This survey of health and lifestyle behaviors of young people in the State of Pohnpei in the Federated States of Micronesia (FSM) is the third in a series of surveys which examine needs issues among young people in the Pacific Island nations. It is part of an initiative by UNICEF Pacific and its government and non-government partners in Pacific nations to develop programs for young people in this region. Previous reports document the health and lifestyles of young people in Vanuatu (2000) and Tonga (2001). The planning and implementation of the Health Behavior and Lifestyle of Pacific Youth (HBLPY) survey was a collaborative initiative between UNICEF Pacific, the Ministry of Health, Education, and Social Affairs in FSM, the Pohnpei Youth Council, Peace Corps FSM, the Australian Centre for Health Promotion at the University of Sydney (a WHO collaborating centre in Health Promotion) and other agencies.
Purpose / Objective
To develop effective youth programs and appropriate policy for the promotion of positive youth development, it is important to identify the existing patterns and prevalence of key youth health and lifestyle characteristics, and the factors that associate with substance use, nutrition, physical activities, mental health and social support. The intention is that the findings from the series of surveys will form an evidence base for planned interventions. The HBLPY is a survey to assess and monitor the health and lifestyles of national samples of young people in the Pacific region. No previous attempts have systematically measured the behaviors, lifestyles, physical and social environments of youth in this region.
The HBLPY survey has several purposes:
- Inform the development of youth health interventions, primarily on the life skills curriculum programme
- Assists countries in tracking trends in youth health behavior over time, in order to gauge the needs for new interventions or the monitor the net sum effectiveness of existing ones
- Compare similar data from different countries in the Pacific
- From a theoretical perspective, the survey will contribute to a better understanding of the factors associated with positive and negative youth health states and behaviors
A sample of 1516 in-school students from Pohnpei and 108 out-of-school youth from this State were surveyed. The survey instrument consisted of core questions from the WHO European Health Behavior in School Children (HBSC) surveys, adapted to FSM and other Pacific Nations. The instrument covered health and lifestyle issues that included: substance use; dietary habits; physical activity; mental well-being and social support; trust in adults and social institutions; injury and bullying; personal hygiene habits, and; sexual health. School students self-completed the survey under the supervision of members of the survey team, while the out-of-school youth completed questionnaire in a group-interview format. The results in this summary below relate to in-school youth, as the out-of school sample was too small to produce reliable estimates. The sample of 1516 youth had equal representation of boys and girls, and was mostly between age 14 and 17 years. There was a high degree of religious affiliation, mostly Catholic or Protestant.
Key Findings and Conclusions
The data about substance use by young people in Pohnpei identified several areas for concern. The prevalence of chewing betel nut was high, with about two-thirds of students reporting that they did this at least weekly, which is a concern given the association between long term use of this substance and oral cancer. One third of students reported chewing tobacco and one in five reported consuming kava at least weekly. Just under one in five students reported smoking at least weekly and one in eight said that they smoked marijuana this often. The experience of drunkenness was also quite common, with almost half of students reporting that they had been drunk at least twice in the past, and one in five reporting that they had been drunk more than 10 times. There were more boys than girls who reported ever consuming each of the substances, and the gender differences were most marked for alcohol, chewing tobacco and kava. The use of most substances increased with age.
Personal well-being and development:
The finding that almost two in five students reported not feeling happy indicated that there was a substantial proportion dealing with at least some level of mental stress. In addition, about one in six reported rarely or never feeling confident or often feeling lonely. The vast majority of students (four in five) stated that they had experienced sadness or depression in the last six months, while just under one quarter reported that they had experienced this at a level of severity that they would describe as almost more than they could take. There was a higher proportion of girls than boys at each age who reported feeling unhappy. From age 15 years onwards there were also higher proportions of girls who reported that they had experienced severe sadness or depression in the past six months. Just under one-third of students who had experienced severe sadness or depression said that they had no one to turn to for support at the time, and this was a more common situation among boys than girls. Following this the most common sources of possible support identified were friends, mothers and boyfriends/girlfriends. Generally students felt positive about their prospects for getting a job after school Friends were most frequently identified by students as people that they could turn to in times of difficulty. Apart from friends, female relatives like mothers and sisters were major sources of social support. Those in formal positions, like youth workers and clergy, did not feature prominently among the people identified by students as easy to approach when they were in need of support.
Generally students were positive about their teachers and peers at school, but had more divided views about their school environment overall. Although just over two in five students did not think that the rules were too strict at school the proportion who held the opposite view was only slightly smaller. About three in five considered the rules at school were fair. Over 70% of students considered their school to be a nice place to be, while a similar proportion had a sense of belonging at school. However, a substantial proportion of students, about two in five, did not consider their school to be clean or safe. Boys viewed the environment at their school more positively than girls, but girls tended to report a more favorable peer environment than boys.
Community participation and community involvement:
Students were most likely to feel comfortable to express their views among their parents and their friends. Over three quarters of students felt encouraged to express their views in these social contexts. Following these, the church was the next context where students were most likely to feel encouraged to express their views. Just under half of students felt encouraged to express their views in the community. Girls were more likely than boys to feel comfortable to express their views in the private sphere, that is, among family and friends, while boys were more comfortable in public contexts like church and the community. While the vast majority of students (over 90%) considered their local community to be important to them only about one in five felt strongly involved in their community, while over two in five felt little or not at all involved. Boys were more likely than girls to consider the community to be important and to feel strongly involved in the community.
Credibility and trust in adults and social institutions:
The results concerning the perceptions of students about their social environment revealed marked differences in the level of credibility that they ascribed to figures in the private and public spheres. Over 80% of students identified members of their immediate family as credible figures in their social environment. These were followed in ratings of credibility by church leaders and teachers. Traditional leaders and government leaders were least often considered to be credible.
Physical injury, violence and bullying:
The findings indicated that injuries were a major problem confronting young people in Pohnpei. A substantial proportion of students, over two in five, reported suffering an injury that required treatment in the past 12 months, and a similar portion said that they suffered an injury deliberately inflicted by another person in this period. Mothers, unidentified 'other people', boyfriends/girlfriends and fathers were the most commonly identified sources of these deliberate injuries. Boys aged 14 years were most at risk of an injury or an injury deliberately inflicted by another person, while boys were more likely than girls to report any form of injury. While there were substantial proportions of students who had been bullied or bullied others at least once in the past school term there was little evidence of regular bullying. About 4% of students had been bullied one or more times per week in the past school term, while a slightly higher proportion (8%) admitted that they bullied others once per week or more.
There is a strong indication that sexual health issues are of importance to young people in FSM. The majority of students reported having sex in the past. However, there were substantially higher proportions of boys (over 80%) than girls (around 40%) who reported this. It was notable that the proportions of boys who reported having sex at age 14 and 15 years were similar to those at older ages, while for girls the experience of sex was more likely to be reported at older ages. In addition more than half of boys said that they had had sex with four or more people in the past while the majority of girls (just under 60%) reported having sex with only one person.
There were only small proportions of sexually active boys and girls, about one in eight, who reported that they always used condoms. Furthermore, about three in five girls and just over two in five boys reported never using condoms. Public health clinics were the most commonly identified venue in Pohnpei for obtaining condoms. Pharmacies were the next most commonly identified source of condoms, followed by dispensaries and grocery stores, although each of these was identified far less often than public heath clinics.
A substantial proportion of the sexually active young people reported having unwanted sex when drunk or high on drugs, but this was much more common among boys (61%) than girls (32%). About 45% of students stated that they had been pressured to have sex in the past, with girls slightly more likely to report this than boys. It was not clear whether this pressure was in the form of force, coercion or peer pressure. Boyfriends or girlfriends were identified as the source of this pressure by about one third of students, and these were followed in frequency by 'other people' known to the students and unknown people.
Developing survey instruments for use in countries and cultures where little previous research has been conducted about youth health and lifestyle presents a number of challenges. The process of developing the survey before applying it in the field showed, however, that the language and cultural factors that may affect the validity of the data collected can be addressed. Initial pilot testing of the survey instrument helped to ensure that it addressed the health needs and concerns of young people in Pohnpei, and feedback from field staff conducting this pilot work indicated a good level of comprehension of survey questions. Careful attention to translation and back-translation of the final survey 98 instrument helped to ensure that the meaning of the questions was accurately portrayed in the local languages.
One of the distinctive and important features of the HBLPY survey in Pohnpei was the involvement of local young people in the design and implementation of the survey. A number of youth identified by the Pohnpei Youth Council and the Pohnpei Health Department also undertook training conducted by the UNICEF Pacific Youth Officer and were involved in implementing the survey in schools and other locations, then later participated in data entry training. This participatory research approach was intended to increase the relevance to, and ownership of, the whole survey process for young people. It also provided an opportunity to enhance youth research capacity and general life skills. Apart from such immediate benefits, the development of local capacity in this manner will increase the potential for such surveys to be sustained and successfully implemented in future.
Aside from local youth, the range of organizations that collaborated in the planning and implementation of the study was critical for its success. This included the national Ministry of Health, Education, and Social Affairs in FSM, Pohnpei Youth Council, Peace Corps FSM, and other agencies. UNICEF Pacific played the critical role of overseeing and managing all aspects of the HBLPY survey, while the carried out the technical support functions of data analysis and report writing.
This study has further demonstrated that it is feasible to collect quality data about youth health in developing countries and report on it at low cost and without the need for substantial funding. This has extended the body of information collected about health and lifestyle issues among young people in the Pacific island nations through the HBLPY surveys already conducted in Vanuatu and Tonga.
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 is unique to Pohnpei State FSM has 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 monitoring and surveillance of emerging youth issues.
PDF files require Acrobat Reader.
WHO/WPRO, Australian Centre for Health Promotion