Pengpid and Peltzer BMC Pediatrics (2020) 20:357

https://doi.org/10.1186/s12887-020-02252-0

RESEARCH ARTICLE Open Access

Trends in the prevalence of twenty health

indicators among adolescents in United
Arab Emirates: cross-sectional national
school surveys from 2005, 2010 and 2016
Supa Pengpid1,2 and Karl Peltzer3*

Abstract
Background: The aim of this study was to assess the trends in the prevalence of various health indicators among
adolescents in United Arab Emirates (UAE).
Methods: Nationally representative data were analysed from 24,220 in-school adolescents (median age = 14 years)
that took part in three cross-sectional surveys (2005, 2010 and 2016) of the “UAE Global School-Based Student
Health Survey (GSHS)”.
Results: Significant improvements were identified among both girls and boys in the reduction of being physically
attacked, inadequate fruit intake, inadequate vegetable consumption, loneliness, and among girls only poor oral
hygiene (< 2 times tooth brushing/day) and among boys only, experiencing hunger and in physical fight.
Significant rises were identified among both girls and boys in the prevalence of bullying victimization, overweight
or obesity, leisure-time sedentary behaviour, injury and inconsistent washing hands prior to eating, and among
boys only obesity and among girls only inadequate physical activity, and school truancy.
Conclusions: Several reductions but even more increases of poor health indicators were identified over three cross-
sectional surveys during a period of 11 years emphasizing the need for enhanced health promotion activities in this
adolescent school population.
Keywords: Obesity, Health indicators, Mental health violence, Protective factors, Hygiene, Injury

Background unhealthy diets, tobacco use, and obesity, are very com-
In United Arab Emirates (UAE), a high-income Arab mon among children and adults in the Arab region [2].
country, 77% of all death are attributed to non- As stated by the World Health Organization (WHO),
communicable diseases (NCDs) [1]. The prevalence of “alcohol use, dietary behaviours, drug use, hygiene, men-
NCDs (diabetes, cancer, chronic lung diseases and car- tal health, physical activity, protective factors, sexual be-
diovascular disease) is on the rise in countries of the haviours, tobacco use, violence and unintentional injury”
Arab region, including the UAE [2]. Behavioural NCD are the leading causes of morbidity/mortality among
health risk indicators, such as physical inactivity, children and adults globally [3]. Monitoring various
health indicators, such as nutrition and diet, substance
use, physical activity, violence, injury and mental health,
* Correspondence: [email protected]
3
Department of Psychology, University of the Free State, Bloemfontein, South among adolescents over time may facilitate targeting
Africa intervention strategies [4–6].
Full list of author information is available at the end of the article

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article's Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 2 of 11

Diverse results were found in research investigating the 2005 UAE GSHS the response rate was 89%, for
trends in health indicators among adolescents [5, 6]. For 2010 91% and for the 2016 UAE GSHS 80% [3]. The
example, in a trend study among adolescents in the data and more detailed information on the study proce-
Philippines [5] poor hand hygiene behaviour decreased dures can be accessed [3].
over time, while it increased in Oman [6], and interper- The GSHS core questionnaire assesses 10 modules:
sonal violence, injury and physical inactivity decreased, “alcohol use, dietary behaviours, drug use, hygiene, men-
while the prevalence of fruit and vegetable intake (one tal health, physical activity, protective factors, sexual be-
study) increased [5, 6]. In terms of injury and interper- haviours that contribute to HIV infection, other
sonal violence, in a large study among adolescents in the sexually-transmitted infections, and unintended preg-
UAE, 18% reported a physical injury in the past 12 nancy, tobacco use, violence and unintentional injury.”
months [7]. In a local study among adolescents in UAE, [3] All core modules of the questionnaire that were im-
15.4% of males and 8.0% of females reported physical plemented in the 2005, 2010 and 2016 UAE GSHS were
violence (having been hit and pushed) in the past month part of this analysis.
[8]. In another study among 1054 school students in
Dubai, peer violence (beating 39.4% and boxing 24.5%) Measures
was commonly reported [9]. The questionnaire used is shown in Table 1 [3]. Over-
Regarding overweight and obesity, in a study among weight/obesity was classified as “more than + 1 standard
6–19 year-old students in Abu Dhabi, UAE, 14.7% were deviation (SD) and obesity more than + 2 SD from the
measured to have overweight and 18.9% obesity [10]. In median body mass index by age and sex,” using the 2007
a study among adolescents in public and private schools WHO Child Growth reference [17]. The consumption of
in Dubai, 72% reported inadequate fruit and vegetable less than “two or more servings of fruits in a day” and
intake [11]. In a meta-analytic review of physical activity less than “three or more servings of vegetables a day”
among adolescents in the UAE, one in four had total were considered inadequate [18]. “Inadequate physical
sedentary behaviour with no physical activity [12]. In a activity was defined as not daily at least 60 minutes of
cross-sectional study (2007–2009) among adolescents in moderate to vigorous-intensity physical activity.” [19]
UAE, the prevalence of current smokers was 14.0% [13]. “Leisure-time sedentary behaviour was defined as spend-
In terms of mental health, in a sample of school adoles- ing three or more hours per day sitting.” [20].
cents (N = 600) in the UAE, 17.2% were found to have
depressive symptoms [14], and in another adolescent
school sample (N = 968) in UAE, the prevalence of anx-
iety disorders was 28% [15]. Covariates
There is a major research gap in the assessment of We categorized age into three groups (≤ 11–13, 14–15,
trends in health indicators over time among adolescents and ≥ 16 years), experience of hunger (as a proxy for so-
in the Eastern Mediterranean region, such as in UAE. cioeconomic status) into three groups (never, rarely or
The present study aims to estimate trends of the preva- sometimes, and most of the time or always) and study
lence of 20 different health and five protective indicators year into three groups (2005, 2010, and 2016), with the
in the 2005, 2010 and 2016 UAE “Global School-based first value being the reference category, respectively.
Student Health Survey (GSHS)”. It is hypothesized that
the prevalence of health indicators differs across the Data analysis
three GSHS from 2005, 2010 and 2016. Research results Statistical analyses were conducted using “STATA soft-
on trends of various health indicators may be beneficial ware version 15.0 (Stata Corporation, College Station,
for health promotion activities in schools [16]. Texas, USA)”. Data were weighted for non-response and
probability selection [3]. In order to test for differences
Methods in proportion Pearson Chi-square tests were utilized. Lo-
Participants and procedure gistic regression analyses were applied to estimate each
Data from the 2005, 2010 and 2016 UAE cross-sectional health indicator outcome adjusted by age group, socio-
GSHS were analysed [3]. A sampling design in two economic status (experience of hunger) and study year
stages (first: schools selected with probability propor- for boys and girls, separately. In order to account for the
tional to sample size, and second: classes of grades 8, 9, sample weight and the multi-stage sampling design, Tay-
and 10 students within schools were randomly selected) lor linearization methods were applied. Results from the
was used to generate a national representative country logistic regression analyses are shown as odds ratios
sample [3]. All students in the selected classes were eli- (ORs) with 95% confidence intervals (CIs). Missing
gible to participate regardless of their age, and values were excluded from the analysis. P < 0.05 was
responded to a self-administered questionnaire [3]. For considered significant.
Table 1 Variable description
Variables Question Response options (coding scheme)
Age “How old are you?” “11 years old or younger to 16 or 18 years old or older”
Sex “What is your sex?” “Male, Female”
Body weight and dietary behaviour
Body weight “How much do you weigh without your shoes on?” kg
Height “How tall are you without your shoes on?” cm
Fruit intake “During the past 30 days, how many times per day did you usually eat fruit such as apples, bananas, “1=I did not eat fruit during the past 30 days to 7=5 or more
and oranges?” times per day (coded 1-3=1 and 4-8=0)”
Pengpid and Peltzer BMC Pediatrics

Vegetable intake “During the past 30 days, how many times per day did you usually eat vegetables, such as salads, “I did not eat vegetables during the past 30 days to 7=5 or
spinach, eggplant, tomatoes, and cucumbers?” more times per day (coded 1-4=1 and 5-8=0”
Physical activity and sedentary behaviour
Physical activity “Physical activity is any activity that increases your heart rate and makes you get out of breath some “0=0 days to 7=7 days (coded 0-6=0 and 7=1)”
of the time. Physical activity can be done in sports, playing with friends, or walking to school. Some
(2020) 20:357

examples of physical activity are running, fast walking, biking, dancing, football, swimming, and
aerobics. During the past 7 days, on how many days were you physically active for a total of at least
60 minutes per day?”
Leisure-time sedentary behaviour “How much time do you spend during a typical or usual day sitting and watching television, playing “1=less than 1 hour per day; 2=1-2 hrs/day; 3=3-4 hrs/day;
computer games, talking with friends, or doing other sitting activities, such as studying or using any 4=5-6 hrs/day; 5=7-8 hrs/day and 6=8 or more hours per day”
electronic devices like IPads?”
Tobacco use
Current tobacco use “During the past 30 days, on how many days did you smoke cigarettes/use any tobacco products “1=0 days to 7=All 30 days (coded 1=0 and 2-7=1)”
other than cigarettes, such as Sheesha, Medwakh, chewed tobacco, or electronic cigarettes?”
Injury and violence
Injury “During the past 12 months, how many times were you seriously injured?” “1=0 times to 8=12 or more times (coded 1=0 and 2–8=1)”
Bullying victimization “During the past 30 days, on how many days were you bullied?” “1=0 days to 7=All 30 days (coded 1=0 and 2–7=1)”
Physically attacked “During the past 12 months, how many times were you physically attacked?” “1=0 times to 8=12 or more times (coded 1=0 and 2–8=1)”
Physical fighting “During the past 12 months, how many times were you in a physical fight?” “1=0 times to 8=12 or more times (coded 1=0 and 2–8=1)”
Oral and hand hygiene
Brushing teeth (≤1 time/day) “During the past 30 days, how many times per day did you usually clean or brush your teeth?” “1=never to 6=4 or more times a day (coded 1-3=1 and
4-6=0)”
Hand washing before eating “During the past 30 days, how often did you wash your hands before eating?” “1=never to 5=always (coded 1–4=1 and 5=0)”
Hand washing with soap “During the past 30 days, how often did you use soap when washing your hands?” “1=never to 5=always (coded 1–4=1 and 5=0)”
Hand washing after toilet “During the past 30 days, how often did you wash your hands after using the toilet or latrine?” “1=never to 5=always (coded 1–4=1 and 5=0)”
Poor mental health indicators
No close friends “How many close friends do you have?” “1 = 0 to 4 = 3 or more (coded 1+=0, 0=1)”
Loneliness “During the past 12 months, how often have you felt lonely?” “1=never to 5=always (coded 1–3=0 and 4–5=1)”
Worry-induced sleep disturbance “During the past 12 months, how often have you been so worried “1=never to 5=always (coded 1–3=0 and 4–5=1)”
Page 3 of 11

about something that you could not sleep at night?”

Table 1 Variable description (Continued)
Variables Question Response options (coding scheme)
Suicidal ideation “During the past 12 months, did you ever seriously consider attempting suicide?” “Yes, No”
Suicide plan “During the past 12 months, did you make a plan about how you would attempt suicide?” “Yes, No”
Protective factors
Peer support “During the past 30 days, how often were most of the students in your school kind and helpful?” “1=never to 5=always (coded 1–3=0 and 4–5=1)”
School truancy “During the past 30 days, on how many days did you miss classes or school without permission?” “1=0 days to 5=10 or more days (coded 1=0 and 2-5=1)”
Parental supervision “During the past 30 days, how often did your parents or guardians check to see if your homework “1=never to 5=always (coded 1–3=0 and 4–5=1)”
was done?”
Pengpid and Peltzer BMC Pediatrics

Parental connectedness “During the past 30 days, how often did your parents or guardians understand your problems “1=never to 5=always (coded 1–3=0 and 4–5=1)”
and worries?”
Parental bonding “During the past 30 days, how often did your parents or guardians really know what you were “1=never to 5=always (coded 1–3=0 and 4–5=1)”
doing with your free time?”
(2020) 20:357
Page 4 of 11
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 5 of 11

Results and the proportion of sedentary behabiour significantly

Description of the study sample increased from 2005 to 2016 among both boys and girls.
Across the 2005, 2010, and 2016 UAE GSHS the overall
sample consisted of 24,220 school-going adolescents, Tobacco use
52.2% females and 47.8% males (median age = 14 year, The prevalence of current tobacco use increased among
interquartile range = 2 years). The number of older ado- both boys and girls over time but this was not statisti-
lescents increased across the three different assessment cally significant.
years (P < 0.001) (see Table 2).
Injury and violence
Having been physically attacked and involved in physical
Health indicator outcomes fighting significantly decreased among boys and physical
Overweight and poor diet assault decreased among girls from 2005 to 2016, while
Among students, 21.2% of males and 21.7% of females the prevalence of injury increased significantly in both
were overweight or obese in 2005, while this significantly sexes from 2005 to 2016. Bullying victimization in-
increased among boys in 2010 (43.7%) and 2016 (42.1%) creased among both boys and girls from 2005 to 2016.
as well as significantly increased but to a lesser extent
among girls than boys in 2010 (36.0%) and 2016 (35.6%). Oral and hand hygiene
Likewise, the prevalence of obesity significantly in- The prevalence of inadequate oral hygiene (tooth brush-
creased over time among boys but not among girls. ing) was 48.6% among male and 37.9% among female
More than two in three male students (68.7%) and 75.2% students in 2005, while this remained unchanged among
female students had less than two servings of fruits per boys a significant reduction was found among girls in
day in 2005, while these prevalences significantly de- 2010 and 2016. Not always washing hands prior to eat-
creased between both sexes in 2016. Inadequate vege- ing significantly increased among both sexes from 2005
table intake significantly reduced between both sexes to 2010 and 2016, while the other two poor hand wash-
from 2005 to 2016. Among girls, the proportion of ex- ing indicators (not always washing hands after toilet use
periencing hunger reduced from 2005 to 2010 but stayed and with soap) did not significantly change over time
unchanged from 2005 to 2016, while hunger experiences among both boys and girls.
reduced among boys from 2005 to 2016.
Poor mental health
Physical activity and sedentary behaviour Loneliness decreased among both boys and girls from
The prevalence of inadequate physical activity did not 2005 to 2016, while there was no significant change for
change among boys but increased among girls over time, the remaining four poor mental health indications

Table 2 Sample characteristics of school adolescents: 2005, 2010 and 2016 surveys in UAE
Variable 2005 (N = 15,790) 2010 (N = 02,581) 2016 (N = 05,849) Total (N = 24,220)
N (%) N (%) N (%) N (%)
Gender
Male 7741 (50.0) 1079 (42.1) 2763 (49.7) 11,583 (47.8)
Female 7893 (50.0) 1483 (57.9) 3041 (50.3) 12,417 (52.2)
Missing 156 (0.9) 19 (0.8) 45 (0.7) 220 (0.8)
Age in years
11 or younger 404 (2.6) 9 (0.4) 41 (0.7) 454 (1.2)
12 2150 (13.1) 123 (4.3) 281 (4.7) 2554 (7.1)
13 3630 (22.3) 669 (23.1) 911 (13.9) 5210 (18.7)
14 3827 (23.6) 846 (31.8) 1126 (19.8) 5799 (24.0)
15 3212 (21.2) 664 (29.2) 1153 (19.8) 5029 (22.6)
16 years or older 2373 (17.2) 259 (11.2) 1314 (41.1) 4946 (26.4)
Missing 194 (1.1) 11 (0.4) 23 (0.4) 228 (0.6)
Grade
7 4215 (26.9) 945 (33.7) 244 (4.6) 5404 (18.7)
8 4064 (25.4) 939 (33.9) 1215 (16.8) 6219 (23.7)
9 3851 (24.2) 677 (32.4) 1156 (22.2) 5684 (25.4)
10 and other 3431 (23.5) 0 3118 (35.9) 6519 (32.2)
Missing 228 (1.4) 20 (0.7) 116 (1.9) 364 (1.5)
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 6 of 11

(worry-induced sleep disturbance, having no close over time except for a decrease in parental supervision
friends, suicide plan and suicidal ideation). among boys and girls (see Tables 3 and 4).

Protective factors
Among both girls and boys, peer support did not
change from 2005 to 2016, and truancy did not change Discussion
among boys but increased among girls over time. The study found across the 2005, 2010 and 2016 GSHS
Among the three parental support indicators (bonding, in UAE a significant reduction of being physically
connectedness and supervision), all remained unchanged attacked, inadequate fruit intake, inadequate vegetable

Table 3 Health risk indicators in 2005, 2010 and 2016 among male school adolescents, UAE
Variable 2005 2010 2016 Change over time compared to 2005
N (%) N (%) N (%) 2010 2016
Adjusteda OR (95% CI) Adjusteda OR (95% CI)
Body weight and dietary behaviour
Overweight or obesity 1510 (21.2) 421 (43.7) 1074 (42.1) 2.93 (2.45, 3.50)*** 2.82 (2.41, 3.32)***
Obesity 928 (13.2) 186 (19.8) 556 (21.3) 1.69 (1.37, 2.10)*** 1.77 (1.46, 2.14)***
Fruits < 2 day 5275 (68.7) 753 (70.6) 1695 (61.6) 1.07 (0.93, 1.23) 0.63 (0.53, 0.76)***
Vegetable < 3 day 6205 (81.0) 853 (79.9) 2159 (78.4) 0.92 (0.79, 1.07) 0.77 (0.66, 0.89)***
Went hungry (mostly/always) 815 (10.0) 59 (6.2) 241 (7.9) 0.60 (0.43, 0.85)** 0.70 (0.55, 0.90)**
Physical activity and sedentary behaviour
Inadequate physical activity 5768 (77.1) 797 (77.5) 2150 (79.7) 1.04 (0.85, 1.27) 1.10 (0.94, 1.29)
Leisure-time sedentary behaviour 2814 (38.0) 475 (45.0) 1322 (51.1) 1.27 (1.04, 1.55)* 1.53 (1.30, 1.80)***
Current tobacco use 1394 (13.2) 251 (19.8) 705 (21.3) 1.24 (0.98, 1.56) 1.10 (0.88, 1.36)
Injury and violence
Any serious injury (past year) 2243 (38.4) 481 (51.8) 1219 (51.0) 1.81 (1.57, 2.09)*** 1.72 (1.50, 1.97)***
Bullied (past month) 1714 (24.5) 260 (25.9) 810 (29.9) 1.14 (0.95, 1.36) 1.41 (1.20, 1.67)***
In physical fight (past year) 4329 (56.9) 646 (60.9) 1403 (50.8) 1.20 (1.01, 1.44)* 0.84 (0.71, 0.99)*
Physically attacked (past year) 3100 (40.8) 448 (42.0) 916 (32.8) 1.15 (0.97, 1.37) 0.79 (0.69, 0.91)**
Oral and hand hygiene
Brushing teeth (≤ once/day) 3665 (48.6) 498 (46.8) 1270 (46.1) 0.91 (0.73. 1.12) 0.83 (0.68, 1.02)
Wash hands before eating (not always) 2210 (29.6) 413 (38.7) 1081 (41.6) 1.53 (1.19, 1.97)*** 1.67 (1.34, 2.08)***
Wash hands after toilet/ latrine use (not always) 1271 (17.1) 203 (19.3) 554 (19.2) 1.24 (1.02, 1.51)* 1.13 (0.90, 1.43)
Wash hands with soap (not always) 2580 (34.9) 363 (34.0) 912 (33.1) 0.97 (0.82, 1.14) 0.92 (0.78, 1.10)
Poor mental health
Having no close friends 478 (6.6) 74 (7.2) 205 (7.0) 1.16 (0.86, 1.56) 1.14 (0.84, 1.55)
Loneliness (past year) 967 (13.1) 166 (15.9) 329 (11.6) 1.32 (1.03, 1.69)* 0.76 (0.64, 0.90)**
Worry-induced sleep disturbance (past year) 792 (10.6) 140 (13.0) 331 (11.9) 1.35 (1.05, 1.73)* 1.00 (0.85, 1.19)
Suicidal ideation (past year) 945 (13.4) 147 (14.7) 199 (12.5) 0.93 (0.70, 1.22) 0.95 (0.69, 1.30)
Suicide plan (past year) 692 (10.3) 145 (14.2) 154 (9.5) 1.29 (1.03, 1.57)* 0.93 (0.69, 1.22)
Protective factors
Truancy (past month) 2461 (34.0) 387 (38.3) 1108 (40.2) 1.19 (0.93, 1.53) 1.10 (0.87, 1.39)
Peer support (mostly/always) 4167 (55.6) 590 (56.7) 1521 (56.9) 1.00 (0.82, 1.23) 1.03 (0.86, 1.24)
Parents/guardians supervision (mostly/always) 4055 (54.8) 522 (52.3) 1248 (44.7) 0.90 (0.74, 1.10) 0.72 (0.60, 0.85)***
Parents/guardians connectedness (mostly/always) 3634 (50.1) 465 (45.0) 1162 (45.2) 0.79 (0.67, 0.94)** 0.88 (0.76, 1.02)
Parents or guardians bonding (mostly/always) 3935 (52.9) 478 (46.1) 1319 (49.9) 0.75 (0.62, 0.91)** 1.03 (0.87, 1.21)
OR Odds Ratio, CI Concidence Interval
a
Adjusted for age group, experiences of hunger (proxy measure for socioeconomic status) (except for hungry as outcome) and study year; ***P < 0.001;
**P < 0.01; *P < 0.05;
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 7 of 11

Table 4 Health risk indicators in 2005, 2010 and 2016 among female school adolescents, UAE
Variable 2005 2010 2016 Change over time compared to 2005
N (%) N (%) N (%) 2010 Adjusteda OR (95% CI) 2016 Adjusteda OR (95% CI)
Body weight and dietary behaviour
Overweight or obesity 1589 (21.7) 484 (36.0) 1013 (35.6) 2.05 (1.69, 2.48)*** 2.09 (1.77, 2.46)***
Obesity 782 (11.0) 177 (12.4) 383 (13.0) 1.20 (0.93, 1.56) 1.16 (0.98, 1.39)
Fruits <2 day 5798 (75.2) 1110 (76.2) 2138 (68.6) 1.05 (0.85, 1.29) 0.62 (0.49, 0.80)***
Vegetable <3 day 6602 (84.7) 1232 (84.8) 2459 (79.5) 0.96 (0.80, 1.17) 0.63 (0.52, 0.78)***
Went hungry (mostly/always) 672 (8.9) 72 (5.0) 332 (9.9) 0.56 (0.38, 0.85)** 1.00 (0.77, 1.30)
Physical activity and sedentary behaviour
Inadequate physical activity 6513 (83.8) 1250 (86.7) 2660 (88.6) 1.26 (0.99, 1.60) 1.37 (1.14, 1.66)***
Leisure-time sedentary behaviour 3019 (39.6) 790 (56.0) 1974 (66.7) 1.90 (1.53, 2.30)*** 2.63 (2.21, 3.12)***
Current tobacco use 453 (5.7) 121 (9.3) 293 (10.4) 1.81 (1.15, 2.84)* 1.43 (0.98, 2.10)
Injury and violence
Any serious injury (past year) 1243 (19.0) 464 (35.1) 940 (34.5) 2.48 (2.07, 2.97)*** 2.22 (1.84, 2.67)***
Bullied (past month) 1292 (17.2) 297 (20.7) 605 (20.5) 1.37 (1.11, 1.69)** 1.27 (1.05, 1.53)*
In physical fight (past year) 2329 (29.5) 539 (36.5) 806 (26.5) 1.48 (1.26, 1.74)*** 0.91 (0.73, 1.13)
Physically attacked (past year) 1838 (23.0) 411 (28.5) 555 (18.2) 1.53 (1.24, 1.88)** 0.79 (0.64, 0.97)*
Oral and hand hygiene
Brushing teeth (≤once/day) 2801 (37.9) 450 (31.4) 870 (28.3) 0.76 (0.63, 0.93)** 0.60 (0.48, 0.75)***
Wash hands before eating (not always) 2385 (31.9) 603 (40.5) 1431 (49.0) 1.44 (1.16, 1.78)*** 2.03 (1.67, 2.47)***
Wash hands after toilet/ latrine use (not always) 1149 (15.3) 236 (15.6) 549 (17.7) 1.10 (0.89, 1.36) 1.15 (0.98, 1.35)
Wash hands with soap (not always) 2175 (28.3) 496 (32.7) 912 (30.6) 1.27 (0.99, 1.62) 1.19 (0.97, 1.47)
Poor mental health
Having no close friends 489 (6.2) 76 (5.3) 204 (6.6) 0.89 (0.68, 1.17) 1.01 (0.81, 1.26)
Loneliness (past year) 1368 (17.7) 260 (17.9) 485 (16.0) 1.14 (0.93, 1.39) 0.72 (0.59, 0.88)**
Worry-induced sleep disturbance (past year) 1360 (18.1) 270 (19.4) 628 (20.5) 1.20 (0.97, 1.49) 0.95 (0.79, 1.14)
Suicidal ideation (past year) 982 (12.5) 240 (17.5) 289 (15.2) 1.13 (0.85, 1.51) 0.98 (0.76, 1.06)
Suicide plan (past year) 717 (9.2) 234 (16.9) 241 (12.4) 1.65 (1.32, 2.05)*** 1.25 (0.97, 1.64)
Protective factors
Truancy (past month) 2089 (28.3) 526 (37.2) 1335 (41.4) 1.63 (1.32, 2.01)*** 1.41 (1.03, 1.92)*
Peer support (mostly/always) 5488 (71.0) 1036 (72.0) 2104 (68.0) 1.00 (0.83, 1.21) 0.87 (0.70, 1.07)
Parents/guardians supervision (mostly/always) 3646 (47.9) 588 (41.6) 1221 (39.0) 0.75 (0.59, 0.95)* 0.78 (0.63, 0.98)*
Parents/guardians connectedness (mostly/always) 3960 (51.2) 691 (47.1) 1428 (47.7) 0.80 (0.67, 0.94)** 0.96 (0.82, 1.13)
Parents or guardians bonding (mostly/always) 4477 (58.3) 756 (51.6) 1676 (56.6) 0.72 (0.62, 0.84)*** 1.06 (0.87, 1.29)
OR Odds Ratio, CI Concidence Interval
a
Adjusted for age group, experiences of hunger (proxy measure for socioeconomic status) (except for hungry as outcome) and study year; ***P<0.001;
**P<0.01; *P<0.05;

consumption, and loneliness among both boys and girls, In 2004, the national health promoting school network
and among girls only poor oral hygiene (< 2 times tooth was implemented in UAE, including the promotion of
brushing/day) and among boys only, experiencing hun- healthy behaviour (diet, physical activity, safety, mental,
ger and in physical fight. Among both boys and girls sig- emotional and social health, comprehensive screening
nificant rises were identified in the prevalence of [21]. In a recent study among adolescents in Dubai,
bullying victimization, overweight or obesity, leisure- UAE, more than one in four had limited health literacy,
time sedentary behaviour, injury and not always washing calling for health literacy training among UAE adoles-
hands prior to eating, and among boys only obesity and cents [22]. A strengthening of the health promotion
among girls only inadequate physical activity, and school school activities is indicated in order to improve on
truancy. some of health indicators.
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 8 of 11

The study showed a stark increase of overweight and The proportion of inadequate tooth brushing (< twice/
obesity in this study from 2005 to 2010 and 2016, in both day) was high across the three UAE GSHS (> 46% in boys
boys and girls and even a greater increase among boys than and > 30% in girls), significantly higher than among ado-
girls did. Previous studies, (e.g. [10]) have reported high lescents in Southeast Asia (22.4%) [35]. In a survey among
rates of overweight and obesity among adolescents in UAE, private school adolescent students in Abu Dhabi, Dubai,
including a steady rise in obesity, especially in boys [23]. 63.6% had sub-optional oral hygiene practices [36], and in
These findings seems to be consistent with global increases a sample of adolescent school children in Sharjah, UAE,
in the prevalence of obesity among adolescents from 1975 19.8% of Emirati and 40.3% other Arabs engaged in inad-
to 2016 [24]. In the 2005 UAE GSHS insufficient fruit and equate tooth brushing (< 2 times/day) [37], indicating the
vegetable consumption was high and further increased to importance of improving oral health hygiene in UAE. Poor
2016. Similar increases in inadequate fruit and vegetable in- hand washing before eating increased in both sexes in this
take were also shown in a trend study in Oman [6] and study, which was similar in the Oman trend study [6],
other countries in the Arab region [25]. The prevalence of while poor hand hygiene decreased among adolescents in
experiencing hunger was low and significantly reduced the Philippines [5]. In a study among primary school stu-
among boys but not girls from 2005 to 2016. dents in Sharjah, UAE, 27% did not always wash hands be-
Violence-related events (in a physical fight and physical fore eating and 31% did not always wash hands after toilet
assault) reduced in the present study over time. Similar re- use [38], and in Al Anin, UAE, among 15 to 55 year-olds
sults were found in four other research studies [4, 26–28], from the community “30% did not always wash their
while in Oman [6], the Philippines [5] and Venezuela [29] hands before and after eating and 20% did not always
one or more types of interpersonal violence increased. wash their hands after using toilets.” [39]. All the more, an
Several local studies among adolescents in UAE have improvement of hand hygiene behaviour among adoles-
stressed the importance of interpersonal violence [8, 9] cents in UAE is indicated.
and this study found an increase in bullying victimization The prevalence of current tobacco use increased
among boys and girls over time. This result may call for among both boys and girls over time but this was not
anti-bullying programmes among school adolescents in statistically significant, and concur with previous investi-
UAE. However, among both boys and girls the prevalence gations in the UAE [13]. On the other hand the preva-
of annual injury significantly increased, which is consistent lence of current tobacco use from the UAE Global
with the trend study in the Philippines [5]. On the other Youth Tobacco Survey (GYTS) in 2005 (19.5%) de-
hand, the injury prevalence among adolescents in creased to 12.2% in 2013 [40, 41]. In terms of four indi-
Morocco declined [30], and no significant trend differ- cators of mental health (suicide plan, suicidal ideation,
ences were identified in Oman [6]. The large increase in worry-induced sleep disturbance, and having no close
the occurrence of injuries calls for school safety promo- friends), the study did not find significant changes over
tion and injury prevention among adolescents in UAE. time, except for a decrease in loneliness in both sexes.
Physical inactivity increased among female students in While the prevalence of loneliness increased among both
this study. Henry et al. [31] concluded from a study boys and girls over time in the Philippines trend study
among female adolescents in the UAE that the physical [5]. As shown in some previous studies among adoles-
activity was very low, attributing this to weather and cul- cents in UAE [14, 15], mental morbidity in the form of
tural restrictions as well as unconducive community atti- depressive and anxiety-related symptoms has been
tudes [31]. Leisure- time sedentary behaviour increased shown as to be a significant burden.
significantly in this study to 51.1% in boys and 66.7% in Consistent with previous studies [4–6], this survey
girls, which is much higher than the global average in found mixed results on protective factors, parental sup-
school-going adolescents (26.4%) [32] and the highest port indicators did not change except for a decrease of
among 10 Eastern Mediterranean countries [33]. Since in one parental indicator (parental supervision) among
this study, leisure-time sedentary behaviour was assessed both girls and boys, peer support did not change, and
with a composite measure ”sitting and watching television, school truancy increased among girls. For example, in
playing computer games, talking with friends, or doing the New Zealand trend study positive school and family
other sitting activities, such as studying or using any elec- connections became better over time [4], in the Oman
tronic devices like IPads” [3], we are not able to identify if trend study peer support increased over time [5], and in
a particular type of sedentary behaviour increased more the Philippines trend study protective factors remained
than another type. Some studies, e.g., in the US, showed unchanged over time [6].
an increase of the use of recreational screen-based devices, The present research findings may contribute to better
such as electronic entertainment and computer use, targeting of specific health indicators among adolescents
among adolescents during the first decade of the 21st cen- in health promotion activities in UAE. For example,
tury [34], which may be applicable to the UAE too. school-based interventions can be effective in reducing
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 9 of 11

excessive weight gain and in promotion of physical activ- Abbreviations

ity and fitness [42, 43]. After-school programmes can GSHS: Global School-Based Student Health Survey; STATA: Statistics and data;
UAE: United Arab Emirates
improve physical activity levels [44]. Dietary behaviours
may be improved by implementing specific school food Acknowledgements
environment policies, such as the direct provision of The data source, the World Health Organization NCD Microdata Repository
(URL: https://extranet.who.int/ncdsmicrodata/index.php/catalog), is hereby
healthy beverages and foods [45]. In the prevention of acknowledged.
bullying and smoking different types of whole-school
health interventions have shown to be effective. [46] Authors’ contributions
Poor mental health (anxiety and depressive symptoms) All authors fulfil the criteria for authorship. SP and KP conceived and
designed the research, performed statistical analysis, drafted the manuscript
among adolescents may be decreased by universal and made critical revision of the manuscript for key intellectual content. All
resilience-focused interventions (especially cognitive- authors read and approved the final version of the manuscript and have
behavioural therapy) [47]. Increased implementation of agreed to authorship and order of authorship for this manuscript.
multi-level (training, funding and policy) interventions
Funding
have shown to reduce absenteeism from school, respira- Not applicable.
tory infections and diarrhoea [48].
Ethics approval and consent to participate
Ethics approval was obtained from the UAE Ministry of Health and written
Limitations of the study informed consent was obtained from the participating schools, parents and
students [18].
Secondary education enrolment ratio was 95.3% in UAE
in 2016 [49], meaning that out-off school adolescents Consent for publication
were excluded in this UAE GSHS. A few study variables Not applicable.
(such as alcohol use, drug use and sexual behaviour)
were excluded in the present analysis, since they had not Availability of data and materials
The data for the current study are publicly available at the World Health
been measured in all three of the UAE GSHS. Further Organization NCD Microdata Repository (URL: https://extranet.who.int/
study limitations include the cross-sectional study design ncdsmicrodata/index.php/catalog).
and the self-report of the data, in particular height and
Competing interests
body weight. Several studies [50, 51] comparing self- The authors declare that they have no competing interests.
report and measured height and weight among adoles-
cents, conclude that self-reported BMI may be used as a Author details
1
ASEAN Institute for Health Development, Mahidol University, Salaya,
valid tool to estimate BMI overweight/obesity in epi- Phutthamonthon, Nakhon Pathom, Thailand. 2Department of Research
demiological studies and that self-reported BMI may be Administration and Development, University of Limpopo, Polokwane, South
an underestimate. Further, it has been shown in previous Africa. 3Department of Psychology, University of the Free State,
Bloemfontein, South Africa.
research that anonymous self-report questionnaires may
generate more accurate data on sensitive variables com- Received: 4 May 2020 Accepted: 21 July 2020
pared to other methods among adolescents [52, 53].
References
Conclusions 1. World Health Organization - Noncommunicable Diseases (NCD) Country
Profiles, 2018, United Arab Emirates. URL: https://www.who.int/nmh/
In three nationally representative surveys of in-school ado- countries/2018/are_en.pdf?ua=1.Accessed 2 Mar 2020.
lescents over a period of 11 years in the UAE, a significant 2. Rahim HF, Sibai A, Khader Y, Hwalla N, Fadhil I, Alsiyabi H, Mataria A, Mendis
reduction of being physically attacked, inadequate fruit in- S, Mokdad AH, Husseini A. Non-communicable diseases in the Arab world.
Lancet. 2014;383(9914):356–67. doi:https://doi.org/10.1016/S0140-
take, inadequate vegetable consumption, and loneliness 6736(13)62383-1.
were found among both boys and girls, while among girls 3. World Health Organization (WHO). Global school-based student health
only poor oral hygiene (< 2 times tooth brushing/day) and survey (GSHS). 2020. URL: https://www.who.int/ncds/surveillance/gshs/en/.
Accessed 10 Apr 2020.
among boys only, experiencing hunger and in physical 4. Clark T, Fleming T, Bullen P, Crengle S, Denny S, Dyson B, Peiris-John R,
fight declined. Significant rises were identified among both Robinson E, Rossen F, Sheridan J, Teevale T, Utter J, Lewycka S. Health and
sexes in the prevalence of bullying victimization, over- well-being of secondary school students in New Zealand: trends between
2001, 2007 and 2012. J Paediatr Child Health. 2013;49(11):925–34. doi:
weight or obesity, leisure-time sedentary behaviour, injury https://doi.org/10.1111/jpc.12427.
and not always washing hands prior to eating, and among 5. Peltzer K, Pengpid S. Health Risk Behaviour among In-School Adolescents in
boys only obesity and among girls only inadequate phys- the Philippines: Trends between 2003, 2007 and 2011, A Cross-Sectional
Study. Int J Environ Res Public Health. 2015;13(1):73. doi:https://doi.org/10.
ical activity, and school truancy. Several poor health indi- 3390/ijerph13010073.
cators declined but even more increased over three cross- 6. Pengpid S, Peltzer K. Trends of dietary behaviour, physical activity,
sectional surveys from 2005 to 2016 emphasizing the need interpersonal violence and hand hygiene behaviour among school-going
adolescents in Oman: cross-sectional national surveys from 2005, 2010 and
for enhanced health promotion activities in this adolescent 2015. Vulnerable Child Youth Stud. 2019. DOI:https://doi.org/10.1080/
school population. 17450128.2019.1710632.
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 10 of 11

7. Barakat-Haddad C, Siddiqua A. Injuries among adolescents in the United 26. Finkelhor D, Turner HA, Shattuck A, Hamby SL. Prevalence of Childhood
Arab Emirates. Inj Prev. 2014;20(2):121–7. https://doi.org/10.1136/injuryprev- Exposure to Violence, Crime, and Abuse: Results From the National Survey
2012-040625. of Children’s Exposure to Violence. JAMA Pediatr. 2015;169(8):746–54. doi:
8. Rigby K, Haroun D, Ali E. Bullying in schools in the United Arab Emirates https://doi.org/10.1001/jamapediatrics.2015.0676.
and the personal safety of students. Child Indic Res 2018;12(1):DOI:https:// 27. Chester KL, Callaghan M, Cosma A, Donnelly P, Craig W, Walsh S, Molcho M.
doi.org/10.1007/s12187-018-9603-y. Cross-national time trends in bullying victimization in 33 countries among
9. Alshareef N, Hussein H, Al Faisal W, El Sawaf E, Wasfy A, AlBehandy N, et al. children aged 11, 13 and 15 from 2002 to 2010. Eur J Public Health. 2015;
Person, place and time characteristics of physical violence among adolescents 25(Suppl 2):61–4. doi:https://doi.org/10.1093/eurpub/ckv029.
in Dubai / UAE. Int J Prev Med Res. 2015;1(4):173–8. http://www.aiscience.org/ 28. Vieno A, Lenzi M, Gini G, Pozzoli T, Cavallo F, Santinello M. Time trends in
journal/ijpmr. bullying behavior in Italy. J Sch Health. 2015;85(7):441–5. doi:https://doi.org/
10. Al Junaibi A, Abdulle A, Sabri S, Hag-Ali M, Nagelkerke N. The prevalence 10.1111/josh.12269.
and potential determinants of obesity among school children and 29. Granero R, Poni ES, Escobar-Poni BC, Escobar J. Trends of violence among
adolescents in Abu Dhabi, United Arab Emirates. Int J Obes. 2013;37(1):68– 7th, 8th and 9th grade students in the state of Lara, Venezuela: The Global
74. https://doi.org/10.1038/ijo.2012.131. School Health Survey 2004 and 2008. Arch Public Health. 2011;69(1):7. doi:
11. Makansi N, Allison P, Awad M, Bedos C. Fruit and vegetable intake among https://doi.org/10.1186/0778-7367-69-7.
Emirati adolescents: a mixed methods study. East Mediterr Health J. 2018; 30. Shaikh MA. Prevalence, correlates, and changes in injury epidemiology
24(7):653–63. doi:https://doi.org/10.26719/2018.24.7.653. between 2006 and 2010 among 13–15 year Moroccan school attending
12. Yammine K. The prevalence of physical activity among the young adolescents. J Pak Med Assoc. 2015;65(5):552–4.
population of UAE: a meta-analysis. Perspect Public Health. 2017;137(5):275– 31. Henry CJ, Lightowler HJ, Al-Hourani HM. Physical activity and levels of inactivity
80. https://doi.org/10.1177/1757913916675388. in adolescent females ages 11–16 years in the United Arab Emirates. Am J
13. Siddiqua A, Dghaim R, Barakat-Haddad C. Sociodemographic predictors of Hum Biol. 2004;16(3):346–53. doi:https://doi.org/10.1002/ajhb.20022.
tobacco smoking among expatriate and national adolescents in the United 32. Vancampfort D. Van Damme T, Firth J, Hallgren M, Smith L, Stubbs B,
Arab Emirates. East Mediterr Health J. 2018;24(3):283–94. https://doi.org/10. Rosenbaum S, Koyanagi A. Correlates of leisure-time sedentary behavior
26719/2018.24.3.283. Published 2018 Jun 10. among 181,793 adolescents aged 12–15 years from 66 low- and middle-
14. Shah SM, Al Dhaheri F, Albanna A, Al Jaberi N, Al Eissaee S, Alshehhi NA, Al income countries. PLoS One. 2019;14(11):e0224339. doi: https://doi.org/10.
Shamisi SA, Al Hamez MM, Abdelrazeq SY, Grivna M, Betancourt TS. Self- 1371/journal.pone.0224339.
esteem and other risk factors for depressive symptoms among adolescents 33. Al Subhi LK, Bose S, Al Ani MF. Prevalence of physically active and sedentary
in United Arab Emirates. PLoS One. 2020;15(1):e0227483. doi:https://doi.org/ adolescents in 10 Eastern Mediterranean countries and its relation with age,
10.1371/journal.pone.0227483. sex, and body mass index. J Phys Act Health. 2015;12(2):257–65. doi:https://
15. Al-Yateem N, Bani Issa W, Rossiter RC, Al-Shujairi A, Radwan H, Awad M, doi.org/10.1123/jpah.2013-0134.
Fakhry R, Mahmoud I. Anxiety related disorders in adolescents in the United 34. Bassett DR, John D, Conger SA, Fitzhugh EC, Coe DP. Trends in Physical
Arab Emirates: a population based cross-sectional study. BMC Pediatr. 2020; Activity and Sedentary Behaviors of United States Youth. J Phys Act Health.
20(1):245. doi:https://doi.org/10.1186/s12887-020-02155-0. 2015;12(8):1102–11. doi:https://doi.org/10.1123/jpah.2014-0050.
16. World Health Organization. Regional Office for the Eastern Mediterranean. 35. Peltzer K, Pengpid S. Oral and hand hygiene behaviour and risk factors
Health-promoting schools initiative in Oman: a WHO case study in among in-school adolescents in four Southeast Asian countries. Int J
intersectoral action / World Health Organization. Regional Office for the Environ Res Public Health. 2014;11(3):2780–92. doi:https://doi.org/10.3390/
Eastern Mediterranean. 2013. URL: http://applications.emro.who.int/dsaf/ ijerph110302780.
EMROPUB_2013_EN_1587.pdf. Accessed 2 May 2019. 36. ur Rehman MM, Mahmood N, ur Rehman B. The relationship of caries with
17. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition oral hygiene status and extra-oral risk factors. J Ayub Med Coll Abbottabad.
for child overweight and obesity worldwide: international survey. BMJ. 2000; 2008;20(1):103–8.
320:1240–3. 37. Khadri FA, Gopinath VK, Hector MP, Davenport ES. Evaluating the risk factors
18. Centers for Disease Control (CDC). State indicator report on fruits and that link obesity and dental caries in 11-17-year-old school going children
vegetables. 2013. Available online: http://www.cdc.gov/nutrition/downloads/ in the United Arab Emirates. Eur J Dent. 2018;12(2):217–24. https://doi.org/
state-indicator-reportfruits-vegetables-2013.pdf (Accessed 10 Oct 2019). 10.4103/ejd.ejd_29_18.
19. World Health Organization. Physical activity fact sheet. 2017. URL: http:// 38. Ghanim M, Dash N, Abdullah B, Issa H, Albarazi R, Saheli ZA. Knowledge and
www.who.int/mediacentre/factsheets/fs385/en/ . Accessed 10 Oct 2019. Practice of Personal Hygiene among Primary School Students in Sharjah-
20. Guthold R, Cowan MJ, Autenrieth CS, Kann L, Riley LM. Physical activity and UAE. J Health Sci. 2016;6(5):67–73. DOI:https://doi.org/10.5923/j.health.
sedentary behavior among schoolchildren: a 34-country comparison. J 20160605.01.
Pediatr. 2010;157:43–9. doi:https://doi.org/10.1016/j.jpeds.2010.01.019. e1. 39. Afifi HS, Abushelaibi AA. Assessment of personal hygiene knowledge, and
21. Al Matroushi M. Chapter 20 United Arab Emirates: Health-Promoting practices in Al Ain, United Arab Emirates. Food Control. 2012;25(1):249–53.
Schools: Strategies for Policy Change. C. Vince Whitman and C.E. Aldinger, DOI:https://doi.org/10.1016/j.foodcont.2011.10.040.
editors Studies in Global School Health Promotion: From Research to 40. Global Youth Tobacco Survey. United. Arab Emirates F. 2005: URL: http://
Practice (pp. 265–282). New: Springer. DOI: https://doi.org/10.1007/978-0- www.emro.who.int/images/stories/tfi/documents/gyts_fs_uae_r2.pdf?ua=1
387-92269-0_20. Accessed 2 May 2020.
22. Awofeso N, Zarooni A, Rabih Z, Bamidele M. Health Literacy Measurements 41. Global Youth Tobacco Survey. United. Arab Emirates F. 2013: URL: http://
with The Newest Vital Sign Instrument Among Adolescents from Dubai, www.emro.who.int/images/stories/tfi/documents/gyts_fs_uae_2013.pdf?ua=
United Arab Emirates. TJFMPC. 2017;11(3):164–70. 1 . Accessed 2 May 2020.
23. AlBlooshi A, Shaban S, AlTunaiji M, Fares N, AlShehhi L, AlShehhi H, 42. Yuksel HS, Şahin FN, Maksimovic N, Drid P, Bianco A. School-Based
AlMazrouei A, Souid AK. Increasing obesity rates in school children in Intervention Programs for Preventing Obesity and Promoting Physical
United Arab Emirates. Version 2. Obes Sci Pract. 2016;2(2):196–202. https:// Activity and Fitness: A Systematic Review. Int J Environ Res Public Health.
doi.org/10.1002/osp4.37. 2020;17(1):347. doi:https://doi.org/10.3390/ijerph17010347.
24. NCD Risk Factor Collaboration (NCD-RisC). Collaborators. (1040) 43. Liu Z, Xu HM, Wen LM, Peng YZ, Lin LZ, Zhou S, Li WH, Wang HJ. A
Worldwide trends in body-mass index, underweight, overweight, and systematic review and meta-analysis of the overall effects of school-based
obesity from 1975 to 2016: a pooled analysis of 2416 population-based obesity prevention interventions and effect differences by intervention
measurement studies in 128.9 million children, adolescents, and adults. components. Int J Behav Nutr Phys Act. 2019;16(1):95. doi:https://doi.org/10.
Lancet 2017;390(10113): 2627e42. doi: https://doi.org/10.1016/S0140- 1186/s12966-019-0848-8.
6736(17)32129-3. 44. Beets MW, Beighle A, Erwin HE, Huberty JL. After-school program impact on
25. Al Ani MF, Al Subhi LK, Bose S. Consumption of fruits and vegetables physical activity and fitness: a meta-analysis. Am J Prev Med. 2009;36(6):527–
among adolescents: a multi-national comparison of eleven countries in the 37. doi:https://doi.org/10.1016/j.amepre.2009.01.033.
Eastern Mediterranean Region. Br J Nutr. 2016;115(6):1092–9. doi:https://doi. 45. Micha R, Karageorgou D, Bakogianni I, Trichia E, Whitsel LP, Story M, Peñalvo
org/10.1017/S0007114515005371. JL, Mozaffarian D. Effectiveness of school food environment policies on
Pengpid and Peltzer BMC Pediatrics (2020) 20:357 Page 11 of 11

children’s dietary behaviors: A systematic review and meta-analysis. PLoS

One. 2018;13(3):e0194555. doi:https://doi.org/10.1371/journal.pone.0194555.
46. Shackleton N, Jamal F, Viner RM, Dickson K, Patton G, Bonell C. School-
Based Interventions Going Beyond Health Education to Promote Adolescent
Health: Systematic Review of Reviews. J Adolesc Health. 2016;58(4):382–96.
doi:https://doi.org/10.1016/j.jadohealth.2015.12.017.
47. Dray J, Bowman J, Campbell E, Freund M, Wolfenden L, Hodder RK,
McElwaine K, Tremain D, Bartlem K, Bailey J, Small T, Palazzi K, Oldmeadow
C, Wiggers J. Systematic Review of Universal Resilience-Focused
Interventions Targeting Child and Adolescent Mental Health in the School
Setting. J Am Acad Child Adolesc Psychiatry. 2017;56(10):813–24. doi:https://
doi.org/10.1016/j.jaac.2017.07.780.
48. Mbakaya BC, Lee PH, Lee RL. Hand Hygiene Intervention Strategies to
Reduce Diarrhoea and Respiratory Infections among Schoolchildren in
Developing Countries: A Systematic Review. Int J Environ Res Public Health.
2017;14(4):371. Published 2017 Apr 1. doi:https://doi.org/10.3390/
ijerph14040371.
49. Fonseca H, Silva AM, Matos MG, Esteves I, Costa P, Guerra A, Gomes-Pedro J.
Validity of BMI based on self-reported weight and height in adolescents.
Acta Paediatr. 2010;99(1):83–8. doi:https://doi.org/10.1111/j.1651-2227.2009.
01518.x.
50. Brener ND, Mcmanus T, Galuska DA, Lowry R, Wechsler H. Reliability and
validity of self-reported height and weight among high school students. J
Adolesc Health. 2003;32(4):281–7. doi:https://doi.org/10.1016/s1054-
139x(02)00708-5.
51. UNESCO. United Arab Emirates, Participation in Education. 2019. URL: http://
uis.unesco.org/en/country/ae.Accessed 2 Apr 2020.
52. Carvalho AF, Stubbs B, Vancampfort D, Kloiber S, Maes M, Firth J, Kurdyak
PA, Stein DJ, Rehm J, Koyanagi A. Cannabis use and suicide attempts
among 86,254 adolescents aged 12–15 years from 21 low- and middle-
income countries. Eur Psychiatry. 2019;56:8–13. doi:https://doi.org/10.1016/j.
eurpsy.2018.10.006.
53. Pigeon WR, Pinquart M, Conner K. Meta-analysis of sleep disturbance and
suicidal thoughts and behaviors. J Clin Psychiatry. 2012;73(9):e1160–7. doi:
https://doi.org/10.4088/JCP.11r07586.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.