Author: Olatunbosun-Alakija, A.; Phongsavan, P.; Bauman, A.; Chen, J.; Smith, B.
In 2000, UNICEF Pacific initiated the life skills curriculum programme among Pacific out-of-school youth. This programme incorporates an element of a situation analysis whereby the principal risk behaviors of the relevant population are assessed. Youth agencies and government ministries in Vanuatu and Tonga also expressed growing interest in obtaining population-based and up-to-date information on the health and lifestyle status of youth for programme planning and policy development.
Purpose / Objective
This survey of health and lifestyle behaviors of young people in the Kingdom of Tonga is an initiative of UNICEF to obtain reliable, population-wide measures of need among students and out-of-school youth in this nation. The purpose of this is to provide a strong information base that can be used by government and non-government organizations in Tonga, and partner agencies such as UNICEF, to determine priorities for action in promoting the development and well-being of youth in the Kingdom of Tonga.
The HBLPY survey has several purposes:
- Inform the development of youth health interventions, primarily on the life skills curriculum programme
- Assist countries in tracking trends in youth health behavior over time, in order to gauge the needs for new interventions or to monitor the net sum effectiveness of existing ones
- Compare similar data from different countries in the Pacific
- From a theoretical perspective, the survey is expected to contribute to a better understanding of the factors associated with positive and negative youth health states and behaviors
A representative sample of 2,880 students from across Tonga was surveyed. In order to gain an indication of health and lifestyle issues among out-of-school youth, a convenience sample of 1,008 young people from across Tonga were also surveyed. The survey instrument consisted of core questions from the Health Behavior in School Children (HBSC) surveys that have been conducted in European countries since 1982, as well as some additional questions that were of specific relevance to young people in Tonga. The health and lifestyle issues covered in this instrument included: substance use; dietary habits; physical activity; mental well-being and social support; injury and bullying; personal hygiene habits, and; sexual health (measured among out-of-school youth only).
School students self-completed the survey in their classroom under the supervision of members of the survey team while the out-of-school youth completed questionnaires in a group-interviewed format. A random sub-sample of school students also had their height and weight measurements taken in order to calculate their body mass index.
The Health Behavior and Lifestyle of Pacific Youth (HBLPY) survey in Tonga is groundbreaking both because of the unique insights it provides and also because of the collaborative research process that was undertaken to conduct this survey in the Kingdom. Those who participated in the design, implementation and reporting of the HBLPY survey included UNICEF Pacific, non-government youth organizations in Tonga, the government of Tonga and its relevant ministries and the Australian Centre for Health Promotion in Sydney, Australia. Local young people played a critical role in the development and testing of the survey instrument and its administration in the field. This participatory approach not only contributed to the relevance and effectiveness of the study, but helped to enhance the capacity of local young people to identify and address their needs in the future.
Key Findings and Conclusions
Tobacco was the substance most commonly used by young people in Tonga. Nearly half of the students reported ever using tobacco while about 1 in 6 said that they used it on a weekly or more regular basis. Kava was the substance that students were next most likely to have ever used, with 1 in 3 reporting this, followed by alcohol. After tobacco, the other substances that were most likely to be used at least weekly were kava (1 in 10) and solvents (1 in 20). About 1 in 6 students reported ever being drunk in the past while a little over 1 in 20 said that they had been drunk at least two times.
Boys were more likely than girls to report ever using all of the substances examined. Among boys, the use of all substances increased with age, while among girls this was only the case for tobacco, alcohol and kava. Out-of-school youth were more likely than those in school to report past consumption of alcohol or methylated spirits, or to have been drunk at least once. Students from the island group of Vava'u had the highest proportions reporting that they had tried the various substances, with the exception of marijuana, where Tongatapu showed the highest proportion of students reporting past usage. Comparison of the levels of usage of tobacco and alcohol among students in Tonga with those of students in Europe revealed that young boys in Tonga were more likely to report ever using tobacco than their counterparts in Europe. On the other hand, students in Tonga reported lower levels of alcohol use and previous drunkenness than have been reported in Europe.
Personal well-being and development:
The data concerning mental well-being among young people in Tonga provided a mixed picture of this area of health need. About 1 in 8 students reported that they did not feel happy, while a slightly higher proportion reported that they rarely or never felt confident, and around 1 in 12 said that they very often felt lonely. These rates were within the range of what is usually observed in such surveys in other countries. However, contrary to these findings, the measures of sadness and optimism among youth in Tonga provided an indication of potential mental health problems that warrant further investigation. Around one third of students reported experiencing severe sadness or depression in the past six months while less than half of the students thought that they would be likely to get a job after school. Nearly one third of the students who reported sadness or depression could not identify anyone as a possible source of support, and this was particularly the case among boys. Friends were the main source of support that students felt they could turn to when they experienced severe sadness. Note that the experience of sadness or depression may have been difficult to translate into Tongan.
Overall, all respondents, including those who did not report any mental health related difficulties, were most likely to identify mothers, siblings, fathers and friends as sources of support when they were having problems. There were higher proportions of out-of-school youth than those in school who reported that they could easily discuss their problems with people inside and outside of their family.
Generally, students were positive about the social and physical environment at their schools and the way they were treated by their teachers. Between 70% and 80% of students felt that school was a nice place to be in, that they belonged there, and that their school was clean and safe. In addition, students generally felt that their teachers encouraged them to express their views, provided extra help when it was needed and were interested in them as people. The peer environment was rated positively by most students in terms of the degree to which students enjoyed being together, and were helpful and accepting towards each other. There was some evidence, however, of divided views about the system of rules and discipline in schools. While 4 in 5 considered the rules at school were fair, about three quarters of respondents thought that students were treated too severely or strictly.
Community participation and community involvement:
Over 4 in 5 students felt encouraged to express their views by their parents, while around 3 in 5 students felt encouraged to express their views in the church context and among friends. The community context was where students felt least able to participate, with about 2 in 5 students reporting that they felt encouraged to express their views in their local community. Out-of-school youth were more likely than those in school to report that they felt comfortable to express their views among friends or in the church or community context. The Ha'apai island group had the highest proportion of students who felt comfortable to express their views in the community.
While the vast majority of young people rated their community as important to them, a substantial proportion did not feel involved in their community. In spite of the fact that students in Ha'apai were most likely to feel comfortable expressing their views in their community, they were the least likely to feel strongly involved in this context.
Physical injury, bullying and violence:
The results concerning deliberately inflicted injuries and bullying indicated that these are issues of concern among young people in Tonga. Around 3 in 5 students said that they had suffered a deliberate injury from another person in the past 12 months. Boys were more likely than girls to report that they had been deliberately injured, while those at younger ages were more likely to report this than those who were older. Almost 4 in 5 boys aged 11 years reported that they had been deliberately injured in the past 12 months. Out-of-school youth were more likely than those in school to report such injuries, and this problem was more prevalent in Ha'apai and Vava'u than Tongatapu. "Other adults" were the primary sources of such deliberately inflicted injuries, followed by boyfriends, fathers and mothers.
About 17% of students had been bullied one or more times per week in the past school term, while a slightly lower proportion admitted that they bullied others once per week or more. Girls were more likely than boys to report that they had been bullied at least once in the last term, or that they had bullied others. The rates of both bullying and being bullied increased across age levels for both genders.
Sexual behavior among out-of-school youth:
The information collected about the sexual health behaviors of out-of-school youth showed that boys were more likely to report being sexually active than girls. In addition, over three quarters of boys who reported ever having sex said that they had had sex with more than one person compared to about half of the girls who had ever had sex. A serious concern was that a high proportion of girls who had engaged in sex, about three quarters, reported that they never used contraceptive measures nor took steps to prevent sexually transmitted infections. Around 2 in 5 boys said that they never took such actions. It was also a concern that about 2 in 5 boys and 1 in 5 girls reported that they had engaged in unwanted sex when they were drunk in the past.
This survey has extended the work completed in the first HBLPY survey in Vanuatu. This Tongan survey further demonstrated that it is feasible to collect quality data about the health and lifestyle needs of youth in developing countries and report these findings at relatively low cost, compared to similar surveys in developed nations.
Fundamental to the success of this initiative was the endorsement of government Ministries in Tonga. UNICEF Pacific has been critical in organizing local youth agencies and providing technical support at the various stages of this survey, such as on the ground coordination and the training and supervision of field staff. Academic institutions, such as the Australian Centre for Health Promotion Research Unit in Sydney, can play a role in processes like these in fostering the development of local research capacity and helping to analyze and interpret the data which are collected.
It is essential that youth health and development programs in developing countries are based on local country data, rather than extrapolations from the regular health behavior surveys that are carried out with young people in developed nations. In this case, data that are unique to Tonga have been collected and can be applied in policies and programs planning to address the needs of young people. An important role that periodic implementation of such surveys can play is in monitoring the extent to which health and lifestyle gains are being made among youth in Pacific Island nations and to provide a source of surveillance of emerging issues among youth.
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WHO/WPRO, Australian Centre for Health Promotion