body changes (Pruneti et al. 2004, McCabe et al. 2002).

Furthermore, there has been increasing recognition that adolescents between 10-24 years of age are a unique population group with needs that differ from those of infants and adults (WHO 2002b, Coleman 2001, WHO 1993), owing to their speedily sprouting and changing physical, social, intellectual, and emotional development (Salam et al. 2016, WHO 1999). A few developmental phases are presented by numerous changes in the same way with the adolescent period at so various levels because of sexual maturity and the beginning of sexuality, rapid increase in social contacts, and cognitive changes. Therefore, the nature and pace of these changes make the adolescence period (Eccles et al. 1993) a distinct population with unique needs and desires.

A previous study showed that home-leaving is a key indicator of the transition to adulthood (Egondi et al. 2013). Lifetime transitions are periods when adolescents go through the most important changes. The transition during the adolescent period can be moving away from parents’ home and stable social network (Lenz 2001), and comparatively intimate elementary schools into more complex, disorderly, chaos and disconnected junior high schools (Simmons et al. 1987). Thus, adolescents are required to adjust and cope in a new environment through developing new skills and learning new experiences. A beneficial transition to adulthood is a cornerstone for adolescents for the next stages of development (Lenz 2001). Moreover, in practice transition implicates achieving independence in cooking skills, planning, and money management, and personal health self-care skills;

adjusting to the arrival of menarche and spermarche or sexual maturation, developing good rapport and relationships with peers through good social skills and behavior development; preparing for a meaningful profession through graduation from vocational schools, college or university;

formation of fundamental beliefs and values or identity; heighten

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proficiency and autonomy; and making a contribution to the community (Boyce et al. 2006, Raphael 1996).

Previous researchers proved that the fruitful transition from adolescence to adulthood is not accomplished by disengaging from significant others (Lamborn & Steinberg 1993). Rather valuable, smooth &

continuous transition to adulthood is completed through stable

attachment and ties with parents (Ryan & Lynch 1989). Furthermore, in the past, the transition from the adolescent period to adulthood was orderly which start with graduation from college and university or high school, then establishing own family and becoming father or mother, and having permanent jobs (Frech 2013, Furstenberg 2010). However, in the modern world, the transition pathways from adolescent period to adulthood are more diverse, unsystematic, messy, and characterized frequently by delayed home-leaving, family establishing and access to full-time work, many years of studies at college or university, cohabitation, and single parenthood (Frech 2013, Amato & Kane 2011).

During teenage, persons are starting to look after themselves.

Adolescents assume responsibility for their personal healthcare, self-care, for their own behaviors, actions, and attitudes (Milligan et al. 1997). Several previous studies indicated that adolescence is generally considered a healthy developmental stage. On the other hand, during the adolescent period, new health risk behaviors start to emerge which can be life- threatening (Kleinert et al. 2007, Patton &Viner 2007, Resnick et al. 1997).

The realization of autonomy in all areas of their lives is the most important developmental task during the adolescent period (Corscadden 2011, Carskadon 1982).

Additionally, evidence showed that the physical, social, societal &

cultural, and media environments where adolescents spend their time change as their age goes up. The place adolescents pass more of their time such as the physical environments that include living quarters or space, playing-field, school facilities, downtown, and farmland; social relations such as, family and group of close friends and peers from divergent backgrounds; culture groups, namely ethnic and religious grouping; and social media platform, that is types of computer games, Internet search,

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and use, music type, radio and television (telly) channels change with adolescent age (Masten et al. 2009). Thus, adults who are responsible for monitoring and supervision vary across contexts. Therefore, the exposure of watching and witnessing the alcohol intake of people in their presence and gaining access to alcohol, tobacco, and drug vary across contexts depending on children’s ages and development (Masten et al. 2009). The previous study indicated enhanced interest and awareness of physical status and health begin to appear during adolescence (Mary et al. 2000).

Adolescents need optimum health, which is critical to achieve their dreams

& ambitions, shoulder their roles and maintain the best possible health status and practice positive health behaviors (Mahasne 2001, Smyke 1993).

The definitions of adolescence are presented in box 2.

Box 2. Definitions of adolescence period.

• Adolescence the Latin word “adolescere” which means grow to maturity (Kotecha et al. 2013, Bhave & Nair 2002), or growing up-adolescence (Sawyer et al. 2012, WHO 2001).

• According to WHO (2012), the age range of the adolescence period is 10-19 years.

• The adolescence period is divided into three phases: early adolescence is between 10-13 years of age; middle adolescence is between 14-16 years of age and late adolescence is 17 to 19 years of age (Petersen & Crockett 1993).

2.3 DEFINITIONS OF HEALTH

Health is developed, experienced, practiced, and explored by people with respect to the ecological conditions of their daily life, including where they study, go to work, play, love and freshen (World Health Organization, Health, and Welfare Canada, & Canadian Public Health Association, 1986).

Thus, people with diverse and dissimilar religious, ethnic, cultural

backgrounds and social norms are likely to describe the states of health in distinct and different ways. Reasonable definitions of states of health should be driven by the social, economic, political, and cultural conditions of communities (Maggie & Wendy 2005). Furthermore, the notion of health

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is changing and has been defined in various manners by members of several disciplines as time goes by (Lynn 2005). According to Smith (2002) health is the state of being free from defects. Another definition comes from the medical model that focuses on the absence of disease or injury (Millstein et al. 1993). According to the life course health development (LCHD) model, health is an established developmental capacity (Halfon et al. 2014). Health is priceless and matchless resource that empowers individuals to achieve life goals-being happy, healthy, and achieving

intellectual growth, and being productive and fruitful. Adolescent health is a developmental capability that gives adolescents the capacity to reach ones’ standard capability and potential which could assist adolescents to respond favorably to their needs and interact, function, and adapt smoothly with their biological bodies, physical and social environments (National Academy of Sciences 2017, Halfon et al. 2014).

Health is the major keystone for achievement and accomplishment. In other words, without superior health, persons’ ability to study, work, enjoy

& have a normal life and establish and maintain social and personal relationships are severely and virtually impaired (Seedhouse 1986). Health develops constantly all over the lifespan and at anytime a human may be advancing toward either superior or inferior levels of health. Human health depends on their internal biological (tissue, cells) and physiological

(cardiovascular, respiratory immune) systems and their external physical and sociocultural environments and the continuous interactions between them (Halfon et al. 2014). Thus, a healthy adolescent means a healthy future and productive and capable human capital for the households, community, and society. Adolescent health deserves distinct, maximum attention and nurturing care because adolescents are teachers, engineers, scientists, problem-solvers, and global leaders of the future (Christian &

Smith 2018). Adolescents are symbol of future, continuity and harmony for families, communities, and nations (Lee & Loke 2005, WHO 1998). The health, capabilities, knowledge, and energy of adolescents will determine and govern the future of communities, cities, and nations worldwide (WHO 1986). The capability of the new generation to shoulder and fulfill its

responsibility, meet, and overcome the challenges of tomorrow and

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promote economic growth is determined by its optimal health

development during this critical adolescent period (Christian & Smith 2018). Adolescents are the most significant natural human resource and reservoir worldwide. Therefore, the young person must be at the core of the development plan in each community and country (WHO 1986). Thus, adolescents must be empowered to follow up and adopt healthy lifestyles and become ambassadors and models of health promotion agents in their family and community through obtaining health-related knowledge, values, skills, and practices (Ratnaprabha et al. 2018, WHO 1997).

WHO emphasizes in its definition wholeness of health which is the most widely mentioned definition of health. Thus, health is defined since 1948, as the condition of absolute physical, emotional, social wellbeing and not purely the non-existence of disease or disability (WHO 1948). Furthermore, complete health and wellbeing are realized by the combination of each constituent of health that is made up of emotional, social, physical, mental, and spiritual wellbeings into a purposeful whole and felt at any level of health or illness (Mahon et al. 2005, Greenberg 1985), whereas from

medical health belief, health indicates the non-existence of illness, disease, or symptoms (Mahon et al. 2005, Laffrey 1986). Health is a dynamic state of well-being, with bodily, social, psychological, and psychic dimensions (Perry 1999). Additionally, the comprehensive view of health that comprises all dimensions (physical, social, psychological, environmental, and spiritual) are important when considering the health behaviors of adolescents, because the consequences of health-risk behaviors could appear in more than one dimension of an adolescent person’s life (Perry 1999).

Moreover, studies showed that a clean environment is critical for human health (Debesay et al. 2015, Seifu & Amy 2011, Tefera 2008). Likewise, positive perceptions of health categories or status (good, very good, excellent) among early teenagers can be achieved by promoting healthy lifestyles among the teenagers, maintaining their vaccination, schooling them to make clean and safe environments, and coaching them to avoid unhealthy situations that make them exposed to illnesses, unprotected from harms, violent acts and evils that lead to negative perceptions of health categories or status such as fair, not good, bad or very bad by the

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school nurses are needed (Mahon et al. 2005, US Department of Health and Human Services 2000). Additionally, geography and health are

fundamentally interconnected. The air to breathe, the food to eat, types of bacteria and viruses available, and the health services individuals can access, directly influence individuals’ health experiences which is absolutely determined by the geographical contexts, where individuals, live, work, and study (Trevor & Dummer 2008). Thus, health behaviors are the products of persons’ education, employment, and income (social positions),

sociocultural status, for example, family, peers, media, religion, culture;

and environmental factors such as geographical location, political climate, social contacts, access to information and technology among other things.

Thus, it is not possible to define the state of health in absolute terms that can be accepted by all cultures and societies. It is advised that health is explained and defined in the socio-economic and cultural context of groups of people in their communities. This kind of approach can serve as a roadmap to healthcare workers and social service providers to become sensitive to local cultures, characteristics of the communities and recognize the states of health from the local people’s perspectives and then design culturally acceptable health preventive, protective, and promotion interventions. Some definitions of health are presented in box 3.

Box 3. Definitions of health.

• Health is a dynamic state of well-being, with bodily, social, psychological, and psychic dimensions (Perry 1999).

• Health is the absence of disease or injury, defect (Millstein et al. 1993).

• Health is the combination of the parts of health that consist of emotional, social, physical, mental, and spiritual into a purposeful whole and felt at any level of health or illness (Mahon et al. 2005, Greenberg 1985).

• Health indicates the non-existence of illness, disease, or symptoms (Laffrey, 1986, Mahon et al. 2005).

• Health is the condition of absolute physical, emotional, social wellbeing and not purely the non-existence of disease or disability (WHO 1948).

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2.4 CONCEPTS OF HEALTHY LIFESTYLES

Lifestyle is routine and typical day-to-day activities which are approved by people during their lifespan and these activities influence the health and the quality life of people (Tol et al. 2013, Delaun & Ladner 2002). Lifestyles are beneficial social practices and ways of life that mirror the

socioeconomic situation, culture and the identity of the community, and a group of people and individuals (Farhud 2015, Cockerham et al. 1997, Giddens 1991). Lifestyle behavior is established in precise time & place, economic, political, cultural, and religious context by individuals, groups, and nations as the ways of living. Lifestyle is day-to-day behavior

associated with physical activity, leisure, and food habits at home and work (Farhud 2015). The lifestyle is closely linked with attitudes, values, and social norms. Also, lifestyle is steady behavioral patterns, attitudes, and beliefs which are unique to the community or group the person wants to belong to (Aarø 1986). Societal norms are the standard behaviors that operate within a group that show the borderlines of a normal code of conduct to promote or discourage certain behaviors (Echeverría et al. 2015, Thoits 2011). Health lifestyles begin to establish during the early years of life (Farhud 2015, Cockerham et al. 1997, Giddens 1991). Health lifestyles are deliberately created patterns of health behavior in line with the choices from options that are presented to individuals derived from their living conditions (Cockerham 1995). And health lifestyles are enacted at the individual level (biological, psychological, knowledge, motivation,

opportunities) but are shaped by the meso (adult support, family values, peers, friends, tribe, religion, sports clubs, playgrounds, transportation) and macro levels (weather, policies/laws, media, state of socio-political- economy). In other words, patterns of health behaviors, mortality, morbidity, and health outcomes are determined by the socio-economic environment or living context. The likelihood of health equalities increases when the socioeconomic determinants of health are fairly and squarely addressed because health lifestyles and health are always shaped and influenced by social, cultural, economic, and political conditions in which individuals live (Short & Mollborn 2015, Jessor & Turbin 2014).

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Thus, lifestyles are crucial to self and group expressions of dissimilarities and similarities that are triggered by rapid social change, economic boom, technological revolution, and political changes in the contemporary world (Cockerham et al. 1997, Giddens 1991). Moreover, lifestyle diseases that threaten the health of people and their quality of life are widespread globally today (Cockerham et al. 1997). Additionally, health-related behavioral patterns, values, and attitudes formed by a cluster of people matching their social, cultural, and economic situations are called healthy lifestyles (Cockerham 1995, Abel 1991). Definitions of lifestyle and a healthy lifestyle are presented in box 4.

Box 4. Definitions of lifestyles and health lifestyles.

• Lifestyle is described as routine and typical day-to-day activities which are approved by people during their lifespan and these activities influence the health and the quality of life of people (Tol et al. 2013, Delaun & Ladner 2002).

• Lifestyles are beneficial social practices and ways of life that mirror

socioeconomic situation, culture, and the identity of the community, and a group of people and individuals (Farhud 2015, Cockerham et al. 1997, Giddens 1991).

• Lifestyle is established in precise time and place, economic, political, cultural, and religious context by individuals, groups, and nations as the ways of living (Farhud 2015).

• Health lifestyles are deliberate patterns of health behavior in line with the choices from options that are presented to individuals derived from their living conditions (Cockerham 1995).

2.5 DEFINITIONS OF HEALTH-RELATED BEHAVIOR

Health-related behavior is any explicit behavior or individual trait that either promotes or impairs health and wellbeing today & in the future (Hassen & Kibret 2016, Ryff 1989). Health behavior is fully and clearly expressed patterns of behaviors, practices, and values for preserving, recovering, and improving health. Also, health behavior refers to all activities performed with the intention of preventing illness, tracing

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symptoms of health problems, and promoting health. Health is protected through using of health services properly, participating in necessary vaccination, frequent screening, listening to health experts and following strictly medical regimens and health promotion advice to the letter and making healthy behavior usual habits (Gochman 1997). There are multiple connections between health and behavior however these connections are neither simple nor straightforward (Institute of Medicine Staff 2001).

Health behaviors are activities carried out by people who believe they are healthy to avoid future ill health by eating healthy food that is low in cholesterol and fat and performing regular physical activity. Also, healthy behaviors include the prevention of health destructive behaviors, namely, excessive alcohol intake, smoking, and drug use, consumption of unhealth diet (Mahasneh 2001, Taylor 1991). Furthermore, usually, three types of health-related behaviors are recognized, these include: health behavior practices that are designed to deter catching diseases through

consumption of healthy diet and performing physical activity frequently;

unwell or ill practice is an activity that is designed to seek out treatment such as visiting the doctor; and a passive-role behavior means all actions are designed to recover, become fresh and normal after serious sickness, specifically, taking prescriptive medication and resting (Kasl and Cobb (1966). Moreover, health behavior is divided into health destructive behaviors and health-protective behaviors. Health destructive behaviors are behavioral pathogens (diseases causing agents), specifically, smoking, eating unhealthy foods, and excessive alcohol intake whereas defensive health behaviors are behavioral immunogens (immune responses, defensive), for example, good personal hygiene, accessing truthful health information (Matarazzo 1984), so as to lower fairytale & folklore and

misinformation & disinformation that misinform and misadvise, afterwards boosting health promoting behaviors (Friedman 1989), having regular screening, getting enough sleeping each day (Matarazzo 1984). Thus, health behaviors can be a double-edged sword depending on the categories of health behaviors established.

Social learning theory advocates that human behaviors are learned within the family, school, faith institutions, and caring organizations

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(Bronfenbrenner 1989, Bandura 1986). The learning of behavior happens through having contact with others in the social gathering places and then observing and imitating their behavior (Pender et al. 2010). Furthermore, according to cognitive social learning theory (CSLT), learning or education is ramped up by watching and emulating the behavior of others, overtly through imitation and copycat strategies that make social rewards happen while rejecting behaviors that cause social punishments (Zaikman & Marks 2017, Bandura & Walters 1963).

Our attitudes, concepts, morals, values, and behaviors are established and tenacious as per cultural expectations and observing and obeying them have reinforced (Zaikman & Marks 2017, Kohlberg 1966). People have the tendency to comply with descriptive (judgments about what others do) and injunctive (judgments about what others approve and disapprove) norms for a variety of reasons (Cislaghi & Heise 2019, Bell & Cox 2015).

Additionally, the situation of the social and the physical environments could provide either environmental opportunities that are favorable to health or environmental condition that are unfavorable to health through forcing individuals to engage in certain behavior. Thus, environments place restrictions on persons’ choices (Institute of Medicine Staff 2001). Inactivity, excessive alcohol intake, and unhealthy nutritional practice that are known as behavioral pathogens are the major causes of premature diseases and injuries, and deaths (WHO 2008). Health-related behaviors and

psychosocial aspects of health were identified as key touchstone variables, with personal way of life and environmental factors as predictors of health and wellbeing (Currie et al. 2009). Evidence showed each behavior is

defined by an individual’s behaviors, recent social & cultural milieus (Flay &

Petraitis 1994). All behaviors that influence individuals’ health conditions, either positively or negatively are called health-related behaviors (Carmody 2007). Health-related behaviors are constantly changing and fluctuating along with the lifespan, between and within groups, areas, and as time passes (Short & Mollborn 2015, Chen & Jacques-Tiura 2014).

Health behaviors are individual ways of life directly linked to health, disease, and death. Precisely, physical activity, consumption of healthy foods, and obedience to medical regimens will promote health and prevent

Health behaviors among adolescents in Ethiopia

JEMBERE BERHANU BELIHU

HEALTH BEHAVIORS AMONG ADOLESCENTS

IN ETHIOPIA

Dissertations in Health Sciences

HEALTH BEHAVIORS AMONG ADOLESCENTS IN

ETHIOPIA

HEALTH BEHAVIORS AMONG ADOLESCENTS IN ETHIOPIA

ACKNOWLEDGEMENTS

CONTENTS

ABBREVIATIONS

1. INTRODUCTION

2. REVIEW OF THE LITERATURE