Lifestyle and Health Risk Behaviours among Elbasan Students

AIM: The purpose of this study is: (1) to help monitor the Albanian students’ lifestyle, the way they spend their free time, the weight that studying, networks, screens and sports have in their life; (2) to assess their health risk behaviours, such as tobacco and drug use, weapon carrying and sports betting; (3) to identify differences in behaviour by gender, grade, socioeconomic and demographic status; (4) to understand the influence of parents on their children.


Introduction
Lifestyle is the typical way of life of an individual. Youth health depends a lot on their lifestyle. Health risk behaviours are those that can have adverse effect on the overall development and wellbeing of youth, or that may prevent them from future success and development. A teenager is a young person whose age falls within the range from thirteen through nineteen.
The lifestyle and behaviours of the Albanian teenagers are affected by three factors such as: the period of growing up from childhood to adulthood -the adolescence, the transition period in Albania and the last, but not the least, is the fast technology progress. The impact of these factors has engendered some new phenomenon, not evident before the 90s, such as drug use, sports betting, computer and video games addiction, three factors which are considered to cause a disturbing increase in the abandonment of books and studies in general. A massive attendance of school has been occurring during these last years in Albania, but, unfortunately, this has not been associated with an increase in the students' interest in their schooling: on the contrary, the number of students interested in studying is too low. They spend too much time watching television, surfing the net or hanging out with friends in bars while abandoning books and study.
The students are forsaking book reading because the technology progress. Teens are not reading as much as they did in the past [1]. The percentage of the students who read books is low. Results from different studies have shown that children and young adults read significantly less than in the past [2]. Adolescent literacy remains a critical problem and a major contributor to low achievements in high school [3].
The time spent on games, web surfing and computer use has considerably been increasing. Due to staying up late at night, chatting on Facebook, they have a low academic performance [4]. While researchers assert that the students should sleep 8.5 -9.25 hours per night [5], school teachers admit that there are students who fall asleep during classes, because of the late hours spent on internet. The lack of sleep affects school performance. Sleep deprivation can have serious consequences. Lack of sufficient sleep can limit the ability to learn, concentrate and solve problems and can lead to aggressive or inappropriate behaviours. Inadequate sleep also has been linked to diabetes, hypertension, obesity and depression. Teens that stay up late are at greater risk of depression [6].
Staying too much online impacts their school, their academic performance as well as their physical and mental health [7]. Researchers say that the students should stay in front of a screen 1-2 hours a day. Screen-media use has been associated with youth alcohol use, precocious sexual practices, negative body concept, eating disorders, aggressive behaviours, worsened educational achievement, and higher BMI (body mass index) [10]. Too much time in front of television and internet means spending less time studying, reading a book or playing outside with friends [8]. Excessive television viewing throughout childhood and adolescence is associated with increased antisocial behaviour in early adulthood [11]. The possible negative effects of television on them are violent and aggressive behaviour, substance use, sexual activity, obesity, decreased school performance. As much as 10-20 % of real -life violence may be attributed to media violence [9]. A new spreading phenomenon is electronic addiction, such as Facebook and online games addiction. Facebook has negative impact on the users' life. Facebook is accused for depression among young people. Excessive Facebook use can damage relationships. More Facebook friends means more stress, researchers say. Facebook encourage envy between its users, jealousy, social tension, isolation, depression [12][13][14].
Another obvious problem among the students is online games addiction. Videogames glorify violence and encourage antisocial behaviour. Results show that playing violent videogames was associated with more aggressive behaviour [15,16]. Violent games decrease helping behaviour and feelings of empathy for others.
A new trait of our society, which came along the last 20 years of transition, is the use of drugs. Before the 90s, drug use in Albania was not spread. According to the Institute of Public Health, before 90s, there were little or no strong drug users at all. The most commonly used drugs were tobacco, alcohol and some pharmaceutical preparations [17]. But nowadays it seems that we are facing the contrary. The number of the students using drugs seems to grow more and more every year. Despite the fact that the number of drug users in Albania is smaller than in the other countries, the situation is worrying. We all know its damages: dependency and death [18]. But even though the students have all the information about that, they still use narcotic substances. This happens because of social problems they face every day, such as: not feeling important enough, economic or family problems, or because of friendship influence or out of curiosity. A review of more than 120 studies strongly suggests that consuming cannabis during adolescence interferes with natural brain development and may hardwire some teens to develop addictions in adulthood. Cannabis consumption during teenage years could also make some individuals more susceptible to suffering from schizophrenia -mainly teens that have a genetic predisposition to the mental illness [33].
A bigger problem, which also leads to drugs, is smoking. Tobacco use is one of the major preventable causes of death in the world. The World Health Organization attributes over four million deaths a year to tobacco [19,20]. What has been noticed after the 90s is the upward trend of tobacco consumption among women and especially among youth, which begin to smoke too early [21]. Because of the increasing levels of use, tobacco usage among young people has been referred to as both a "pediatric disease" and a "pediatric epidemic" [22].
Another issue in this study are energy drinks that are a new occurrence of these years. Energy drinks contain too much caffeine and other additives that we don't know enough about. Different studies indicate that those are cause of some tumors or cancers. Also, there have been a couple of reported teenage deaths because of them. Too much caffeine in abundance give irritability, insomnia, tachycardia, hands tremor, high blood pressure, obesity and other medical problem in teens [23][24][25]. Teens who drink more than 2 energy drinks in a day are more aggressive, anxious, agitated [26].
Another occurrence unfolded during the transition period in Albania is football pools, which is on rise across the country. For many, gambling can grow from an occasional social activity to a compulsion. It is an addictive behaviour and the consequences are huge debts, which may lead the teen to stealing, and cause him depression, disruption of relationships with friends and family, involvement with bookies, who may be connected with organized crime [27]. Institute researchers identify gambling as a high-risk behaviour in the same list as kids having sexual intercourse, using drugs, and getting into trouble with the police [28].

Method
The study was conducted in May 2013 and was a classroom survey. The target or in-scope population comprised the 8 th to 12 th graders enrolled in school system in Elbasan (a city in the center of the Albania). The sampling frame consisted of the regular public, private and technical schools that included the grades in our target. The schools were selected randomly from urban and rural areas based on the criteria of inclusion in the study all types and levels of them. The classes within the participating schools were then selected by using a weighted probability technique to ensure that students were equally likely to be included.
Because the objective of this study was the lifestyle of the students from 8 through 12 grades, all the students in the selected classes were eligible to participate in the survey, without regard to their age. The students, who were absent didn't take part in the study. All the students (n = 1,654) in the participating classes completed the survey. The students involved were 13-20 years old with an average age of 16 ± 1.3. It was a representative sample of the 8 th to 12 th graders (total number = 22,183) enrolled in Elbasan schools. The margin error was ± 2.32% points.
A self-completed questionnaire was distributed to them. It was not used a standardized one, but was an ad hoc questionnaire, which relied on self-reporting of the questions about their lifestyle and health risk behaviours. The administration procedures were designed to protect students' privacy by assuring that student participation was anonymous and voluntary. Students completed the self-administered questionnaire during one class period. Students were informed that participation was voluntary and anonymous and were instructed not to write their name on the questionnaires. Teachers were not required to remain in the classroom during administration. The questionnaire consisted of 20 questions and included item on the following topics: reading books, hours before a television and computer, violent videogames, team sports participation and health risk behaviours such as tobacco and drug use, cold weapon carrying, football pools.
Descriptive analyses were conducted to obtain the prevalence of tobacco and drug use, weapon carrying, betting and participating in sports activity by age and gender Prevalence estimates and confidence intervals were computed for all variables. Data were analyzed with likelihood ratio test to assess consistency of associations and correlations were considered statistically significant if the p value was < 0.05.

Study limitation
The findings in this report are subject to at least four limitations. First, this study is based on a self-completed questionnaire, possibly leading to under or over reporting of behaviour. A number of the students are not responded to specific questions, especially about their health risk behaviours. So, the students' response rates for specific questions ranged from 75.5% to 100% (median 87.7%) Second, these data apply only to youth who were in school the day of survey administration and in this study are not included adolescents who are not attending school. Therefore are not representative of all persons in this age group.
Third, the questions should have been more in details. So the students are not asked about the nature of the television programs that they see. The students are asked if they have used once in their life drugs and are not asked if they currently use drugs or about the kind of drugs that use. The students are asked if they smoke, but they are not asked about the number of the cigarettes per day and the age of beginning of the smoking.
Not including of the alcohol use and sexual risk behaviours as the topics in the current study is the fourth limitation. According to the Centers for Disease Control and Prevention alcohol use and sexual risk behaviours are two of the six priority health risk behaviours of youth and their involvement in the youth survey is important to understand the full spectrum of risk behaviours among students.

Results
Out of 1654 students asked, 70.2 % live in the city, 29.8% in the rural areas, 46.7% are males and 53 .3% females. The majority of the students were 17year olds (26.5%), while the 13 year olds constituted of 0.1% of the participants (Table 1). During free time only 35.7 % of student's report that read a book, 35.3% chat on facebook and 25.8% spend their free time in bars with friends. The percentage of reading a book during free time was higher among female (49.8%) than male (19.6%) students. Girls read 2.5 times more than boys. There were no differences between urban and rural areas. The rate of the students that study one hour/day was higher among those that do not read (30%) than among those that read (9%) (Fig. 1). The rate of chatting in Facebook during free time was higher among male (41.7%) than female (29.8%) students; higher among students who live in city (40%) than those in rural areas (24.3%). The rate of hanging out in bars with friends was higher among male (37.3%) than female (15.8%) students; higher among students who live in city (29.3%) than those from rural areas (17.6%). The rate of staying up late in computer was higher among male (47.5%) than female (20.5%) students; boys stay up late in computer 2.5 time more than girls; slightly higher among students from city (34.4%) than those from rural areas (30%).The rate of the students who do not study at all was higher among those that stay up late on computer (7%) than among those that don't (1%). The rate of participating in a sport team was nearly 2 times higher among male than female students, 73% and 37.9% respectively; there were no differences between urban and rural areas. Football results to be the most popular sport for boys, followed by basketball and volleyball, while girls prefer more volleyball than basketball whereas dancing takes third place. The percentage of health risk behaviours was lower among students involved in team sports than among those who don't ( Fig. 3). The rate of playing violent videogames was higher among male (50%) than female (37.7%) students, slightly higher among rural (46.4%) than urban (42.2%) ones. The rate of the students that carry a cold weapon was higher among those that play violent videogames (11%) than among those that do not play (7%). The rate of watching TV more than 3 hours/day was higher among male (17.2%) than female (11.3%) students; there were no differences between urban and rural areas.
The rate of staying on computer more than 3 hours/day was higher among male (24.6%) than female (11.3%) students, was higher among students from city (19.4%) than those from rural areas (12.9%). 10.58% of students report that stay in front of a screen (TV or/and computer) more than 7 hours/day. The percentage was higher among male (14.2%) than female (7.3%) students; there were no significant differences between urban and rural areas. The rate of the students that do not study at all was higher among those that stay in front of a screen more than 7 hours/day (8%) than among those that stay in front of a screen less than 7 hours/day (1.6%). Out of all the responding students, who were asked if they have used drugs at least once in their lifetime, 7.9% of them answered positively. The rate of using drugs at least once in life was higher among male (13.9%) than female (2.6%) students; while between urban and rural areas the percentage was 7.3% and 9.3% respectively. The students using drugs that have parents with higher level of education was 35%, those who have parents with secondary education was 38% and students who have parents with primary education was 27%. Also the rate of the students having both unemployed parents was 33% and for those having employed parents the percentage is 24%. 11.2 % of the participants smoke. The rate of smoking was significantly higher among male (18.7%) than female (4.5%) students; was slightly higher among rural (13.9%) than urban (9.9%) areas. Table 6: Number, percentage and confidence interval of the students reporting studying, watching TV and staying on computer more than 3 hours and staying in front of a screen more than 7 hours by sex and region. Eight point six percentages (8.6%) of the students carry a cold weapon. The rate of carrying weapon was significantly higher among male (15.6%) than female (2.4%) students; there was no difference in rates between urban and rural areas. 0ne in two students, who carry a cold weapon, have used at least once in their lives drugs.
One third (33%) of the students play football pools. The percentage was significantly higher among male (59.8%) than female (9.5%) students, while the percentage in the city is 33.9% compared to the rural areas 30.8%. The percentage of other health risk behaviours (drug and tobacco use, weapon carrying) was higher among students who play football pools than among those who don't. More than one third (39.2%) of the students drink energy drinks when they are out with friends. There were no sex and regional differences.

Discussion
This study is aimed at surveying the lifestyle of the present-day students in Elbasan, Albania. Findings drawn out from the study show a complicated picture regarding teenagers' lifestyle, revealing and even attesting a lot of serious problems teenagers are being confronted with. It was the first time that such a study has been conducted in Elbasan County and in Albania as a whole. Other studies have also been accomplished previously, but they were focused solely on isolated issues such as the use of drugs or tobacco, whilst not dealing with the other issues this study covers and which make it an authentic undertaking. The importance of this survey relies on the fact that it provides current information about the health risk behaviours and other issues featuring teenage at present. To this regard, the data show that the number of students involved in reading books during their free time results to be downcast .In the study "To read or not to read", NEA 2007 affirms that 22% of the 17 year olds read for fun, whereas this study reveals that 17 year old students read books, in their free time, amounts to 34.8%. Since the questions asked to the students referred solely to their free time, further studies are necessary to investigate the development trend regarding reading as well as the factors affecting this trend. An obvious consequence of this downward inclination is that students not involved in reading have a lower academic performance compared to those who read. A relationship between reading books in free time and the effective study hours was observed in this study (χ 2 f = 170.99, p < 0.0001). Students who are not involved in reading during their free time were significantly less likely to study than others. Data of the study also indicate that there are a considerable number of those who spend the free time in front of a screen or hanging out in bar with friends. Our findings can't be compared with findings of other studies about the way the teenagers spend their free time because it is not used a standardized questionnaire. Our survey demonstrates that 35.3% of the students mainly use solely Facebook during their free time. There is a distinct increase in the use of Facebook with decreasing age, namely Facebook is more common in younger ages. Moreover, there is an increase of percentage alongside the increase in age for spending free time in bars and staying up late, but it is evident that these phenomena are widespread in younger ages, too. Male students are not more likely than female to stay up late on computer (χ 2 f = 5.733, p = 0.057), also, students from rural areas are not more likely than those from city (χ 2 f = 0.555, p = 0.758). There is a negative association between staying up late on computer and the time devoted to studying, (χ 2 f = 110.45, p < 0.0001). Students staying up late are significantly less likely to study than those that go to bed earlier.
Obviously, the young teens involved into playing sports are healthier and feel happier about life. By being involved into sports, students benefit physically, socially and mentally. Recently, the number of students organized in sports teams has been greatly increased. Our findings (54.3%) result to have no difference with those from other studies (58.4%) [35]. Boys are significantly more likely to take part in sport activities than girls (χ 2 f = 89.979, p <0.0001), students from rural areas are not more likely than those from city (χ 2 f = 4.832, p = 0.089). Findings in our study suggest that there is a negative association between being involved in sports and engagement in health risk behaviours. Students who take part in sports team are less likely to use drug (χ 2 f = 29.18, p < 0.0001), to smoke (χ 2 f = 20.02, p = 0.0004), to carry a cold weapon (χ 2 f = 33.439, p < 0. 0001) and to bet (χ 2 f = 112.30, p < 0.0001) than those who are not involved in sports team.
Regarding violent videogames there is a distinct increase of prevalence with decreasing age, violent videogames are more widespread in younger ages. Our findings are lower than those of other studies. The Gallup Poll Tuesday Briefing found in an online survey of teenagers aged 13 to 17 conducted in August that 71 percent of boys in that age group have played "GTA," along with 34 percent of girls, meanwhile in our findings resulted that 50% of boys and 37.7 of girls have played violent videogames (counterstrike). It resulted from the survey that there is a positive correlation between playing violent videogames and carrying cold weapons. Students that play violent videogames are significantly more likely to carry a cold weapons than others (χ 2 f = 6.88, p = 0.008).
Boys are significantly less likely than girls (χ 2 f = 81.745, p < 0.0001) and students from rural areas are significantly less likely than those from city (χ 2 f = 42.522, p < 0.0001) to study.
Regarding the phenomena of students watching TV 3 or more hours/day, our findings (31.4%) result to be the same with those from the other study 32.4% [35]. Boys are significantly more likely than girls to see more than 3 hours television (χ 2 f = 106.172, p < 0.0001) and students from rural areas are more likely than those from city ( χ 2 f = 19.20, p = 0.004).
Regarding the prevalence of the students who used computer 3 or more hours/day, our findings are the same with those from the other study (31.1%) [35]. There is a big difference in prevalence between urban and rural areas (χ 2 f = 41.748, p < 0.0001) for the students who stay more than 3 hours/day on computer, while male students are not more likely than female (χ 2 f = 4.411, p = 0.621). It is noticed that the prevalence is increased with the decreasing age, which means the younger ages are more inclined in working on computer.
Regarding the prevalence of staying more than 7 hours in front of a screen, our study findings http://www.mjms.mk/ http://www.id-press.eu/mjms/ (10.58%) result to be the same with those from other studies (10.2%) [34]. Boys are twice more inclined to stay more than 7 hours/day in front of a screen than girls. Consequently, staying hours and hours in front of a screen means less time for study, not mentioning the health problems it causes. Moreover, the study shows that there is a negative correlation between staying more than 7 hours in front of a screen and the time allocated to studying. Students who stay more than 7 hours in front of a screen are less likely to study than others (χ 2 f = 31.79, p < 0.001). The healthy risky behaviours are growing rapidly although the rates are lower than other European countries. So, according to the Institute of Public Health there are 6-7 % of the teenagers that use drugs [30]. In our study the percentage is 7.9%. However this result is, by definition, below average of other European countries, confirmed to17% [32]. Another conclusion of this study, regarding the abovementioned phenomena, is the great difference between boys and girls. The number of boys reporting to have used drugs, at least once in their life, is three times greater than the number of girls. It is noticed that the prevalence tends to increase with increasing age. Also, data shows that there is an extension of the drug use among younger ages. The prevalence of using drugs at least once in their lifetime in urban and rural areas is 7.3% and 9.3%, respectively, (χ 2 f = 9.494, p = 0.009) meaning that students from rural areas are more likely inclined to report their status as drug users than students from city, whereas 3.5 % of the students do not prefer to declare their status as such. Also, differences in rates between city and rural areas may be explained by taking into consideration the number of students from rural areas attending the city schools.
Furthermore, this study attested that there are a significant proportion of students that smoke. Data featuring this phenomenon suggest that the majority of smokers begin using tobacco well before 18. According to Albanian Demographic and Health Survey conducted in 2008-2009 [31], 13 % of the young men aged 15-19 are smoking addicts, whereas this study revealed that the percentage of the tobacco smokers amounts to 11% of the 15-19 year-olds. The prevalence is below average of other European countries which, according to "ESPAD" [32] is 26%. There is a significant difference in prevalence between male and female students. Boys smoke 3 times more than girls while there is a higher prevalence with increasing age, although smoking begins too early. There are no significant variation in the prevalence of smoking among adolescents by urban-rural residents (χ 2 f = 4.32, p = 0.115). Frequency of tobacco use among teenagers correlates with the frequency of parents' smoking (χ 2 f = 25.95, p < 0.0001). Three in four students have one of their parents smoking. So, students having one smoking addict parent are more likely to smoke than others.
Another issue this study dealt with is the prevalence on carrying cold weapons. There are no previous studies and data about the Albanian teenagers' prevalence to this regard while in this study there is a higher prevalence (9%) compared with OSDUHS "The mental health and well-being of Ontario students" 1991-2011, (4.6%), while compared with European countries there is no difference in prevalence, 11.9% in Republic of Macedonia, 11.3 % in Belgium [37]. An increasing rate of carrying a cold weapon with increasing age has been noticed. It also appears that this health-risk behaviour is widespread in younger ages. Student from rural areas are not more inclined to carry a cold weapons than those from city (χ 2 f = 3.35, p = 0.187). The research also indicated a positive correlation between carrying cold weapon and drug use (χ 2 f = 410.52, p < 0.0001). Students carrying cold weapons are more inclined to use drugs. So, two in three students carrying a cold weapon, use drugs, too.
With regard to football pools, the study shows no differences in prevalence with other studies, 35% compared with 38% [29]. Boys bet 6 times more than girls, students from rural are not more likely than those from city to play football pools (χ 2 f = 2.437, p = 0.296) The result show a higher prevalence of other health risk behaviours among the students involved in betting compared to those that are not involved. Teenagers playing football pools have prevalence nearly 5 times more to use drugs (χ 2 f = 135.99, p < 0.0001), nearly 4 times more to smoke (χ 2 f = 127.30, p < 0.0001) and 4-5 times more to keep a cold weapon (χ 2 f = 150.77, p < 0.0001) than those not involved in betting. Our findings suggest that there is a correlation between students' betting and parents' betting; the students that have father who bets are more likely to play football pools that those whose father don't ( χ 2 f = 404.77, p < 0.0001). Regarding to energy drinks, there are not different variations between our finding and the results of the other studies, 39.2% vs. 39.7% [29]. There is an increasing rate with decreasing age, showing that energy drinks are most likely among younger ages. Popularity among youth and especially among younger ages, as result of infinity of media advertisings, lots of different brands marketing energy drinks and the lack of restriction rules against sales or consumption by minors, should be concerning problem of Public Health.
This study was undertaken in response to the persistence of the excessive violence among school students. Various programmes have been initiated by the Ministry of Health of Albania and other organizations to address the health risk behaviours among schoolchildren and especially among teenagers, but, how effective have they really been? In the meantime, almost nothing has been done to improve the ways the schoolchildren and teenagers spend their free time, while this has been considered "an issue of national problem: the after -school hours have been identified as a time of risk, when teenagers use drugs, commit crime and have sex" [36]. This study as well as the other ones focusing on the Albanian teenagers, state that the number of the teenagers engaged in health risk behaviours is far smaller as compared to that of the other European countries, but how real is this? Should we consider that these data are solely the tip of the iceberg? Why? Because all studies focus on the schoolchildren and none of them includes street children, those not attending schools and are more vulnerable, more inclined and more exposed to dangerous behaviours.
That is why it is necessary for other studies, perhaps on a national scale, to analyze problems more in details. More research is needed to understand the factors that influence overall health risk behaviours in order to increase the effectiveness of any preventive measures and programs to be undertaken in the future.
In conclusion, self-reported data on individual behavioural patterns suggest that: the teenagers' involvement in reading and studying processes is low, because of staying in front of a screen and in bars for hours and hours and at the same time they are engaged in health risk behaviours and what is more worrying, these health risk behaviours are extending to younger group-ages.
Systematic surveillance of youth health risk behaviours is the first step in attempting to prevent and to control them. The study results urge the need for continuous monitoring of the teenagers' lifestyle, nationally, even more often than it has been done so far as well as the exigency to advocate for more efficient and productive programs aiming to prevent the current teenage health risk behaviours.
These findings suggest that the preventive programs should initiate in secondary schools, because this is the most likely time for the initiation of the engagement in health risk behaviours. These findings reinforce the need for effective programs where the cooperation students -parents -teachers are essential.
Data gathered in the course of this study divulged serious problems existing in their lifestyle alongside the ways to incite public health responses for the reduction of their consequences. The need to change the way in which society views and treats these problems is also pretty evident and appalling.