Kathmandu University School of Medical Sciences

Institutional Review Committee

Dhulikhel, Kavre, Nepal

Application for Ethical Approval of Research Proposal

(KUSMS/IRC)

Physiotherapy
KUSMS

Title (Proposal 2)
Surveillance of Youth Risk Behavior among Adolescents in Kathmandu
Municipality.

Submitted By
Punjita Timalsina
M.Sc. Nursing, 1st Year
Seat Number: 3033
Community Health Nursing
1st Batch
KUSMS

1
 Table of Contents
1. Summary of the Proposed Research Protocol............................................................1

2. Introduction...................................................................................................................2

2.1 Background.......................................................................................................2

2.2 Statement of the Problem.................................................................................3

2.3 Rationale/Need of the Study..............................................................................4

2.4 Significance of the Study..................................................................................5

2.5 Objectives of the Research................................................................................5

2.6 Research Hypothesis........................................................................................6

2.7 Study Variables..................................................................................................6

2.8 Conceptual Framework.....................................................................................7

2.9 Operational Definition.......................................................................................7

3. Literature Review..........................................................................................................8

4. Methods/Methodology.................................................................................................10

4.1 Study design....................................................................................................10

4.2 Participants/ Study population.........................................................................10

4.3 Selection Criteria.............................................................................................10

4.4 Study Site and justification:...........................................................................10

4.5 Sampling..........................................................................................................11

4.5.1 Sampling method/ technique...........................................................11

4.5.2 Sample Size......................................................................................11

4.6 Data Collection Tools/ Measures....................................................................12

4.6.1 Instrument for Data Collection........................................................12

4.6.2 Pre-test..............................................................................................12
4.6.3 Validity of the Instrument.................................................................12
 4.6.4 Reliability of the Instrument.............................................................12

4.7 Procedure.........................................................................................................13

4.8 Plan for data analysis.......................................................................................13

4.8.1 Software that will be used for data analysis....................................13

4.8.2 Statistical tests..................................................................................13

4.9 Limitations of the Study..............................................................................................13

4.10 Plan for Supervision and Monitoring........................................................................14

4.11 Plan for Data Management........................................................................................14

4.12 Plan for dissemination of the research......................................................................14

4.13 Work Plan......................................................................................................15

4.14 Ethical Consideration....................................................................................16

5. Budget Plan..................................................................................................................17

Annexes.............................................................................................................................18

Bibliography..........................................................................................................18

Informed Consent20

Questionnaire21
 Research Proposal Description

Do you have funding for your project?

a. Yes b. No c. Applied for funding but not approved

Do you have any collaboration for this research project?

a. None b. National c. International

1. Summary of the Proposed Research Protocol

Adolescence is a critical transitional period that includes the biological changes of

puberty, the need to increase independence, preoccupation with the self and normative
experimentation. Youth risk behaviors are the leading causes of morbidity and mortality
among adolescents worldwide. The study will focus on ten major risk factors: alcohol
use, dietary behaviors, drug use, hygiene, mental health, physical activity, protective
factors, sexual behaviors that contribute to HIV infection and other sexually transmitted
infections and unintended pregnancy, tobacco use and finally violence and unintentional
injury. The objective of the study will be to assess the prevalence of health risk behaviors
among adolescents students of grade 9 to 12 of Kathmandu Metropolitan city.
Mixed method study design will be used for the study. Questionnaire based on global
school based student health survey will be used. Multistage stratified cluster random
sampling will be used. 692 students involved in the study and focused group discussion
will be conducted for explaining the results from quantitative study. Data analysis will
involve descriptive and inferential statistics and content analysis will be done for focused
group discussion. The results might be useful in creating awareness and formulation of
plans and policies for minimizing health risk behavior among adolescents.

1
 2. Introduction

2.1 Background

Adolescence is a critical transitional period that includes the biological changes of

puberty, the need to increase independence, preoccupation with the self and normative
experimentation. During the transition from childhood to adulthood, adolescents struggle
to make lifestyle choices and establish patterns of behaviour that affect both their current
and future health.(1)
Youth risk behavior are the leading causes of morbidity and mortality among adolescents
worldwide include major ten categories: alcohol use, dietary behaviors, drug use,
hygiene, mental health, physical activity, protective factors, sexual behaviors that
contribute to HIV infection and other sexually transmitted infections and unintended
pregnancy, tobacco use and finally violence and unintentional injury.(2)
The majority of health-risk behaviors (i.e., interrelated and preventable behaviors that
contribute to the leading causes of morbidity and mortality among youths and adults)
often are established during childhood and adolescence and extend into adulthood. The
identification of risk behavior enable public health professionals, educators, policy
makers, and researchers to identify prevalence and determine trends and improve health
related policies and programs in terms of youth population.(3)
Tobacco use at a young age has been associated with emotional and psychological
problems, risky behaviors such as violence and sexual activity and an increased risk of
cancers later in life. On the other hand, sedentary life-style has been linked to an
undesirable cardiovascular disease risk profile including obesity, insulin resistance, and
high blood pressure. In addition, childhood obesity has been linked to increased risk of
dyslipidemia, hyperinsulinemia, hypertension and a number of psychosocial problems.(4)
The global school-based health survey (GSHS) has been developed by World Health
Organization (WHO) and Centers for Disease Control and Prevention in cooperation with
United Nations UNICEF, UNESCO, UNAIDS. The GSHS was designed to help
countries measure and assess the behavioral risk factors and protective factors among
children and adolescents aged 13-17 years.(2)

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2.2 Statement of the Problem

Around 1 in 6 persons in the world is an adolescent: that is 1.2 billion people aged 10 to
19.(5) Young people between 10 and 24 years of age are a distinct population group with
needs that differ from those of infants or adults. Youth from marginalized groups and
lower- and middle-income countries are especially vulnerable. The increased availability
of tobacco, alcohol and other psychoactive drugs, the increased burden of chronic
diseases, and the ongoing problems of poverty and conflict are major barriers to
adolescent development. These issues have brought youth health to global prominence in
recent years (WHO, 2000a).(6)
An estimated 1.3 million adolescents died in 2015, mostly from preventable or treatable
causes. Road traffic injuries were the leading cause of death in 2012, with some 330
adolescents dying every day. Other main causes of adolescent deaths include HIV,
suicide, lower respiratory infections and interpersonal violence. Globally, there are 49
births per 1000 girls aged 15 to 19 per year. Half of all mental health disorders in
adulthood start by age 14, but most cases are undetected and untreated. Main health
issues include early pregnancy and childbirth, HIV, Other infectious diseases, mental
health, violence, alcohol and drugs, injuries, malnutrition and obesity, exercise and
nutrition and tobacco use. (5)
Adolescence is a critical phase for the development of obesity because of various
biological, psychological, social and environmental changes. Adolescent overweight and
obesity may persist into adulthood. Adolescence overweight and obesity may increase the
risk of developing NCDs at a younger age and consequently a premature death. In
addition to future health risks, overweight and obese adolescents also suffer short term
health consequences. In addition, their participation in school and other daily activities is
also limited depending on the degree of obesity.(7) Shifting away from healthy eating
habits to fast foods, high-calorie low-nutrient diets combined with sedentary activities
has made children and adolescents more prone for development of overweight and its
associated comorbidities as type two diabetes, cardiovascular and fatty liver diseases.(4)
Tobacco use is one of the chief preventable causes of death and illness in the world.
Recent trends indicate that tobacco use has earlier age of initiation and rising smoking

3
prevalence rates among children and adolescents especially among those from
developing countries.(8) A person needs to pass several stages to become an established
smoker. Both smoking susceptibility (SS) and intention to smoke (IS) are two important
characteristics in the earlier stages of smoking behaviors among adolescents, which is
risk factor for various diseases.(9)
In this life span, many young people become sexually active and begin to develop
patterns of sexual behavior. Youths are more exposed and involved in sexual activities
than other children of similar age. They are among the high risk and insecure groups and
vulnerable to various forms of exploitation and abuses. (10)

2.3 Rationale/Need of the Study

In Nepal, the adolescents comprise more than one fifteen (22%) of the total population, a
proportion that is expected to grow over the year to come due to a high fertility rate.(11)
Adolescents are often thought of as a healthy group. Nevertheless, many adolescents do
die prematurely due to accidents, suicide, violence, pregnancy related complications and
other illnesses that are either preventable or treatable. Many more suffer chronic ill-
health and disability. In addition, many serious diseases in adulthood have their roots in
adolescence. For example, tobacco use, sexually transmitted infections including HIV,
poor eating and exercise habits, lead to illness or premature death later in life.(12)
A study was done to estimate smoking susceptibility and intention to smoke among
secondary school adolescents in Nepal which concluded that smoking is prevalent in
Nepalese school going adolescents. Similar study done among adolescent students of
Pokhara submetropolitan city revelas that high percentage of students were tobacco users
with low age of initiation.(9)
Another study regarding oral health of children revealed that children had poor oral
health and dental hygiene which could serve as a precursor to various diseases.(13)
Study on overweight among urban school adolescents in Lalitpur concluded that
overweight was present in 12.2% of adolescent students with socioeconomic status,
watching television and consuming less fruit as major risk factors.(7)

4
In this context, protecting every adolescent from risk behavior initiation is the best
intervention for the promotion of health. Data from surveillance systems are critical for
planning and evaluating public health programs. Unfortunately, there is very limited
information to describe magnitude of risk behavior among adolescents in Nepal.

2.4 Significance of the Study

This study is an attempt to fill the information and knowledge gap in this area, and the
potential use of this information will be in designing policy and programmes to
appropriately address this problem in a timely manner.
Identification of youth risk behavior in school adolescents can guide schools to be
developed as entry point for health promotion with the active participation of teachers,
parents and students. Also, coordination could be established between school and local
health workers.
The priorities of the intervention programs for health promotion of children and
adolescents can be established in terms of promoting physical activity, healthy eating and
improved lifestyle behaviors for primordial and primary prevention of NCDs.
The survey will help to provide data on the health status of the school children
and adolescents in Nepal which will help to strengthen the adolescent health of
the nation as it is one of the priority area of health in Nepal.

2.5 Objectives of the Research

General Objective
To assess youth risk behavior among adolescents.

Specific Objective(s)
To assess prevalence of alcohol use among adolescents.
To identify dietary behaviors of adolescents.
To identify mental health status of adolescents.
To assess drug usage among adolescents.

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 To assess pattern of sexual behavior among adolescents.
To identify protective factors among adolescents.
To assess pattern of tobacco use among adolescents.
To find out prevalence of violence and unintentional injury among
adolescents.
To assess hygienic practices among adolescents.
To identify pattern of physical activity among adolescents.
To identify relation between various risk factors and socio-demographic
variables of adolescents.

2.6 Research Hypothesis

Null Hypothesis (H0): There will be no significant association between risk factors
and socio-demographic variables.

2.7 Study Variables

Dependent variable: Risk Behavior (alcohol use, dietary behaviors, drug use,
hygiene, mental health, physical activity, protective factors, sexual behaviors that
contribute to HIV infection and other sexually transmitted infections and
unintended pregnancy, tobacco use and finally violence and unintentional injury)
Independent variable: Sociodemographic variables

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2.8 Conceptual Framework
A
S o c d o
i o d lR e
e m si sc
o g r ek n
a p h tB
i c
He
V a r h
i a b le a a
e s l t
v i
ho
r s
Fig: Conceptual Framework for Surveillance of Youth Risk Behavior among Adolescents.

1.9 Operational Definition

Adolescent: It refers secondary and higher secondary students of 13 to 17 years
of age.

Adolescent Health: Adolescent health is termed as the absence of risk behaviors

in adolescents.

Risk Behaviors: Selected risk behavior includes alcohol use, inappropriate

dietary behaviors, drug use, poor hygiene, poor mental health, reduced physical
activity, lack of protective factors, inappropriate sexual behaviors, tobacco use,
violence and unintentional injury.

7
 3. Literature Review

Non-communicable diseases (NCDs) are currently responsible for 56 percent of

all deaths and 46 percent of the disease burden measured in disability-adjusted
life years (DALYs) in low- and middle-income countries. From a projected total
of 58 million deaths from all causes in 2005, it was estimated that non-
communicable diseases accounted for 35 million, which is double the number of
deaths from all communicable diseases (including HIV/AIDS, tuberculosis and
malaria), maternal and perinatal conditions and nutritional deficiencies combined.
This alarming figure of burden of disease due to NCDs is projected to increase
rapidly in the years ahead, posing a danger of a double burden of infectious and
non-infectious diseases.(10)
A clinical review done by Abdul Ghaffar, K Srinath Reddy, Monica Singhi
explores the burden of the major non-communicable diseases in South Asia and
the extent to which obstacles hinder prevention and management of these
diseases. The summary point of this review was that mortality, morbidity, and
disability attributable to the major non-communicable diseases account for about
60% of all deaths and 47% of the global burden of disease; these rates are
expected to rise. Almost half of the adult disease burden in South Asia is
attributable to non-communicable diseases. Environmental factors are the major
determinants of almost all non-communicable diseases and obstacles to managing
the non-communicable diseases epidemic in South Asia include sedentary
lifestyles, extreme poverty, and inadequate health systems.(11)
A research by R. Wesonga et. al. on Burden of cumulative risk factors associated
with non-communicable diseases among adults in Uganda: evidence from a
national baseline survey concluded that 38.6% exhibited one or two NCD risk
factors each. Of the total sample, 56.4% had at least two risk factors whereas only
5.3% showed no risk factor at all. Body mass index, systolic blood pressure,
diastolic blood pressure, consumption of fruit and vegetables, age, region,
residence, type of residence and land tenure system were statistically significant
predictors of number of NCD risk factors.(1)
Another study done by B.M. Watson et. al. in Republic of Palau, regarding
STEPS survey of profile of non communicable disease risk factors among adults
on 2.184 individuals in 2011 indicated that the prevalence of current cigarette
smoking was 25% in men and 10% in women. Betel nut chewing with tobacco
was prevalent in 58% in men and 69% in women. In terms of all types of tobacco
use, 60% of men and 58% of women were current users. Overweight or obesity
was very common among 84% in men, 86% in women. Hypertension was found
in 55% of men and 49% of women, with the stage 2 hypertension being 21% and
19%, respectively. The prevalence of diabetic level hyperglycemia was more than

8
 20%. Raised total cholesterol was detected in 16% of men and 20% of women.
This survey revealed an alarmingly high prevalence of NCD risk factors,
especially tobacco use, obesity, hypertension and raised blood glucose.(12)
National survey or risk factors for non-communicable disease in Vietnam by T.V.
Bui, C.L. Blizzard et. al. estimated the proportions of current smokers (males
57.70 %, females 1.73 %), and binge-drinkers (males 25.11 %, females 0.63 %),
and regional differences in diet, reflected the geographical and socio-cultural
characteristics of the country. Provinces with a higher proportion of urban
population had greater mean levels of BMI (r = 0.82), and lesser proportions of
active people. (13)
The national survey of non communicable diseases risk factors STEPS survey
Nepal 2013 also revealed the national burden of NCD risk factors. It was found
that all the major NCD risk factors both modifiable behavioural risk factors as
well as biological risk factors was remarkably high. It was found that only 0.4%
of the study population was totally free from the established risk factors meaning
massive 99.6% had at least one risk factor. Though prevention and control of
NCD risk factors is easy and cost effective than treating them, there has been
negligible action taken for prevention and control of NCDs and their risk factors
in Nepal so far.(3)
A research article of U.R. Aryal, A. Vaidya et. al. on Establishing a health
demographic surveillance site in Bhaktapur district, Nepal presented that various
health problems were found commonly and some of them included respiratory
problems (41.9%); headache, vertigo and dizziness (16.7%); bone and joint pain
(14.4%); gastrointestinal problems (13.9%); heart disease, including hypertension
(8.8%); accidents and injuries (2.9%); and diabetes mellitus (2.6%). The
prevalence of non-communicable disease (NCD) was 4.3% among individuals
older than 30 years. Age-adjusted odds ratios showed that risk factors, such as
sex, ethnic group, occupation and education, associated with NCD.(14)
Recently, Nepal has taken steps in the control of NCDs through the ratification of
a national policy in 2009, and a strategy and plan of action in 2014 for prevention
and control of NCDs. Implementing such policies into practice requires
knowledge of the burden of NCDs and a national registry system to monitor
NCDs does not exist in Nepal. Moreover, there are no available studies on various
settings regarding risk factor of NCDs. Thus, documentation of available
evidence from existing studies will serve as an information base which the policy
makers and program planners can use in decision making and program planning.

4. Methods/Methodology

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 4.1 Study design

The present study will utilize a mixed methods design. The explanatory design
will be used that begins with the collection of quantitative data, followed by the
collection of the qualitative data to explain and enrich the quantitative findings. In this
study, the priority will be given to the quantitative data. After analysis of the
questionnaire data, qualitative data collection will be conducted regarding findings that
will require additional explanation.

4.2 Participants/ Study population

Target Population: All the school adolescents aged 13 to 17 years of age of

Kathmandu Metropolitan City.

Study Population: Selected students of grade 9 to 12 grades form selected

schools.

4.3 Selection Criteria

Inclusion Criteria

All the students aged 13 to 17 years of age in sample population.

Exclusion Criteria

Those aged less than 13 years or more than 17 years.

Those who are mentally unfit to participate in the study.

Those unable or unwilling to give informed consent.

Those students who are absent on the day of the survey.

10

4.4 Study Site and justification:

Study site will be Kathmandu Metropolitan City. Kathmandu Metropolitan city is
facing economic transition and the urbanisation process are precipitated that increases
levels of lifestyle-related risk factors such as low physical activity and changes in dietary
habits in adolescents and the density of schools is also high in this area. Furthermore,
research on the prevalence of risk behaviors among Nepalese adolescents has so far been
limited.

4.5 Sampling

4.5.1 Sampling method/ technique

A multistage stratified cluster random sampling method will be used to select the
sample to produce more precision and better representative of the study population. In
first stage, four public and four private schools will be randomly selected. 22 students
will be selected from each grade randomly and total number of 88 students will be
selected from each school.
For qualitative study, data will be collected through focused group discussions
after initial analysis of quantitative data. Homogeneous group of adolescents, parents and
teachers will be selected for focused group discussion. Focus group discussion will be
used to explore barriers and opportunities of behaviors and identify their suggestions for
intervention from various perspectives.

4.5.2 Sample Size

Sample size will be determined by applying the formula

2
Z PQ
n= 2 , where
z
at 95% confidence interval is 1.96, p = proportion, q
d

= (1-p),
d =error taken at 20% of prevalence)

11
 (1.96)2 0.122 0.878
n= , where p is taken as 17.4% as Nepal STEPS survey
(0.0244)2

2013.

n=691.17 participants.

n 692 participants.

Thus the sample size will be 692 participants.

4.6 Data Collection Tools/ Measures

4.6.1 Instrument for Data Collection

Quanitative data will be collected by using an anonymours self administered
questionnaire based on global student based school health survey. Anthropometric
measurements will be taken by weighing machine and non stretchable measuring tape in
light indoor clothing, and without shoes or other heavy accessories. For qualitative data,
focused group discussions will be audio-recorded and verbatim will be transcribed after
receiving permission from the participants.

4.6.2 Pre-test

Both the instrument and data collection process will be validated through
pretesting and expert suggestions. Pretesting will be done in 10% of the sample size in
similar school setting of Lalitpur Metropolitan city which will be mainly focused on
identifying issues with the questions, their coherency and consistency. Necessary changes
will be made to the questionnaires following the pretesting by consulting with research
advisor.

12

4.6.3 Validity of the Instrument

The validity of the instrument will be maintained by thorough review of the

related literature, consulting research advisor, seeking opinions of the subject experts,
discussion with friends for relevancy and adequacy of the instruments and pretesting of
the instrument in similar setting.

4.6.4 Reliability of the Instrument

The reliability of the instrument will be maintained by using the test-retest

method. The research instrument will be administered to the sample of subjects of
pretesting on two different occasions. Scores of correlation coefficient will be calculated
and compared by using formula for Karl Pearsons Correlation Coefficient for estimating
reliability.



4.7 Procedure

The survey proposal will be forwarded for review and approval and ethical
approval will be sought before the commencement of data collection from the
Institutional Review Committee (IRC) of Kathmandu University. Tool and procedure will
be pretested for reliability and validity. Real study will be conducted. Passive written
consent will be obtained from guardians for the participation of the student in the survey
after adequate explanations of the objectives and procedures of the project. The privacy
and confidentiality will be maintained. Nobody will be forced to participate in the study
without their interest and respondents will be informed that they were free to opt not to
participate in the survey. After analysis of the questionnaire data, qualitative data
collection will be conducted regarding findings that will require additional explanation.
Homogeneous group of adolescents, parents and teachers will be selected for
focused group discussion which will consist of 6-8 participants and will last for 1 to 1.5

13
hours. Six focused group discussion two sets in each public and private school will be
done.

4.8 Plan for data analysis

4.8.1 Software that will be used for data analysis

SPSS version 20.0 will be used for descriptive as well as inferential statistics.

4.8.2 Statistical tests

Data will be analyzed using simple descriptive statistical method (percentage,

mean, standard deviation) and inferential statistics method (logistic chi square regression
test) will be used to assess the relation between dependent and independent variables.
Content analysis will be done in case of qualitative findings.

4.9 Limitations of the Study

The self administered questionnaire will be used so there will be a possibility
of reporting false information.

4.10 Plan for Supervision and Monitoring

Supervision and monitoring will be done by the research advisor.

4.11 Plan for Data Management

Data will be stored in locked and safe cabinet.
The collected data will be coded appropriately.
The data will then be transferred to personal computer and saved in Microsoft
Excel format.
Later the entered data will be transferred to SPSS, version 20.0 for analysis.
The results will be used in research reports with interpretation.

14
 Data will then finally be destroyed.

4.12 Plan for dissemination of the research

The research report will be disseminated to

KUH Library
Research Advisor
Concerned schools
Different journals for publication

4.13 Work Plan

Mo O N D J F M A M J J A S O N
nth De
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2016- 31
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Dat o Jan m 1
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2 8 months
Du 3 3 m 3
rati mont on
on w hs th

15
 e
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Ac
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es
Lite
ratu
re
Rev
iew
Top
ic
Sel
ecti
on
Prot
oco
l
Wri
ting
Ant
icip
ated
Tim
e of
Pro
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Ap
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Dat
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Col
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Dat
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Ana
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 Pre
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to
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to
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17
 4.14 Ethical Consideration

4.14.1 Ethical issues Y Justification if yes
es/ No
a. Are human participants Y As the research is based on
included in the study? es surveillance of health risk behavior
among adolescent population.
b. Are vulnerable members N
of the population required o
for this research? (includes -
age under 18, pregnant

women etc)
c. Are there any risks involved N
for the participants? If yes, o
identify clearly what are the
expected risks for the
-
human participants in the
research and provide a
justification for these risks.
d. Are there any benefits Y Though there is no direct
involved for the es benefit seen, the research has got long
participants? If yes, identify term benefit as the findings can be
clearly what are the used to develop plan, policies and
expected benefits for the health promotion programs to
participants. minimize risky behavior among
adolescent that might contribute to
healthy well-being.

4.14.2 Clearly indicate the participants responsibilities in the research. What is
expected of the research participants during the research?

Participants will be expected to participate in the study and answer the questions
regarding their information. However, nobody will be forced to participate in the study without
their interest and respondents will be informed that they are free to opt not to participate in the
survey. Regarding focused group discussion the participants will be expected to discuss actively.

4.14.3 Obtaining the Consent

4.14.3.1 How will the informed consent be obtained from the research participants?

The passive informed consent will be obtained from guardians of adolescents after the
complete explanation of the procedure and objectives of the study.

18

4.14.3.2 Who will obtain the consent from the study participants?

The consent will be obtained passively obtained from the guardians through the student.

4.14.3.3 Is there anything being withheld from the research participants at the time
the informed consent is being sought? Mention YES or NO. If yes, explain.

NO.



5 Budget Plan

Items Total
S (NRs)
N
Ethical clearance 500
1
Cost for printing/ photocopy 3000
2
Nepali Question Typing 500
3
Travel and Lodging 5000
4.
Extras 6000
5
Total 15000

19
 Annexes

Bibliography

1. Achhab Y El, Ammari A El, Kazdouh H El, Najdi A, Berraho M, Tachfouti N, et
al. Health risk behaviours amongst school adolescents: protocol for a mixed methods
study. BMC Public Health [Internet]. 2016;49. Available from:
http://dx.doi.org/10.1186/s12889-016-3873-4
2. Centers for Disease Control and Prevention. Global Student Health Survey
(GSHS). 2009; Available from: http://www.cdc.gov/gshs/questionnaire/index.htm
3. Brener ND, Kann L, Kinchen S a, Grunbaum JA, Whalen L, Eaton D, et al.
Methodology of the youth risk behavior surveillance system. MMWR Recomm Rep.
2004;53(RR-12):113.
4. Kelishadi R, Ardalan G, Qorbani M, Ataie-Jafari A, Bahreynian M, Taslimi M, et
al. Methodology and early findings of the fourth survey of childhood and adolescence
surveillance and prevention of adult non-communicable disease in Iran: The CASPIAN-
IV study. Int J Prev Med. 2013;4(12):145160.
5. WHO | Adolescents: health risks and solutions [Internet]. 2014. Available from:
http://www.who.int/mediacentre/factsheets/fs345/en/
6. vv.aa. Health for the World s Adolescents A second chance in the second decade.
2014;
7. S. P, K.P. B, B. P, A.K. P. Overweight and its associated risk factors among urban
school adolescents in Nepal: A cross-sectional study. BMJ Open [Internet]. 2016;6(5):no
pagination. Available from: http://bmjopen.bmj.com/content/6/5/e010335.full.pdf
%5Cnhttp://ovidsp.ovid.com/ovidweb.cgi?
T=JS&PAGE=reference&D=emed18a&NEWS=N&AN=610515133
8. smoking 20N.pdf.
9. Aryal UR, Bhatta DN. Smoking Susceptibility and Intention to Smoke among
Secondary School Adolescents in Nepal. J Nepal Health Res Counc. 2015;13(29):2630.
10. Gurung G. Knowledge and Attitude on HIV / AIDS and Sexual Behaviour of

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 Street Teenagers in Kathmandu Valley. J Nepal Health Res Counc. 2004;2(2):913.
11. HMG-Nepal. National Adolescent Health and Development Strategy.
2000;2057:141.
12. WHO. WHO | Adolescent health [Internet]. Available from:
http://www.who.int/topics/adolescent_health/en/
13. Thapa P, Kk A, Dhimal M, Mehata S, Au P, Pandit A, et al. Oral Health Condition
of School Children in Nawalparasi District , Nepal. 2015;13(1):713.
14. Devkota B, Prithucharan B, Chhetri HS. Health Needs Assessment of Primary
School Children in Nepal [Internet]. Health Needs Assessment. 2008. Available from:
http://www.jnhrc.com.np/index.php/jnhrc/article/viewFile/22/22
15. Paudel D. Tobacco Use among Adolescent Students in Secondary Schools of
Pokhara Sub Metropolitan City of Nepal Department of Community Medicine and Family
Health. 2003;

21
 Parent/Guardian Permission Form

Namaste,
I am Punjita Timalsina. I am conducting a research study on Surveillance of Youth Risk
Behavior among Adolescents in Kathmandu Metropolitan City.

Description of the study: The study consists of the participants to complete a brief
questionnaire. Completing the study will take approximately 45 minutes. The questions
will ask about health/safety risk behaviors of 9th through 12th grade students that are
directly related to the leading causes of health and social problems among youth. The
multiple choice questions ask about drug or alcohol use, tobacco use, violence and other
injury-causing behaviors, sexual behaviors, diet and exercise. The survey results supply
important information that cannot be collected in any other way. The results of this
survey will be used to help your child and other children in the future.

Participation: Participation of your child is voluntary. Your child do not have to take part
in this study if you do not want to do so. If your child begin the study and then decide
that they want to stop, they can do so whenever you wish and there will be no punishment
or penalty.

Anonymity: Collected information will be seen only by the researcher and will not have
your name attached to it. Name will not be included in the data collection.

Potential Risks and Benefits: There are no foreseeable risks or direct benefits to
participation in this study. The only potential risk is that some students might find certain
questions to be sensitive. Students will be instructed that they can skip any question they
do not want to answer or stop at any time. In addition, your child will be given the
opportunity to refuse to participate at all, even if you allow your child to complete the
survey.

I would like the selected student to participate but it is your decision. I would be glad to
answer any questions if you have. If you later have some questions about the study, you
may contact at following address.
Punjita Timalsina
9843767964
Kathmandu University
School of Medical Sciences

Please put a tick mark () on desired option and return the form to the school within 3
days. Thank you.
YES, my child may participate in the
survey.
NO,my child may not participate in the

22
 survey.

_____________________ ______________________ __________

Signature of the guardian Signature of the participant Date

23
 Kathmandu University
School of Medical Sciences
Dhulikhel, Kavre

Questionnaire
For
Surveillance of Youth Risk Behavior among Adolescents

Namaste,
My Name is Punjita Timalsina. I am conducting a research study regarding Surveillance
of Youth Risk Behavior among adolescents of Kathmandu Metropolitan City. This survey
is about your health and the things you do that may affect your health. Students like you
all over your country are doing this survey. Students in many other countries around the
world also are doing this survey. The information you give will be used to develop better
health programs for young people like yourself.
DO NOT write your name on this survey or the answer sheet. The answers you give will
be kept private. No one will know how you answer. Answer the questions based on what
you really know or do. There are no right or wrong answers.
Completing the survey is voluntary. Your grade or mark in this class will not be affected
whether or not you answer the questions. If you do not want to answer a question, just
leave it blank.
Make sure to read every question. Fill in the circles on your answer sheet that match your
answer. Use only the pencil you are given. When you are done, do what the person who is
giving you the survey says to do.

Code Number:______

Demographic Information
Question Response
S

24
 Age ___ years
1
Gender Male Female
2
Grade/class Nine Ten Eleven
3 Twelve
Section A: Drinking Alcohol
Have you ever consumed alcohol? Yes No
1 If No, go to section B
How old were you when you had your first
2 drink alcohol? ____ years
During the past 30 days, on how many days 0 days 1 to 2
3 did you have at least one drink containing days
alcohol? 3 to 5 days 6 to 9
days
10 to 19 days 20 to
29 days
3 to 5 days All 30
days
If o days, go to Q.5
During the past 30 days, on the days you less than one drink 1
4 drank alcohol, how many drinks did you drink
usually drink per day? 2 drinks 2
drinks
3 drinks 4
drinks
5 or more drinks
How did you usually get the alcohol you I bought it in a store,
shop, or from a street
5 drank?
vendor
I gave someone else
money to buy it for me
I got it from my friends

25
 I got it from my family
I stole it or got it without
permission
I got it some other way
During your life, how many times did you 0 times 1 to 2
drink so much alcohol that you were really
6 times
drunk?
3 to 9 times 10 or
more times
During your life, how many times have you 0 times 1 to 2
got into trouble with your family or friends,
7 times
missed school, or got into fights, as a result
of drinking alcohol? 3 to 9 times 10 or
more times
Section B: Height, Weight and going Hungry
Height ___ cm
1
Weight ____ cm
2
During the past 30 days, how often Never Rarely
did you go hungry because there
3 Sometimes
was not enough food in your
home? Most of the time Always
Section C: Eating and Drinking
During the past 7 days, how many I did not eat Less than one
times per day did you usually eat
1 time/day
fruit?
1 time/day 2 times/day
3 times/day 4 times/day
5 or more times/day
During the past 7 days, how many I did not eat Less than one
times per day did you usually eat
2 time/day
vegetables?
1 time/day 2 times/day
3 times/day 4 times/day
5 or more times/day
During the past 7 days, how many I did not eat Less than one
times per day did you drink
3 time/day
carbonated soft drinks?

26
 1 time/day 2 times/day
3 times/day 4 times/day
5 or more times/day
During the past 7 days, on how
many days did you eat food from a
4
fast food restaurant? ____ days
Section D: Drug Usage
Have you ever used drugs? Yes No
1 If No, go to Section E
How old were you when you had your
2 first used drugs? ____ years
During your life how many times have 1 or 2 times 3 to 9 times
3 you used drugs? 10 to 19 times 20 or more
times
During past 30 days, how many times 1 or 2 times 3 to 9 times
4 have you used drugs? 10 to 19 times 20 or more
times
Section E: Cleaning Teeth and Washing Hands
During the past 7 days, how many I do not clean or brush my
1 times per day did you usually clean or teeth
brush your teeth? ____ time(s)/days
During the past 7 days, how often did Never Rarely
2 you wash your hands before eating? Sometimes
Most of the time
Always
During the past 7 days, how often did Never Rarely
3 you wash your hands after using toilet? Sometimes
Most of the time
Always
During the past 7 days, how often did Never Rarely
4 you use soap when washing your Sometimes
hands? Most of the time
Always

27
 Section F: Your Feelings and Friendships
During the past 30 days, how often Never Rarely
1 have you felt lonely? Sometimes
Most of the time
Always
During the past 30 days, how often Never Rarely
2 have you been so worried about Sometimes
something that you could not sleep at Most of the time
night? Always
During the past 12 months, did you Yes No
3 ever seriously consider attempting
suicide?
During the past 12 months, did you Yes No
4 make a plan about how you would
attempt suicide?
During the past 12 months, how many 1 times 2 or 3 times
5 times did you actually attempt suicide? 4 or 5 times 6 or more
times
How many close friends do you have? 0 1 2 3or more
6
Section G: Physical Activity
During the past 7 days, on how many 0 days 1 day 2
1 days were you physically active for a days
total of at least 60 minutes per day? 3 days 4 days 5
days
6 days 7 days
During the past 7 days, on how many 0 days 1 day 2
2 days did you walk or ride a bicycle to days
or from school? 3 days 4 days 5
days
6 days 7 days
During this school year, on how many 0 days 1 day 2
3 days did you go to physical education days

28
 (PE) class each week? 3 days 4 days 5
days
6 days 7 days
How much time do you spend during a Less than 1 hr/day 1-2
4 typical or usual day sitting and hrs/day 3-4 hrs/day
watching television, playing computer 5-6 hrs/day 7-8
games, talking with friends, or doing hrs/day
other sitting activities?
more than 8 hrs/day
Section H: Experience at School and at Home
During the last 7 days, on how many 0 days 1 or 2 days 3
1 days did you miss classes or school to 9 days 6-9 days 10 or
without permission? more days
During the last 7 days, how often were Never Rarely
2 most of the students in your school Sometimes
kind and helpful? Most of the time
Always
During the last 7 days, how often did Never Rarely
3 your parents or guardians check to see Sometimes
if your homework was done? Most of the time
Always
During the last 7 days, how often did Never Rarely
4 your parents or guardians understand Sometimes
your problems and worries? Most of the time
Always
During the last 7 days, how often did Never Rarely
5 your parents or guardians really know Sometimes
what you were doing with your free Most of the time
time? Always
During the last 7 days, how often did Never Rarely
6 your parents or guardians go through Sometimes
your things without your approval? Most of the time
Always

29
 Section I: Sexual Intercourse
Have you ever had sexual intercourse? Yes No
1 If No, go to section J
How old were you when you had
2 sexual intercourse for the first time? ____ years
During your life, with how many
3 people have you had sexual ____ persons
intercourse?
The last time you had sexual Yes No
4 intercourse, did you or your partner use
a condom?
The last time you had sexual Yes
5 intercourse, did you or your partner use No
any other method of birth control, such Dont know
as withdrawal, rhythm (safe time), birth

control pills, or any other method to
prevent pregnancy?
Section J: Cigarette and Other Tobacco Use
Have you ever tried Yes No
1 cigarette? If No, go to section K
How old were you when
2 you had your tried ____ years
cigarette?
During the past 30 days, on 0 days 1 to 2 days
3 how many days did you 3 to 5 days 6 to 9 days
smoke cigarettes? 10 to 19 days 20 to 29 days
3 to 5 days All 30 days
If o days, go to Q.5
During the past 30 days, on 0 days 1 to 2 days
4 how many days did you use 3 to 5 days 6 to 9 days
any tobacco products other 10 to 19 days 20 to 29 days
than cigarettes?
3 to 5 days All 30 days

30
 Have you ever tried to stop Yes No
5 smoking cigarettes?
Which of your parents or Neither Father/male guadian
6 guardians use any form of Both Mother/female guardian
tobacco? Dont know
Section K: Physical Attacks and Injury
During the past 30 days, 0 times 1 time
1 how many times were you 2 or 3 times 4 or 5 times
physically attacked? 6 or 7 times 8 or 9 times
10 or 11 times 12 or more times
During the past 30 days, ___ times
2 how many times were you If 0 times, go to Q.
in a physical fight?
During the past 30 days, ___ times
3 how many times were you If 0 times, go to Q.
seriously injured?
During the past 30 days, broken bone cut or stab
4 what was the most serious wound
injury that happened to you? gunshot wound burn
poisoned
head and neck injury (could not breath)
others
During the past 30 days, motor vehicle accident falls
5 what was the cause of the attack, abuse and fight hitten by
most serious injury that something
happened to you? inhalation or swallowing bad thing
others
During the past 30 days, on 0 days 1 to 2 days
6 how many days were you 3 to 5 days 6 to 9 days
bullied? 10 to 19 days 20 to 29 days
3 to 5 days All 30 days

31
 If 0 days, go to section L
During the past 30 days, hit, kicked, pushed or locked indoors
7 how were you bullied most made fun of my race, nationality, color
often? made fun of my religion
made fun with sexual joke, comments or
gestures
left out or completely ignored with
purpose
others
Section L: HIV Infection or AIDS
Have you ever heard of HIV infection or AIDS? yes no
1
Were you taught about HIV infection or AIDS in yes no
2 school? dont know
Were you taught ways to avoid HIV infection or yes no
3 AIDS? dont know
Have you ever talked about HIV infection or AIDS yes no
4 with your parent or guardian? dont know

32

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