KNOWLEDGE ON NON COMMUNICABLE DISEASES AMONG ADVANCED LEVEL SCHOOL CHILDREN IN THE ANURADHAPURA MUNICIPAL COUNCIL AREA IN SRI LANKA

Background: The lifestyles of residents of Anuradhapura, a rural area in Sri Lanka, has changed from active farming based ones to more sedentary ones. Although data is available on non communicable diseases (NCDs) in urban areas of Sri Lanka, data from rural areas are lacking. Objectives: The objective of this study was to evaluate the knowledge on NCDs among advanced level children schooling in the Anuradhapura Municipal Council area. Methods: This was a cross sectional study conducted among school children (n=106; age16±1years) in Anuradhapura, using a self administered questionnaire. Results: Among the participants, 11% was not aware that NCD cannot spread between people. Almost 90% knew that a sedentary life style is a risk factor for NCDs. A significant percentage (35%) either did not know or had given the incorrect answer regarding the time duration that a person should spend on exercises per day. Nearly one fifth were unaware about the body mass index (BMI), 33% did not know how to measure BMI and 28% either did not know or had given the incorrect answer regarding the normal range of BMI for Sri Lankans. Of the participants, 38.6% did not know that childhood obesity or malnutrition are risk factors for NCDs and 57% did not know that maternal malnutrition could give rise to NCDs in children. Twenty eight percent were unaware that mental stress is a risk factor for NCDs. More than 30% did not know that early detection of breast and cervical cancers would lead to a better outcome. Conclusions: The present study population had an average knowledge regarding NCDs. However, knowledge on dietary habits, physical activities and alcohol and tobacco use is yet to be improved.


Introduction
According to reports by the World Health Organization (WHO), more than 75% of deaths in Sri Lanka are due to non communicable diseases (NCDs).Nearly 1 in 5 people die prematurely due to a NCD.In Sri Lanka, the death rate due to cardio vascular diseases, cancers, diabetes, chronic respiratory diseases and other NCDs are 40%, 10%, 7%, 8%, 10% respectively 1 .This rising burden of NCD significantly affects the socio-economical development of the country.Tobacco use, unhealthy dietary practices, sedentary life styles and harmful use of alcohol are the main predisposing factors for NCDs in middle and low income countries 1 .Based on the data of the Population Reference Bureau 2016, among other risk factors for NCDs, low physical activity will become the most decisive risk factor for future NCDs in Sri Lanka, as 83% of males and 89% females between the ages of 13 to 15 years have low physical activity 2 .
According to data from 2011, the prevalence of diabetes in the North Central province of Sri Lanka was 9.6%.In comparison to the Uva Province, another rural area which had a comparable mean energy consumption of the population, the prevelance of diabetes was higher in the North Central Province (6.8% vs 9.6% respectively) 3 .Anuradhapura is the capital of the North Central Province and in recent years there has been significant change of lifestyles in this area, from an agricultural environment towards a more nonagricultural sedentary framework 4,5 .Since changes in lifestyle, dietary patterns and physical activity could worsen the burden of NCDs even in rural areas in Sri Lanka, people should be educated regarding the prevention of NCDs.
The World Health Organization (WHO) reports that behavior begun at the adolescent age is responsible for 70% of premature deaths in adults in the world 2 .
Previous researchers have emphasized "adolescence" as the phase where healthy positive behaviors should be implemented and supported, as behaviors developed during this phase of life are often carried up to the adulthood 2 .Furthermore, unhealthy dietary habits, alcohol and tobacco use and substance abuse developed during this phase of life are likely to persist throughout life and are difficult to change 2 .Therefore, improvements in the knowledge on NCDs and practices among adolescents are crucial measures to prevent NCDs and to reduce the burden of these diseases.
Although there is published data on the awareness on NCDs among school children in other countries, data is lacking in the Sri Lankan context.In Sri Lanka, nearly 79% of students continue their studies in Advanced level after ordinary level examination 6 .Therefore, we recruited adolescents from advanced level classes from government schools in the Anuradhapura Municipal Council area for the present study, to explore their level of knowledge and attitudes towards NCDs.

Methodology
This was a self-administered questionnaire based cross sectional study.
The sample size was calculated to be 66.The questionnaire was developed according to WHO STEP wise approach to chronic disease risk factor surveillance 1 .It was pretested and developed in the participants' native mother tongue (Sinhala/ Tamil/ English).The questionnaire contained 4 sections, namely, sections on 1) demographic data, 2) general knowledge on NCDs, 3) knowledge on risk factors for NCDs (including knowledge on dietary habits) and 4) knowledge on hypertension, cardio vascular diseases, diabetes and cervical cancers.Answers included some questions requiring "Yes", "No" and "Don't know" responses, as well questions that required value ranges (i.e., for questions on BMI, time spent on physical activities etc.).
Advanced level students (grade 12) were selected by simple random sampling method from each stream from five government schools; and the schools too were selected using simple random sampling from among all schools in the Anuradhapura Municipal Council area.Questionnaires were distributed to the participants, to be filled within 30 minutes, without using any referencing or data mining.
Data were presented as percentages.
Ethical approval for the study was obtained from the Ethics Review Committee of the Faculty of Medicine and Allied Sciences, Rajarata University of Sri Lanka (ERC/2016/71).

Results
A hundred and six participants with a mean age of 16 years (SD1) were recruited.Fifty four (50.9%) were males (Table 1).The percentage of students who had given correct answers for the questions on general knowledge on NCDs is shown in table 2. From among the participants, 11% was not aware (either said "do not know" or given the wrong answer) that NCDs cannot spread between people and 18% was not aware of the significant public health problem being caused by NCDs in Sri Lanka.
The percentage of students who have given correct answers for the questions on risk factors for NCDs is shown in Table 3. Almost 60% knew plant oils are healthier than animal oils.A majority did not know that skimmed milk is the healthier type of milk, which contains more nutrients per volume.However, a majority (93.4%) were aware that certain oils are not suitable for reuse and about the importance of fruits in the diet (98%).More than 10% were not aware that smoking, alcohol and unhealthy dietary habits are risk factors for NCDs.
Almost 90% knew that sedentary life style is a risk factor for NCDs.A significant percentage of students (35%) either did not know or had given the incorrect answer for the time duration that a person should spend for exercises per day.One fifth of students considered certain activities such as cooking and washing clothes, which are not considered exercises, as exercises.
Nearly one fifth [19% (18/106)] of students were unaware about body mass index (BMI), 33% (35/106) did not know how to measure BMI and 28% (30/106) either did not know or had given the incorrect answer for the normal range of BMI for Sri Lankans.
Childhood obesity or malnutrition were not recognized as risk factors for NCDs by 38.6%, and 57% did not know that maternal malnutrition could give rise to NCDs in children.Twenty eight percent was unaware (either said "do not know" or had given the wrong answer) that mental stress is a risk factor for NCDs.However, compared to students in the other three streams, students in the bio science stream possessed better knowledge on tobacco and alcohol use and had correctly answered certain questions related to diet.The percentage of students who have given correct answers for the questions related to knowledge on NCDs is shown in Table 4.

Characteristic
From the participants, 36% was unaware that high salt consumption has a relationship with hypertension.Smoking and stress were identified as risk factors for cardio vascular diseases (CVD) by only 60% and 55% respectively.The fact that a positive family history increases the risk of CVD and diabetes was known by 22% and 46% respectively.More than 40% were not aware that diabetes can adversely affect the eyes and kidneys.Half of the population (52%) did not know (24%) or did not believe (27%) that there are home remedies and herbs which can reduce blood glucose; of the students who did not believe the effects of home remedies, 93% were students doing science subjects.Sixteen percent (17/106) of students were not aware that diabetes is related to elevated blood glucose levels.
More than 30% did not know that early detection of breast and cervical cancers improves prognosis.However, compared to students in the other three streams, students in the bio science stream had a better knowledge regarding hypertension and diabetes.

Discussion
In the present study, although 11% was not aware that NCD cannot spread between people and 18% was not aware of the burden caused by NCDs among Sri Lankans, a known family history of NCD was present in 38.7% (41/106) of students.
According to the WHO, 3.3 million deaths in the world in 2012 were due to alcohol consumption and more than half of these deaths were related to NCDs 2 .In 2011, the percentage of 13-15 year old school children in Sri Lanka who used at least one product of tobacco was 16% in males and 5% in females 2 .Although alcohol and tobacco consumption is rising among adolescents in Sri Lanka 2 , 8   Most educational training programs for adolescents on NCD prevention have elicited significant positive outcomes 19,20,15 .A report of the Population Reference Bureau in 2016 recommended that schoolbased nutrition, exercise, harmful substance education and intervention programs and media-based education and messaging via television, movies, and radio, as well as social media platforms, such as Facebook, Twitter, and YouTube as NCD preventive measures should be implemented to reduce the risk factors for NCDs 2 .

Table 4 : Percentage of students who have given correct answers for the questions on NCDs
Alcohol misuse and a sedentary life style as risk factors were identified by only one tenth of the population in the study carried out in India, in contrast to the 86% and more than 90% who identified these risk factors respectively, in the present study.Another study conducted in India among adolescent school children in a rural area revealed that only 0.3% had a good level of knowledge regarding lifestyle risk factors, nearly 63% had no idea about the prevention of NCDs, and almost one third had a perception that non-communicable diseases were communicable in nature 17 while only 10% of the present study had this misperception.The knowledge on NCDs among adolescents in the Anuradhapura area in Sri Lanka was satisfactory, not only compared to other studies carried out in Asian countries, but even when compared to countries in other areas of the world 18 .