Assessment of health risk behaviours among ...

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Assessment of health risk behaviours among university students: a crosssectional study in Lebanon a

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P. Salameh , L. Jomaa , C. Issa , G. Farhat , H. Zeghondi c

, N. Gerges , M. T. Sabbagh e

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, M. Chaaya , B. Barbour , M.

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Waked , J. Salamé , N. Saadallah-Zeidan & I. Baldi on behalf of the Lebanese National Conference for Health in University Study Group

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Laboratory of Clinical and Epidemiological Research, Faculties of Pharmacy & of Public Health, Lebanese University, Beirut, Lebanon b

Faculty of Health Sciences, University of Balamand, Beirut, Lebanon c

Faculty of Public Health, Lebanese University, Beirut, Lebanon

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Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon e

Faculty of Medicine, University of Balamand, Beirut, Lebanon

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Faculty of Medicine, Lebanese University, Beirut, Lebanon

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Institut de Santé Publique d'Epidémiologie et Développement, Laboratoire Santé Travail Environnement, Bordeaux Segalen University, Bordeaux, France Version of record first published: 12 Nov 2012.

To cite this article: P. Salameh, L. Jomaa, C. Issa, G. Farhat, H. Zeghondi, N. Gerges, M. T. Sabbagh, M. Chaaya, B. Barbour, M. Waked, J. Salamé, N. Saadallah-Zeidan & I. Baldi on behalf of the Lebanese National Conference for Health in University Study Group (2012): Assessment of health risk behaviours among university students: a cross-sectional study in Lebanon, International Journal of Adolescence and Youth, DOI:10.1080/02673843.2012.733313 To link to this article: http://dx.doi.org/10.1080/02673843.2012.733313

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International Journal of Adolescence and Youth 2012, 1–14, iFirst article

Assessment of health risk behaviours among university students: a cross-sectional study in Lebanon P. Salameha*, L. Jomaab, C. Issac, G. Farhatb, H. Zeghondic, N. Gergesc, M.T. Sabbaghb,c, M. Chaayad, B. Barbourc, M. Wakede, J. Salame´f, N. Saadallah-Zeidanc and I. Baldig on behalf of the Lebanese National Conference for Health in University Study Group


a

Laboratory of Clinical and Epidemiological Research, Faculties of Pharmacy & of Public Health, Lebanese University, Beirut, Lebanon; bFaculty of Health Sciences, University of Balamand, Beirut, Lebanon; cFaculty of Public Health, Lebanese University, Beirut, Lebanon; dFaculty of Health Sciences, American University of Beirut, Beirut, Lebanon; eFaculty of Medicine, University of Balamand, Beirut, Lebanon; fFaculty of Medicine, Lebanese University, Beirut, Lebanon; g Institut de Sante´ Publique d’Epide´miologie et De´veloppement, Laboratoire Sante´ Travail Environnement, Bordeaux Segalen University, Bordeaux, France (Received 18 August 2012; final version received 20 September 2012) There are insufficient data concerning health risk behaviours of university students in the Middle East, particularly Lebanon. Our objective was to identify health risk factors among university students in Lebanon, focusing on preventable behaviours. A crosssectional study was carried out, using a proportionate cluster sample of Lebanese students in public and private universities. A standardised questionnaire was distributed across university campuses. Data concerning socio-demographic characteristics, toxic substances consumption (including tobacco, alcohol and illicit drugs), nutrition and sedentarity behaviours, in addition to sexual behaviours, were collected. Among 3384 participants, 20% were current cigarette smokers, while 23% were current waterpipe smokers and 33.5% declared consuming alcohol. Higher rates were found for smoking and alcohol consumption in private versus public universities ( p , 0.001). Participants also reported a very low consumption of fruits and vegetables. Moreover, 31% of boys and 8.6% of girls declared having regular sexual activity; among them, 41% of boys and 26% of girls declared using a condom regularly. Substantial proportions of university students in Lebanon adopt risky behaviours for health, particularly in private universities. Health-promotion activities should be established to decrease the occurrence of these behaviours and prevent their future adverse health outcomes. Keywords: youth; university; students; risky; tobacco; alcohol; drug; nutrition; sedentarity; sexual activity

Introduction The Lebanese population is considered at risk of chronic diseases, such as cardiovascular, respiratory diseases and cancer, due to the epidemiological transition characterised by the progressive onset of the occidental lifestyle (Nasreddine, Hwalla, Sibai, Hamze´, & ParentMassin, 2006; Shamseddine et al., 2004). Young adults represent the right age bracket in which health-promotion activities should be carried out, aiming at facilitating their adoption of health-promoting behaviours and eventually reducing premature mortality at

*Corresponding author. Email: [email protected] ISSN 0267-3843 print/ISSN 2164-4527 online q 2012 Taylor & Francis http://dx.doi.org/10.1080/02673843.2012.733313 http://www.tandfonline.com


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a later stage. Factors such as lifestyle behaviour and environmental exposure should be tackled (World Health Organization, n.d.a) Risk is perceived differently by young adults versus more aged ones given peer and media influence (Quadrel, Fischhoff, & Davis, 1993). In parallel with the modern urban lifestyle, young adults can adopt certain risky and addictive behaviours (such as smoking, alcohol consumption and illegal substance use among other behaviour, etc.) that are more frequent at this age (Kelder, 2006). Existing research shows a high rate of tobacco, alcohol, and drug consumption among youth (Arvanitidou et al., 2008; Lund, Tefre, Amundsen, & Nordlund, 2008). Waterpipe smoking, which is perceived as less toxic than cigarettes, is mostly carried out in cases of stress or for mere pleasure (Jackson & Aveyard, 2008; Jawaid et al., 2008; Roskin & Aveyard, 2009). Alcohol consumption (O’Connor, O’Connor, & Bradley, 2008), particularly in the case of psychological problems (Brar & Moneta, 2009), as well as drugs consumption (Carvalho, Sant’Anna, Coates, & Omar, 2008; Gil, Mello, Ferriani, & Silva, 2008) is also high among university students. In addition, sexual behaviours are largely influenced by religion, parental attitude, and lifestyle, particularly in developing countries (Hiltabiddle, 1996; Kabiru & Orpinas, 2009). Contraceptive use is often inadequate, leading to a higher risk of sexually transmitted diseases (Hiltabiddle, 1996; Kabiru & Orpinas, 2009; Vivancos, Abubakar, & Hunter, 2008). Moreover, diet westernisation in most developing countries is affecting youth, leading to increased rates of obesity along with its negative metabolic and mental consequences (Papandreou et al., 2008; Sakamaki, Amamoto, Mochida, Shinfuku, & Toyama, 2005). It is worth noting that these risky health behaviours and exposures may be interrelated (Leigh et al., 2008; Nelson, Lust, Story, & Ehlinger, 2009). On the opposite side, health-promoting lifestyle behaviours have been shown to be relatively low (Lee & Loke, 2005; Suraj & Singh, 2011; Wang, Ou, Chen, & Duan, 2009). In Lebanon, there are some data concerning health risk behaviours of youth and mostly in schools (El-Roueiheb et al., 2008; Salameh & Barbour, 2011; Salameh, Barbour, Rachidi, & Issa, 2011). A few studies were carried out in universities, but they were limited to some private universities and focused on only one or two behaviours (Musharrafieh, Tamim, & Rahi, 2008; Tamim et al., 2003, 2006; Yahia, Achkar, Abdallah, & Rizk, 2008); the results obtained on Lebanon youth from these limited data were generally comparable with those found in other countries: high tobacco use (Tamim et al., 2003), low physical activity engaging (Musharrafieh et al., 2008), and frequent unhealthy eating habits (Tamim et al., 2006; Yahia et al., 2008). Our study aims at exploring a number of health risk factors and behaviours of young Lebanese adults, primarily focusing on preventable risky behaviours. The primary objective of this study was to identify preventable health risk factors in university students in Lebanon. Materials and methods General study design A cross-sectional study was carried out using a proportionate cluster sample of Lebanese students in the public and private universities. A list of universities in Lebanon, provided by the Centre for Pedagogic Researches, was used to adjust the sample size (Center for Educational Research & Development, n.d.). A sample size of at least 3000 individuals was targeted to allow for adequate power for bivariate and multivariate analysis to be carried out. Data collection process Most universities’ administrative offices in Lebanon that we approached did not allow drawing a random sample of their enrolled students to participate in the study: they did not


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provide us with the lists of students and permission was not granted to enter classrooms and search for students nominatively. Thus our research group had to work with a nonrandom sample of students outside their classes. Students were approached on campus during break times between courses by a field worker. The latter explained the study objectives to the student; and after obtaining oral consent, the student was handed the anonymous and self-administered questionnaire. On average, the questionnaire was completed by participants within approximately 20 minutes. At the end of the process, the completed questionnaires were placed in closed boxes and sent for data entry. During the data collection process, the anonymity of the students was guaranteed. Out of 4900 distributed questionnaires, 3384 (69.1%) were returned to the field worker. The anonymous questionnaire was in Arabic language; it was composed of different sections: socio-demographic characteristics, a screening section for all risky behaviours, a thorough cigarette and waterpipe smoking history, tobacco dependence using the Fagerstrom Test for Nicotine Dependence (Heatherton, Kozlowski, Frecker, & Fagerstro¨m, 1991) for cigarette smoking and the Lebanese Waterpipe Dependence Scale-11 (Salameh, Waked, & Aoun, 2008) for waterpipe smoking, the Alcohol, Smoking and Substance Involvement Screening Test score for toxic substances abuse including alcohol (World Health Organization, n.d.b), in addition to sexual (Neme`iæ et al., 2005), nutritional (Center for Disease Control, n.d.), physical activity (Ainsworth et al., 2000), and sedentary behaviours (Center for Disease Control, n.d.). Statistical analysis Data were entered and analysed using SPSS, version 19.0. In descriptive analyses, means and standard deviations were presented for continuous variables, while percentages along with their 95% confidence interval were presented for categorical variables. In bivariate analyses, correlation coefficients, Student’s test for means comparison between two groups and the chi-square test for comparing percentages were used. A p value less than 0.05 was considered significant. Subgroup analyses, public – private universities differences, were also performed. The socio-economic status of respondents was assessed using the declared household monthly income divided by the number of individuals per household as a surrogate measure. The obtained number was subsequently divided into quartiles, according to which individuals were classified. In this article, the screening results are presented. Results Total sample description A total of 3384 participants were included in the sample, after weighing the student distribution in the different universities (according to the Centre for Pedagogic Research), as follows: 1630 (48.2%) from the public Lebanese University and 1754 (51.8%) from private universities. Socio-demographic characteristics There was a fair student distribution over all ages, majors and study levels, in both private and public universities. There were more females than males, particularly in the public university; more than 95% of participants were single. The highest percentage of

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participants resided in the region of Mount Lebanon, with lower percentages from other regions. Participants from these regions were mainly found in the public Lebanese University, while Beirut residents were mainly found in private universities. Moreover, as expected, higher percentages of individuals of the lowest socio-economic quartile were found in the public university, while higher percentages belonging to the highest socioeconomic quartile were found in private universities (Table 1).


Toxic substance consumption Table 2 shows the results on declared toxic substances consumption, in the total sample and in both types of universities. For cigarette smoking, 19% of the sample was made of current smokers while 23% were current waterpipe smokers. Private universities included significantly higher rates for both types of smoking ( p , 0.001). Moreover, 33.5% declared consuming alcohol; with higher rates in private versus public universities ( p , 0.001). As for other substances, percentages of declared consumption were low for all; nevertheless, private universities included higher rates of consumers versus the public university ( p , 0.001 for Marijuana, cocaine, and opiates) (Table 2). Moreover, toxic substance consumption was significantly more frequent among boys compared with girls, among high versus low socio-economic status individuals, among higher age groups versus younger ones, and among students in fields other than health ( p , 0.001 for all).

Food consumption in the last 24 hours Students were asked to report the consumption frequency of a number of food items within the last 24 hours as part of the questionnaire. Overall we observed that there is a very low consumption of fruits and vegetables: 8.9% consumed green vegetables twice daily or more, while 19% consumed fruits twice daily or more. Moreover, participants from the Lebanese public university reported consuming more fruits than students from the private universities ( p ¼ 0.003), but less green salad ( p , 0.001) (Table 3). Furthermore, compared with the Lebanese public university, participants from private universities consumed fast foods and sweets more frequently ( p , 0.001), but fried potatoes and chips less frequently ( p ¼ 0.025) (Table 3). Females reported less consumption of unhealthy food versus males ( p , 0.001); higher socio-economic status participants also reported higher consumption of fast food and sweets versus lower socio-economic status participants ( p , 0.001); for other factors, there was no statistically significant difference.

Physical activity and sedentary behaviours Around 60% of participants declared performing regular physical activity; however, the public university participants declared performing daily physical activity more frequently than private universities’ students (12% versus 6%; p , 0.001). With respect to sedentary behaviours, private university participants reported spending more time in front of the computer, in transportation means, while those of the public university reported more studying and performing quiet activities. Moreover, 35% of participants reported that they did not sweat during the last week due to physical activity (Table 4). Moreover, girls had lower physical activity and higher sedentarity versus boys ( p , 0.001), along with higher physical activity in younger individuals (p , 0.001).


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Table 1. Socio-demographic characteristics.


Characteristic Major Sciences and Computer Sciences Health Sciences Humanities and Laws Business and Economics Engineering Arts Year First year Second year Third year Fourth year Fifth year and above Age category 17 – 19 years 20 – 21 years 22 years and above Gender Male Female Marital status Unmarried Other Place of residence Beirut Mount Lebanon North Lebanon South Lebanon Bekaa Socioeconomic status quartile Quartile 1: lowest Quartile 2: medium low Quartile 3: medium high Quartile 4: highest

Lebanese Universitya, Private universitiesb, n ¼ 1630 (100%) n ¼ 1754 (100%)

Total numberc, n ¼ 3384 (100%)

385 (23.6%)

124 (7.1%)

510 (15.1%)

388 636 97 67 49

(23.8%) (39.0%) (5.9%) (4.1%) (3.0%)

365 (20.8%) 90 (5.1%) 785 (44.8%) 207 (11.8%) 169 (9.6%)

753 726 882 274 218

(22.3%) (21.4%) (26.1%) (8.1%) (6.4%)

402 412 438 256 80

(24.7%) (25.2%) (26.9%) (15.7%) (4.9%)

371 (21.1%) 422 (24.0%) 378 (21.6%) 319 (18.2%) 79 (4.4%)

773 833 816 575 159

(22.8%) (24.6%) (24.1%) (17.0%) (4.7%)

471 (28.9%) 717 (44.0%) 438 (26.9%)

487 (27.7%) 707 (40.3%) 544 (31.0%)

958 (28.3%) 1424 (42.1%) 982 (29.0%)

518 (31.8%) 1111 (68.2%)

881 (50.2%) 869 (49.5%)

1399 (41.3%) 1980 (58.5%)

1556 (95.4%) 72 (4.4%)

1687 (96.2%) 53 (3.0%)

3243 (95.8%) 124 (3.7%)

123 612 377 388 117

(7.6%) (37.5%) (23.1%) (23.8%) (7.2%)

403 (23.0%) 994 (56.7%) 128 (7.3%) 85 (4.9%) 103 (5.9%)

526 1606 505 474 221

(15.5%) (47.5%) (14.9%) (14.0%) (6.5%)

563 454 276 223

(34.6%) (27.8%) (16.9%) (13.7%)

172 (9.8%) 292 (16.6%) 356 (20.3%) 523 (29.8%)

736 746 632 746

(21.7%) (22.0%) (18.7%) (22.1%)

Notes: a Includes: Section I (426, 26.1%), Section II (393, 24.1%), Section III (346, 21.2%), Section IV (92, 5.6%) and Section V (360, 22.1%). b Includes: Univeriste´ Saint Esprit de Kaslik (USEK) (159, 9.1%); Antonine University (70, 4.0%), Sagesse University (41, 2.3%), American University of Science & Technology (AUST) (122, 7.0%), Balamand University (69, 3.9%), Beirut Arab University (355, 20.2%), Islamic University (42, 2.4%), Lebanese American University (LAU) (97, 5.5%), Lebanese International University (LIU) (153, 8.7%), Notre Dame University (NDU) (93, 5.3%), Universite´ Saint Joseph (USJ) (197, 11.2%), Others including American University College (AUC), American University of Culture & Education (AUCE), Conservatoire National des Arts et Me´tiers (CNAM) and American University of Lebanon (AUL) (356, 20.3%). c Numbers may be below 100% because of missing values.

Sexual activity In universities who agreed to allow the questions on sexual activity as part of the questionnaire, 31% of boys and 8.6% of girls declared having regular sexual activity. Among sexually active individuals, 41% of boys and 26% of girls declared using a condom regularly. On the other hand, 32% of boys and 78% of girls reported never having any sexual experience (Figure 1).

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Table 2. Risky behaviours of participants: toxic substance consumption.


Risky behaviour Ever smoked cigarettes No Tried but stopped Yes, and still smoking Age of first cigarette, mean (standard deviation) Ever smoked waterpipe No Tried but stopped Yes, and still smoking Age of first waterpipe, mean (standard deviation) Ever consumed alcohol No Tried but stopped Yes, and still drinking Age of first alcohol consumption, mean (standard deviation) Ever consumed Marijuana No Tried but stopped Yes, and still consumes Ever consumed cocaine No Tried but stopped Yes, and still consumes Ever consumed stimulants No Tried but stopped Yes, and still consumes Ever consumed solvents No Tried but stopped Yes, and still consumes Ever consumed tranquilizers No Tried but stopped Yes, and still consumes Ever consumed hallucinogens No Tried but stopped Yes, and still consumes Ever consumed opiates No Tried but stopped Yes, and still consumes

Lebanese Universitya, n ¼ 1630 (100%)

Private universitiesa, n ¼ 1754 (100%)

1008 (61.9%) 417 (25.6%) 205 (12.6%) 16.14 (2.45)

917 (52.3%) 385 (22.0%) 445 (25.4%) 15.83 (2.42)

,0.001

786 (48.2%) 537 (33.0%) 307 (18.8%) 16.45 (2.57)

853 (48.6%) 411 (23.5%) 472 (26.9%) 16.49 (2.37)

,0.001

870 (53.4%) 172 (10.6%) 477 (29.3%) 14.40 (3.86)

470 (26.8%) 272 (15.5%) 722 (41.2%) 14.47 (3.43)

,0.001

1203 (73.8%) 72 (4.4%) 13 (0.8%)

852 (48.6%) 141 (8.0%) 22 (1.2%)

,0.001

2055 (60.7%) 213 (6.3%) 35 (1.0%)

1237 (75.9%) 13 (0.8%) 6 (0.4%)

918 (52.3%) 34 (1.9%) 9 (0.5%)

,0.001

2155 (63.7%) 46 (1.4%) 15 (0.5%)

1185 (72.7%) 59 (3.6%) 15 (0.9%)

877 (50.0%) 60 (3.4%) 16 (0.9%)

0.150

2062 (60.9%) 119 (3.5%) 32 (0.9%)

1209 (74.1%) 21 (1.3%) 16 (1%)

932 (53.1%) 12 (0.7%) 9 (0.5%)

0.539

2140 (63.2%) 33 (1.0%) 26 (0.8%)

1168 (71.6%) 68 (4.1%) 17 (1.1%)

868 (49.5%) 67 (3.8%) 19 (1.1%)

0.143

2036 (60.2%) 135 (4.0%) 37 (1.1%)

1217 (74.6%) 11 (0.6%) 5 (0.3%)

931 (53.1%) 15 (0.8%) 5 (0.3%)

0.313

2148 (63.55) 25 (0.7%) 10 (0.3%)

1213 (74.4%) 9 (0.5%) 3 (0.2%)

909 (51.8%) 24 (1.4%) 5 (0.3%)

0.001

2122 (62.5%) 33 (1.0%) 8 (0.2%)

p valueb

0.101c

0.851c

0.724c

Total numbera, n ¼ 3384 (100%) 1926 (56.9%) 802 (23.7%) 649 (19.2%) 15.93 (2.43) 1639 (48.4%) 949 (28.0%) 779 (23.0%) 16.47 (2.46) 1341 (39.6%) 444 (13.1%) 1199 (35.4%) 14.44 (3.61)

Notes: a Numbers may be below 100% because of missing values. b p value for the chi-square test. c Student t test used.

Moreover, 21% of private universities students and 15.5% of the public university students declared having regular sexual activity; out of whom, 41.3% and 32.6% declared using a condom regularly, respectively. In private universities 45% declared never having sexual experience, compared with 70% in the public university (Figure 1).


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Table 3. Food consumption of university students.


Food consumed yesterday Fruits No Yes, once Yes, twice or more Fruit juice drinking No Yes, once Yes, twice or more Green salad No Yes, once Yes, twice or more Cooked vegetables No Yes, once Yes, twice or more Hamburger, hot dogs, sausage No Yes, once Yes, twice or more French fries or potato chips No Yes, once Yes, twice or more Cookies, doughnuts, pie or cake No Yes, once Yes, twice or more

Lebanese Universitya, n ¼ 1630 (100%)

Private universitiesa, n ¼ 1754 (100%)

p valueb

Total numbera, n ¼ 3384 (100%)

509 (31.6%) 765 (47.5%) 335 (20.8%)

490 (34.0%) 719 (49.9%) 231 (16.0%)

0.003

999 (32.8%) 1484 (48.7%) 566 (18.6%)

856 (53.2%) 601 (37.4%) 151 (9.4%)

777 (54.0%) 539 (37.4%) 124 (8.6%)

0.746

1633 (53.6%) 1140 (37.4%) 275 (9.0%)

651 (40.8%) 823 (51.6%) 122 (7.6%)

492 (34.3%) 792 (55.3%) 149 (10.4%)

,0.001

1143 (37.7%) 1615 (53.3%) 271 (8.9%)

1089 (68.1%) 462 (28.9%) 47 (2.9%)

971 (68.2%) 396 (27.8%) 56 (3.9%)

0.287

2060 (68.2%) 858 (28.4%) 103 (3.4%)

1196 (74.9%) 366 (22.9%) 35 (2.2%)

958 (67.3%) 421 (29.6%) 44 (3.1%)

,0.001

2154 (71.3%) 787 (26.1%) 79 (2.6%)

540 (33.6%) 895 (55.8%) 170 (10.6%)

543 (38.1%) 728 (51.1%) 155 (10.9%)

0.025

1083 (35.7%) 1623 (53.5%) 325 (10.7%)

388 (24.1%) 942 (58.5%) 279 (17.3%)

391 (27.2%) 738 (51.4%) 306 (21.3%)

,0.001

779 (25.6%) 1680 (55.2%) 585 (19.2%)

Notes: a Numbers may be below 100% because of missing values. b p value for the chi-square test.

Discussion Main findings In this study, we were able to describe some of the health risk behaviours of university students in Lebanon. We found significant differences between private and public university students. Participants belonging to the private university included more males, and exhibited behaviours that could affect health more frequently than those of the public university: they smoked more frequently, whether cigarette or waterpipe. Private university students also drank alcohol, and consumed illicit and licit drugs more frequently than those of the public university. The consumption of foods that are of low nutritional value was found to be high among our sample, particularly among students from private universities. Slightly less than two-thirds of our sample reported being involved in some sport or form of physical activity; however, students from private universities reported less activity levels and more engagement in sedentary behaviours compared with public university students. With respect to sexual behaviours, private university students reported

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Table 4. Sedentarity and physical activity.


Behaviour Performs any sport Sport frequency per week Never Twice a week or less Three to six times weekly Once daily Television viewing per day One hour or less Two hours or less More than two hours Computer stay per day One hour or less Two hours or less More than two hours Studying frequency per day One hour or less Two hours or less More than two hours Quiet activities per day Half an hour or less One hour or less More than one hour Time in a transportation means One hour or less Two hours or less More than two hours Number of sleeping hours Less than 7 hours Seven hours More than seven hours Last week sweating during physical activity Never Once to twice More than twice

Total numbera, Lebanese Universitya, Private universitiesa, n ¼ 1630 n ¼ 1754 n ¼ 3384 (100%) (100%) p-valueb (100%) 1015 (62.3%)

978 (55.8%)

0.008 1993 (58.9%)

584 (36.7%) 363 (22.8%) 449 (28.2%) 196 (12.3%)

454 392 469 89

(32.3%) (27.9%) (33.4%) (6.3%)

,0.001 1038 (34.6%) 755 (25.2%) 918 (30.6%) 285 (9.5%)

511 (32.6%) 439 (28.0%) 618 (39.4%)

493 (36.3%) 381 (28.0%) 485 (35.7%)

0.062 1004 (34.3%) 820 (28.0%) 1103 (37.7%)

557 (36.2%) 336 (21.9%) 644 (41.9%)

280 (20.4%) 270 (19.7%) 824 (60.0%)

,0.001

837 (28.8%) 606 (20.8%) 1468 (50.4%)

454 (29.1%) 383 (24.5%) 724 (46.4%)

520 (38.4%) 299 (22.1%) 535 (39.5%)

,0.001

974 (33.4%) 682 (23.4%) 1259 (43.2%)

544 (39.0%) 558 (40.0%) 294 (21.1%)

428 (35.6%) 452 (37.6%) 323 (26.8%)

0.002

972 (37.4%) 1010 (38.9%) 617 (23.7%)

601 (38.9%) 607 (39.3%) 336 (21.8%)

439 (32.5%) 485 (35.9%) 426 (31.6%)

481 (30.3%) 375 (23.6%) 731 (46.1%)

479 (34.8%) 283 (20.6%) 613 (44.6%)

0.017

581 (36.4%) 544 (34.1%) 472 (29.6%)

475 (33.2%) 508 (35.5%) 448 (31.3%)

0.182 1056 (34.9%) 1051 (34.7%) 920 (30.4%)

,0.001 1040 (35.9%) 1092 (37.7%) 762 (26.3%) 961 (32.4%) 658 (22.2%) 1344 (45.4%)

Notes: a Numbers may be below 100% because of missing values. bp-value for the chi-square test.

more regular sexual activity than public university students; however, the former group reported using a condom more frequently. Our results also show that youth from a higher socio-economic status and with easier access to cash money may be at increased risk of being engaged in unhealthy and sometimes risky behaviours. What is already known about the subject Our results were more or less similar to those found by other researchers reported in other studies conducted in Lebanon and other countries: almost one-quarter of university students are current cigarette smokers (Yahia, El-Ghazale, Achkar, & Rizk, 2011) and waterpipe smokers (Akl et al., 2011; Chaaya et al., 2004). These rates are, however, higher than those



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Figure 1. Sexual activity of university students: results are given for universities who agreed to allow these questions.

found in 2001 by Tamim et al. (2003). Ever using alcohol (40%) in our study was similar to that found by Karam and collaborators, but ever using tranquillisers was lower (5% versus 10%) (Karam et al., 2000). Results regarding nutrition were not different from those reported by Yahia et al. (2008) that indicated low consumption of fruits and vegetables. For physical activity, we found higher figures than those reported in Beirut by Musharrafieh and her research team (Musharrafieh et al., 2008). For sexual activity, results were similar to those we had previously found, with males declaring more sexual relationships and females using condoms less frequently (Barbour & Salameh, 2009). For socio-economic differences, a similar discrepancy between public and private universities has been reported in other developing countries (Awusabo-Asare & Annim, 2008; Salonna et al., 2008), but not in developed countries (Richter et al., 2009; Richter, Leppin, & Nic Gabhainn, 2006).

What this study adds This is the first epidemiological study to be carried out on such a big sample of students from all universities, and to take into account all these risky behaviours. Overall, some health risk behaviours such as tobacco consumption seem to have increased compared with previous studies. Differences may be explained by sampling fluctuations, respondent bias or real changes over time. For other behaviours, such as alcohol consumption, nutrition, physical and sexual activity, there was no change compared with other studies. This valuable information will be useful for tailoring health-promotion initiatives and campaigns to specific subpopulations of university students, where shifting health damaging to sustainable health-promoting behaviours would be a challenge for the concerned authorities. Examples could be taken from other countries of the world, where

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health-promoting interventions gave positive results on students’ behaviours (Moore, Werch, & Bian, 2012; White et al., 2006).


Limitations of the study Our study, as with any, has its limitations: a selection bias could have been possible since the sample is not a random sample and may not be representative of the young adults and students’ population in Lebanon. This non-random sampling could lead to an overrepresentation of students who skip classes and may have higher risky behaviours; however, on the other hand, the length of the questionnaire may also lead to an underrepresentation of this students’ category, leading to compensation of the latter phenomenon. There could also be a possibility of respondent and information bias, since the results of our study are based on a self-administered and completed questionnaire. Despite the fact that we ensured anonymity and confidentiality of all data that have been collected, including sensitive sections that refer to sexual behaviours and the use of illicit drugs, respondents may have under-reported some of their behaviours that lead to missing values. Thus the assessment of health risk behaviours may have been underestimated in our study. We suggest that further research be carried taking into account these limitations; we also suggest thorough investigations to assess the factors correlated with every risky behaviour, in addition to qualitative research that can explore the knowledge, attitudes, and values behind these behaviours in order to identify the personal, environmental, social and psychological predictors of risky behaviours. Conclusion A substantial proportion of university students in Lebanon adopt risky health behaviours, particularly in private universities. Health-promotion activities should be established in all institutions to decrease these behaviours among young adults and prevent future adverse outcomes on their various aspects of health. Acknowledgements This work was funded by the CEDRE programme for French-Lebanese Cooperation (Ref. CEDRE 118/2009).

Notes on contributors P. Salameh, PharmD, MPH, PhD, is currently a full professor of epidemiology at the Lebanese University, in the Faculties of Pharmacy, Public Heath, and Doctoral School of Sciences & Technologies. An expert in research direction with a diploma of Ability to Direct Research, with a high expertise in research designing, data collection, management and analysis. Also an expert in basic and advanced statistical operations, with more than 70 publications. L. Jomaa has a PhD in the field of nutritional sciences with a focus on community nutrition and nutrition education. Her research interests include the exploration of eating and lifestyle behaviors of infants, children and adolescents in relation to health outcomes, primarily obesity and related comorbidities. Her previous research work included assessing nutrition and wellness policies in schools of Pennsylvania in the United States to address the problem of childhood obesity and exploring the role that students play in making healthier changes in their school environment. C. Issa has been teaching nutrition for the past 10 years and is currently an associate professor and researcher in nutrition at the Lebanese University. Initially holder of a BS degree in nutrition and dietetics (American University of Beirut), she holds a PhD in nutritional epidemiology (Marseille,


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France) and two Master degrees, one in nutrition and food security (Marseille, France) and another one in food service management (Rochester, NY). Her research interests include nutritional quality of traditional dishes, adherence to the Mediterranean diet and adolescent health.


G. Farhat is a non-communicable disease epidemiologist with strong expertise in the areas of breast cancer, cardiovascular disease, and osteoporosis. She has extensive experience in the design, conduct, management, and statistical analysis of multi-center epidemiologic studies established through her current and previous work on major studies such as the Women’s Health Initiative Observational Study and Clinical Trials, the Study of Women’s Health Across the Nation, and the Health, Aging, and Body Composition Study. H. Zeghondi has a BS in nursing, midwife diploma and pediatrics nurse, an MS in nursing sciences, and a Masters in Public Health. She is currently a nursing teacher and Masters administrative coordinator at the Lebanese University. She has worked for UNICEF and the Ministry of Public Health, as a national coordinator for the implementation of “baby friendly hospital” and other public health programmes for the encouragement, protection and support of breastfeeding. She is also a Lebanese nursing order member, Lebanese Alliance for Early Child Development (LAECD) member, member of the technical team for “Baby friendly hospitals” training, member of the technical team for NRP (Neonatal Resuscitation Training Program). She has an interest in research concerning youth health in schools and universities. N. Gerges is a nurse with a Masters in Public Health; she has experience in education (nursing courses, research methodology, SPSS, management) and research (smoking, resilience, health of students, etc). She is a full time teacher at the Lebanese University. M.T. Sabbagh, (Dr) BS nursing, PhD education, is a trainer in health education and for health professionals. She is currently assistant director of the nursing programme at the University of Balamand, and an instructor at the Faculty of Public Health at the Lebanese University and the Institute of Educators in Saint Joseph University in Lebanon. A member of the Scientific committee at the Order of Nurses in Lebanon, she has worked as a nurse and launched a Continuing Education Unit in the Hospital Notre Dame des Secours Jbeil, and has participated for more than 20 years in the training and teaching nurses, social workers, health educators, health workers and educators with several institutions: Lebanese Red Cross, St Joseph University, WHO, UNICEF Lebanon and Ministry of Education (Health education programme in schools). M. Chaaya is a professor and chair at the Department of Epidemiology and Population Health in the American University of Beirut. She is a 1999 graduate of the Johns Hopkins Bloomberg School of Public Health with a Dr PH in mental heath. Her main research interests focus on two priorities in public health, namely tobacco control and mental health. B. Barbour, PhD, is currently a full time associate professor at the Lebanese University in the Faculty of Public Health and has more than 15 publications in the fields of social sciences and health, with high expertise in field work organisation and data collection. Mi. Waked is a practicing pulmonologist, and a full professor at the University of Balamand. She has been interested for years in public health and epidemiological research, in the fields of asthma, COPD, and smoking epidemiology in Lebanon. She has also occupied several chairs in her field. J. Salame´, MD, is a physician with high interest in public health, working as a participant member of the Clinical and Epidemiological research team of the Lebanese University, Doctoral School of Sciences & technologies, with several publications in unhealthy behaviours of the Lebanese population. N. Saadallah-Zeidan has a PhD in Genetics from the University of Birmingham, England. She is dean of the Faculty of Public Health, at the Lebanese University, a Fulbright Scholar, and leader of joint projects between the Ministry of Public Health, WHO, Italian corporation and the Faculty of Public Health in Lebanon. I. Baldi is a physician with a PhD in epidemiology; assistant professor in occupational epidemiology and public health, Bordeaux University and INSERM U897. She has been collaborating with Lebanese researchers for years. She has a research interest in the effects of toxics on human health, in the fields of occupational and environmental toxicology.

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