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Mental Health Status of Adolescents in South-East Asia: Evidence for Action

April 2017

Publisher: WHO-SERO
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ISBN: 9789290225737

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World Health Organization WHO

Mental health conditions such as depression, anxiety or other conditions may lead to behavioural problems such as tobacco, alcohol and drug use. The multi-directional linkages between mental health conditions and other health, educational, social and development problems call for evidence for action in this area. This publication, is a step towards building an evidence base to facilitate informed policy and programmatic actions by the WHO Regional Office for South-East Asia.

Percentage of students (13-17 year olds) reporting low level of parental engagement in the South-East Asia Region countries.

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: Selected suicidal behaviour indicators among 13-17-year-old students in the WHO South-East Asia Region

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: Selected warning symptoms of mental health problems among 13-17-year-old students in the WHO South-East Asia Region

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: Selected indicators of tobacco use among 13-17-year-old students in the WHO South-East Asia Region

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: Selected indicators of alcohol use among 13-17-year-old students in the WHO South-East Asia Region

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Let’s talk

Mental Health Status

of Adolescents in

South-East Asia:

Evidence for Action

April, 2017

World Health House

Indraprastha Estate

Mahatma Gandhi Marg

New Delhi-110002, India

ISBN 978 92 9022 573 7

Suggested citation. Mental health status of adolescents in South-East Asia:

Evidence for action. New Delhi: World Health Organization, Regional Office

for South-East Asia; 2017. Licence: CC BY-NC-SA 3.0 IGO.

Adolescents constitute an important social and

demographic group in the WHO South-East Asia

Region, accounting for almost one fifth of the total

population of the Region. The failure to recognize

and address mental health problems in children

and adolescents is a serious public health problem

in the context of Sustainable Development Goals

(SDG 3.4 and 3.5). Mental health conditions such

as depression, anxiety or other conditions may

lead to behavioural problems such as tobacco,

alcohol and drug use. The multi-directional

linkages between mental health conditions and

other health, educational, social and development

problems call for evidence for action in this area.

This publication, is a step towards building an

evidence base to facilitate informed policy and

programmatic actions by the WHO Regional Office

for South-East Asia.

Cover credit: Musanna Nabi Chowdhury, 21, Bangladesh

Best concept design, Category B (age 18-25 years), WHO South-East Asia Regional

MindART Competition on the World Health Day 2017 theme on depression

Explanation of the artwork by the young artist:

“It is difficult to help those who don’t admit they are hurting. Losing self-esteem every

day, they fail to make space for themselves in this colourful world. They need to open-up

to someone, talk their way out of the dark world. A little bit of nurturing and a whole lot

of love and attention can do wonders for them!”

Mental health status of adolescents in South-East Asia: Evidence for action i

Mental Health Status of

Adolescents in South-East Asia:

Evidence for Action

April, 2017

Mental health status of adolescents in South-East Asia: Evidence for action

ISBN: 978-92-9022-573-7

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World Health Organization, Regional Office for South-East Asia; 2017. Licence: CC BY-NC-SA 3.0 IGO.

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Mental health status of adolescents in South-East Asia: Evidence for action iii

Contents

Acronyms v

Foreword vii

List of contributors viii

Part I

1 Introduction 1

2 Data and methods 2

3 Results 4

3.1 Burden of mental health problems 4

3.1.1 Suicidal ideation, plans and attempts 4

3.1.2 Loneliness and feeling anxious 4

3.1.3 Substance use 5

3.2 Protective factors for mental health: Parental engagement 5

3.2.1 Association between parental engagement and mental

health problems and substance use 6

3.3 Risk factors for mental health: Experience of being bullied 7

3.3.1 Association between being bullied and mental health

problems and substance use 8

3.4 Co-existence of mental health problems and substance use 8

4 Conclusions and way forward 9

References 11

Part II

Country Profiles 12

Bangladesh 13

Bhutan 17

India 21

Indonesia 25

Maldives 29

Myanmar 33

Nepal 37

Sri Lanka 41

Thailand 45

Timor-Leste 49

Mental health status of adolescents in South-East Asia: Evidence for action

Part III

Regional Indicator Data Tables 54

Table 1: Estimated suicide rates per 100 000 population aged 15–29 years 55

Table 2: Selected suicidal behaviour indicators 56

Table 3: Selected warning symptoms of mental health problems 57

Table 4: Selected indicators of tobacco use 58

Table 5: Selected indicators of alcohol use 59

Table 6: Selected indicators of drug use 60

Table 7: Selected indicators of school experiences 61

Table 8: Selected indicators of perceived parental engagement 62

Table 9: Level of perceived parental engagement index 63

Table 10: Parental engagement as a predictor of mental health problems 64

Table 11: Parental engagement as a predictor of substance use 65

Table 12: Being bullied as a predictor of mental health problems 66

Table 13: Being bullied as a predictor of substance use 67

Table 14: Mental health problems as predictor of cigarette smoking 68

Table 15: Mental health problems as predictor of alcohol use 69

Table 16: Mental health problems as predictor of marijuana use 70

Mental health status of adolescents in South-East Asia: Evidence for action v

Acronyms

CDC Centers for Disease Control and Prevention, Atlanta, USA

CI Confidence Interval

DALYs The disability-adjusted life years

GSHS Global School-based Student Health Surveys

SEA South-East Asia

SDGs Sustainable Development Goals

SEAR South-East Asia Region

WHO World Health Organization

Mental health status of adolescents in South-East Asia: Evidence for action

Mental health status of adolescents in South-East Asia: Evidence for action vii

Foreword

Mental health and substance use disorders are one of the largest

contributors to the regional and global burden of disease. Overall,

more than 6% of the global burden of disease is attributed to these

disorders. According to WHO’s Global Health Estimates 2015,

suicide or self-harm is the second most common cause of mortality

– after road-traffic injuries – among people aged 15–29 years in the

South-East Asia Region. Mental health problems in young people

thus present not only a major public health challenge but are also

a development issue in low- and middle-income countries and may

be central to achieving different Sustainable Development Goals.

Recognizing and addressing mental health needs of young people

help them function better socially, academically and vocationally,

and develop into well-adjusted and productive adults. An urgent task in addressing

adolescent mental health is improving and expanding the evidence base, particularly in

resource-constrained countries. The evidence is required not only to inform policies and

programmes but also to generate public awareness of mental health issues and mobilize

social support for adolescents.

The theme of World Health Day 2017 is Depression. The campaign slogan is “Depression:

Let’s Talk”. Having “depression” as the theme of World Health Day acknowledges the public

health importance of mental health issues and of depression in particular, and recognizes

the burden these conditions place on individuals, families and communities. I am pleased

that this publication “Mental Health Status of Adolescents in South-East Asia: Evidence for

Action” is being launched on the eve of World Health Day 2017. This report presents evidence

on mental health and substance use collected in Global School-based Student Health Surveys

among adolescents aged 13–17 years. These surveys assess the leading causes of morbidity

and mortality among school-going adolescents and have been supported by WHO and the

Centers for Disease Control, Atlanta, USA in all Member States of the WHO South-East Asia

Region.

I hope the information provided in this publication will encourage evidence-based and

context-relevant policy actions for promotion of mental health and mental well-being of

adolescents in the Region and eventually to a better-adjusted and productive adult workforce

in the WHO SEA Region.

Dr Poonam Khetrapal Singh

Regional Director

Mental health status of adolescents in South-East Asia: Evidence for action

viii

List of contributors

Bangladesh Dr Kamrun Nahar Choudhury (GSHS Survey coordinator)

Assistant Professor of Epidemiology, National Center for Control of

Rheumatic Fever and Heart Disease, Dhaka, Bangladesh

Dr Mohammad Mostafa Zaman, Adviser, Research and Publication, WHO

Country office, Bangladesh

Bhutan Mr Sangay Thinley (GSHS Survey coordinator)

Program Officer, Comprehensive School Health Program

Health Promotion Division, Department of Public Health

Ministry of Health, Thimphu, Bhutan

Mr Tshering Dhendup, National Professional Officer

WHO Country office, Bhutan

India Dr. Sadhana Parashar (GSHS Survey coordinator)

Education Officer, Central Board of Secondary Education

New Delhi, India

Dr Atreyi Ganguli, National Professional Officer (Mental Health and

Substance Abuse), WHO Country Office for India

Indonesia Dr Nunik Kusumawardani (GSHS Survey coordinator)

Badan Litbang Kesehatan, Jakarta, Indonesia

Priska Primastuti, National Professional Officer

WHO Country office, Indonesia

Maldives Ms Aishath Naseera (GSHS Survey coordinator)

Education Development Officer

Ministry of Education, Malè, Maldives

Ms Fathimath Azza, Director General

Ministry of Education, Malè, Maldives

Mr Hussein Rasheed Moosa, Deputy Director General

Ministry of Education, Malè, Maldives

Ms Fathimath Hudha, National Professional Officer

WHO Country office, Maldives

Myanmar Dr Sanda (GSHS Survey coordinator)

Director (School Health), Department of Public Health

Dr Win Lae Htut, Department of Public Health

Ministry of Health and Sports, Myanmar

Dr Myo-Paing, National Professional Officer

WHO Country office, Myanmar

Nepal Mr Badri Bahadur Khadka

Director, National Health Education Information Communication Centre

Department of Health Services , Ministry of Health and Population

Dr Krishna Aryal, Chief Research Section

Nepal Health Research Council, Kathmandu, Nepal

Dr Lonim Dixit, National Professional Officer

WHO Country office, Nepal

Mental health status of adolescents in South-East Asia: Evidence for action ix

Sri Lanka Dr Champika Wickramasinghe

Dr Sameera Senanayake

Dr Shanthi Gunawardena

(GSHS Survey coordinators)

Ministry of Health, Nutrition and Indigenous Medicine

Mr T. Suveendran, National Professional Officer – Mental Health &

Substance Abuse, WHO Country office, Sri Lanka

Thailand Dr Kitti Larpsombatsiri (GSHS Survey coordinator)

Chief, School Age and Youth Health Group

Ministry of Public Health, Bangkok, Thailand

Ms Sushera Bunluesin, National Professional Officer, (NCD)

WHO Country office, Thailand

Timor-Leste Mr Pedro Canisio da Costa Amaral, SKM

(GSHS Survey coordinator)

Public Health Directorate, Ministry of Health, Timor-Leste

Mrs Rita Soares, School Health Officer,

Health Promotion and Education Department

Mr Delfim da Costa Xavier Ferreira, MPH, Senior Research Officer

National Health Science Institution, MOH

Mr Leoneto Soares Pinto, (NCD, Mental Health and Tobacco Control

Program Associate), WHO Country office, Timor-Leste

CDC Dr Laura Kann, Yoshimi Yamakawa, Tim McManus, Connie Lim,

Denise Bradford, School-Based Surveillance Branch

The Centers for Disease Control and Prevention, Atlanta, USA

WHO-HQ Ms Leanne Riley, Team Leader, Surveillance, Surveillance and Population-

based Prevention Unit, Prevention of Noncommunicable Diseases

Department, World Health Organization, Geneva, Switzerland

WHO-SEARO Dr Thaksaphon Thamarangsi

Director, Noncommunicable Diseases and Environmental Health

Dr Manju Rani, Regional Advisor (NCD and Tobacco Surveillance)

Dr Nazneen Anwar, Regional Advisor (Mental Health)

Dr Jagdish Kaur, Regional Advisor (TFI)

Dr Gampo Dorji, Technical officer (NCD)

Mr Naveen Agarwal, Surveillance Management Associate

(NCD and Tobacco Surveillance)

WHO South East-Asia Regional Office, New Delhi, India

Editorial

and design

support

(WHO-SEARO)

Mr Gautam Basu, Assitant Report Officer (DOC)

Mr Subhankar Bhowmik, Graphic Art Associate

Mr Kapil Mathur (Text Processing and Designing)

Anika Singh, Communication Consultant

Noncommunicable Diseases and Mental Health Services

Hanuman Prasad, Executive Assistant, Mental Health (MHS)

WHO South East-Asia Regional Office, New Delhi, India

Part I

Mental health status of adolescents in South-East Asia: Evidence for action 1

1 Introduction

Adolescence, usually defined as the period between 10 and 19 years of age, is the phase of

transition from a “child” into an “adult”. These are the formative as well as impressionable

years when substantial physical, psychological and behavioural changes take place.

Adolescents constitute an important social and demographic group in the WHO South-East

Asia Region accounting for almost one fifth or 18.8% (362.2 million individuals) of the total

regional population (UN Population Prospects, 2016). Of this, 13–17 year olds comprise 181

million or nearly one tenth (9.4%) of total regional population (UN Population Prospects,

2016). In the coming years, the group may account for even a larger share of the total

population as fertility rates decline further.

Mental health problems are estimated to affect 10–20% of children and adolescents

worldwide, accounting for 15–30% of Disability-Adjusted Life Years (DALYs) lost during

the first three decades of life (Kieling, Baker-Henningham et al. 2011). Suicide or self-harm,

itself, accounts for an estimated 6% of all deaths among 15–29 year olds population and is

the second leading cause of death in this age group after road-traffic injuries (WHO, 2014).

The estimated suicide rates per 100,000 populations in this age group varied from 3.6 in

Indonesia to 25.8 in Nepal to 35.5 in India (WHO, 2014) (see Part III – Table 1) However,

the ‘reported’ suicide rate in the countries may be much lower due to stigma, social taboos,

and legal issues around reporting of suicide, and hence may significantly underestimate the

problem.

The physical, psychological, and behavioural changes taking place during adolescence

contribute to many of these mental health problems. Many mental health disorders

first emerge in late childhood and early adolescence and may continue into adulthood.

However, mental health disorders such as anxiety and depression in early adolescence often

go undiagnosed and untreated, especially in developing countries, due to limited access

to psychological and psychiatric services and substantial social stigma attached to mental

health issues.

Mental health issues such as depression, anxiety, or other conditions may lead to

behavioural problems at home and school, increased participation in risk-taking behaviours,

such as tobacco, alcohol and drug use, and underachievement in schools (Ranasinghe,

Ramesh et al. 2016). However, these sensitive issues are rarely addressed in schools and

within families. The failure to recognize and address mental health problems in children and

adolescents is a serious public health issue with important consequences on the achievement

of basic development goals in low- and middle-income countries (Kieling, Baker-Henningham

et al. 2011). This becomes even more important in the context of Sustainable Development

Goals (SDG). The SDG Target 3.4 under SDG goal 3 calls for reducing premature mortality

by one third by 2030 from noncommunicable diseases through prevention and treatment of

NCDs and promotion of mental health and well-being. Similarly the SDG Target 3.5 call for

strengthening prevention and treatment of substance abuse, including narcotic drug abuse

and harmful use of alcohol.

Given the multi-directional linkages between mental health conditions and other health,

educational, social and development problems, there may be high return on investments for

addressing mental health issues of adolescents.

Mental health status of adolescents in South-East Asia: Evidence for action

This publication provides evidence from nationally representative school health surveys,

implemented as part of the Global School-based Student Health Survey Initiative, on

prevalence of self-reported suicidal behaviours and other warning signs of mental health

problems. It thereby aims to raise awareness of mental health problems among adolescents.

It also aims to show associations of suicidal behaviours and mental health symptoms with

potential protective behaviours (e.g. parental engagement) and risk factors (e.g. bullying)

that may help inform public health interventions to address this important issue. Finally, it

assesses the co-morbidity of substance use and mental health problems.

2 Data and methods

The data used in the report are from the latest round of the global school-based student

health surveys (GSHS) (WHO, 2016) implemented by the Member States of the WHO South-

East Asia Region. Almost all the Member States in the Region have implemented at least

one round of GSHS in collaboration with the US Centers for Disease Control and Prevention

(CDC) and the World Health Organization. All the countries that participated in the GSHS

follow a standard protocol for sampling, surveying, and data management, ethics approval,

and select survey questions from the same validated questionnaire bank. While the questions

asked on key indicators are the largely the same across all countries, the exceptions are

noted wherever applicable.

GSHS are cross-sectional surveys that collect data from adolescents enrolled in middle-

to high- schools approximately 13–17 years old. However, the Indian survey covered only

middle-school students approximately aged 13–15 years. GSHS measures behaviours and

protective factors related to the leading causes of mortality and morbidity among youth. A

two-stage cluster sampling design is used to sample schools in the first stage and classes

within the sampled schools in the second stage. Table below provides sample sizes included

in GSHS in different countries.

Table: Sample size of students 13–17 years included in different GSHS in the South-East

Asia Region

Country (Survey year) Sample size

Total Boys Girls Missing*

Bangladesh (2014) 2878 1179 1695 4

Bhutan (2016) 5809 2515 3255 39

India (2007) (13-15 years)** 6751 3724 2997 30

Indonesia (2015) 8899 4094 4798 7

Maldives (2014) 3039 1264 1738 37

Myanmar (2016) 2502 1156 1329 17

Nepal (2015) 5747 2668 3014 65

Sri Lanka (2016) 3173 1391 1766 16

Thailand (2015) 4990 2121 2856 13

Timor-Leste (2015) 2853 1228 1533 92

Notes: *Either the age or gender was missing for these observations and were excluded from the final

analysis. **The data are only from schools under Central Board of Secondary Education.

Mental health status of adolescents in South-East Asia: Evidence for action 3

The GSHS uses anonymous reporting by respondent students through self-administered

questionnaires in a nationally representative sample of schools. Anonymous self-reported

surveys may provide better results for reporting of behaviours or practices that are considered

to be social taboos. The recall period for most of the questions varied from a week, 30 days

(e.g. for substance use questions) to 12 months (e.g. for most mental health indicators),

depending upon the indicator. There were no skip patterns used in the questionnaires, and

all the students were expected to respond to all the questions.

The report presents point estimates along with 95% confidence intervals for key self-

reported mental health (suicide attempts and suicidal ideation, and other signs of mental

health problems) and substance use indicators as part of individual country profiles (Part II)

and regional indicator data tables (Part III) providing a comparative snapshot. The extent of

perceived parental engagement/connectedness and self-reported experience of bullying in

school and their relationship with mental health indicators was also examined in terms of

unadjusted odds ratio. In addition, data are presented on co-existence of substance use and

mental health problems.

All of the counts reported in this report are unadjusted, but all of the proportions, odd

ratios and statistical tests are based on weighted results (computed using svy command in

STATA). Regional-level pooled estimates are also computed using country 13–17 year old

populations as a proportion of the total 13–17 year old populations in the Region as the

weighting factor. Two-sided Pearson’s chi-squared tests were used to test for differences

in the responses to key variables by sex. All of these analyses were conducted with STATA

(version 11) and tested at a significance level of 90% and 95%.

Part-II of the report provides individual country profile for all the 10 member states

showing the key indicator by sex and key relationships observed. The detailed tables included

in country profile also provide 95% confidence intervals.

Part-III provides indicator-wise regional tables to provide a comparative perspective.

The findings presented in the subsequent “Results” section should be interpreted in the

light of some limitations. The data are self-reported and not validated by direct observation

or any other means. Second, since the survey is school-based, the data exclude non-school-

going adolescents, which may account for a substantial proportion of the total adolescent

population in many countries of the WHO South-East Asia Region. If mental health problems

and substance use are higher among out-of-school adolescents, then the data presented

may underestimate the prevalence of both mental health problems and substance use.

In addition, the cross-sectional survey design does not allow for examination of causality.

Finally, the cross-country comparisons of various indicators should be interpreted in the

context of differential local social norms and other cultural aspects that may affect how

adolescents may perceive and report different mental health issues.

Mental health status of adolescents in South-East Asia: Evidence for action

3 Results

3.1 Burden of mental health problems

3.1.1 Suicidal ideation, plans and attempts

The data from GSHS show that suicidal behaviour, namely, suicidal ideation, plans, and

attempts, is a common problem among adolescents in the WHO South-East Asia Region.

Although this information was not collected in GSHS in India, among the remaining countries,

the percentage of 13–17-year-old students who reported that they seriously considered

attempting suicide in the last 12 months varied from 4.9% in Bangladesh to 13.7% in Nepal.

The pooled 12-month prevalence of suicide ideation across nine countries (excluding India)

was 6.8%. In general, female students reported higher rates of suicidal ideation than male

students though the differences were statistically significant at 95% level in only three of the

countries. Only in Timor-Leste and Thailand did male students report higher levels of suicidal

ideation, though the differences were significant at a 90% level only in Timor-Leste (see Part

III – Table 2).

The percentage of adolescents that reported attempting suicide at least once in the

past 12 months varied from 3.9% in Indonesia to 13.3% in Thailand. The pooled 12-month

prevalence of at least one suicidal attempt across 9 countries (excluding India) was 6.4%.

While the prevalence of suicidal ideation was more among female students with some

exceptions, the prevalence of reported suicidal attempt was higher among male students,

with the exception of Bhutan, Myanmar, and Nepal where female students reported a higher

rate of both suicidal ideation and attempts (see Part III – Table 2).

3.1.2 Loneliness and feeling anxious

The percentage of students who reported feeling lonely most of the time or always in the

past 12 months varied from 6.7% in Indonesia and Nepal to 15.5% in Maldives. The pooled

12-month prevalence of loneliness across the 10 countries was 8.4%. Similar to suicide

ideation, in most of countries female students were more likely to report feeling lonely

than male students, except in Bangladesh, Thailand and Timor-Leste where male students

reported higher prevalence of feeling lonely (though differences were not significant in

Bangladesh and Sri Lanka and significant only at 90% level in the other two countries) (see

Part III – Table 3).

The percentage of students who reported feeling so worried about something that they

could not sleep at night varied from 3.9% in Myanmar to 15.1% in Maldives. The pooled

12-month prevalence of feeling anxious across the 10 countries was 6.9% (see Part III –

Table 3).

A substantial proportion of students also reported having no close friends, ranging from

3.0% in Indonesia to 10.1% in India. The pooled 12-month prevalence of students reporting

no close friends across the 10 countries was 8.6%. (see Part III – Table 3).

Mental health status of adolescents in South-East Asia: Evidence for action 5

3.1.3 Substance use

GSHS examined the current use of smoking cigarettes as well as the use of any other

form of tobacco (smoked and/or smokeless), alcohol and drug use. The cross-sectional

association between substance use and mental health problems is well documented and

hence the extent of substance use was examined as part of mental health problems among

adolescents.

The results show substantial substance use among adolescents in the South-East Asia

Region. The reported prevalence of current cigarette smoking, defined as smoking cigarettes

on any of the days in the past 30 days, varied from 1.2% in India (for 13–15 year olds only)

to 5.9% in Nepal to 20.1% in Timor-Leste and 24.6% in Bhutan. The pooled prevalence of

current cigarette smoking across nine countries (excluding India which has estimates only

for 13–15 year olds) was estimated at 9.7%. (see Part III – Table 4).

In addition to smoking cigarettes, the use of other tobacco products is also high. Inclusive

of other tobacco products, the prevalence of current use of any tobacco product varied from

3.6% in India (among 13–15 year olds) to 27.1% in Timor-Leste to 29.3% in Bhutan. The

pooled estimate across the nine countries (excluding India where data are available only for

13–15- year-olds) is 11.7% (see Part III – Table 4).

Similar to tobacco use, alcohol use also remains high but varies highly across countries

ranging from 1.6% in Bangladesh to 23% in Thailand and 24.2% in Bhutan. For two countries

(India and Maldives), the ever-use prevalence is reported. The pooled estimate across the 10

countries is 7.1% (see Part III – Table 5).

Current drug use also remains high especially in some countries such as Bhutan, Maldives,

Thailand and Timor-Leste. GSHS in most countries primarily examined current marijuana use

and ever use of amphetamines, though in some countries, the use of other drugs (e.g.

cocaine, heroin, etc.) was also examined. Two of the countries (India and Myanmar) did

not ask about any specific drug but use of any drug. This report presents data on current

marijuana use (except in India and Myanmar where current use of any drug is reported) as a

proxy indicator of drug use as these data were collected for most countries and varied from

1.0% in Indonesia to 12.0% in Bhutan. The pooled estimate across the 10 countries is 2.5%

(see Part III – Table 6)

Male students were significantly more likely to indulge in substance use (cigarette

smoking, tobacco use, alcohol use or marijuana) than female students almost across all the

countries with few exceptions.

Multiple substance use (use of more than one substance) was also quite common,

ranging from 1.3% in Bangladesh to 20.3% in Bhutan (see Part III – Table 6) and was

significantly higher among male than female students.

3.2 Protective factors for mental health: Parental engagement

Previous literature has suggested that a healthy parental engagement protects adolescents

from substance use and mental health problems.

Mental health status of adolescents in South-East Asia: Evidence for action

A series of 3 to 12 questions with five response options (never, rarely, sometimes, most

of the times, always) were asked in the GSHS survey to elicit respondents’ perception of

the connectedness and engagement of their parents with them in the past 30 days. A

summative parental engagement index was created based on three common questions

asked in all the countries in the Region. First, a binary variable is created with a value of 1 if

respondent reported ‘most of the times’ or ‘always’ for a particular question, and value of 0,

otherwise. In the second stage, a summative parental engagement index was created using

the binary variables based on those 3 questions, which was categorized as ‘low’ if the score

was 0, ‘medium’ if the score was 1, and ‘high’ if the score was 2–3.

A significant number of students reported low levels of parental engagement ranging

from 15.0% students in Sri Lanka to almost one fifth of students in India and Myanmar to

more than half of all students in Timor-Leste (see below Figure 1 and Part III – Table 9)

Figure 1: Percentage of students (13–17 year olds) reporting low level of parental

engagement in the South-East Asia Region countries.

23%

37%

21%

36% 38%

22%

26%

15%

41%

55%

10%

20%

30%

40%

50%

60%

Bangladesh Bhutan India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Timor-Leste

Source: Authors’ calculations from various GSHS surveys.

3.2.1 Association between parental engagement and mental health

problems and substance use

Not only was the proportion of student reporting low-level of parental engagement was

very high across the countries, it was also found to significantly increase the risk of suicidal

attempts, feeling lonely or feeling anxious as well substance use across all the countries in

Region, with few exceptions (e.g. Timor-Leste) (see below figure 2 and Part III – Table 10

and 11). Stated otherwise, the higher level of parental engagement seems to be protective

against mental health problems and substance use. The relationship was significant among

both boys and girls.

Mental health status of adolescents in South-East Asia: Evidence for action 7

Figure 2: Unadjusted odds ratios with 95% confidence interval showing association

between parental engagement (dependent variable, reference group= high level of

parental engagement) and selected mental health problems and substance use indicators

among students 13–17 year olds in the South-East Asia Region.

Source: Authors’ calculations from Global School-based Student Health Survey 2014–2016

Notes: An odds ratio of 1 implies or 95% CI inclusive of 1 implies no association.

*In Myanmar, instead of current cigarette smoking, current tobacco smoking is used. For current

alcohol use, in Maldives, it refers to ‘ever’ use of alcohol rather than current use. For Marijuana use,

in India and Myanmar it refers to ‘any drug use’.

3.3 Risk factors for mental health: Experience of being bullied

A significant proportion of students reported being bullied on one or more days in the past

30 days, ranging from almost one fifth (20.7%) students in Indonesia to almost half or more

than half of all students in Myanmar and Nepal. In general, boys were more likely to report

being bullied than girls, though differences were not statistically significant in many of the

countries (e.g. Bhutan, Maldives, and Myanmar) (see below Figure 3 and Part III – Table 7)

Figure 3: Percentage of students (13–17 year olds) who reported being bullied on one or

more days in past 30 days in the South-East Asia Region.

25% 26%

21%

27%

50% 51%

38%

29% 28%

10%

20%

30%

40%

50%

60%

Bangladesh Bhutan Indonesia Maldives Myanmar Nepal Sri Lanka Thialand Timor-Leste

Source: Various Global School-based Student Survey 2014-2016

Mental health status of adolescents in South-East Asia: Evidence for action

3.3.1 Association between being bullied and mental health problems and

substance use

Not only is bullying highly prevalent in countries of the WHO South-East Asia Region as

shown earlier, being bullied was associated with significantly higher reporting of mental

health problems (attempting suicide, loneliness, or feeling worried) and substance use fairly

consistently across all the countries in the Region (see Part III – Table 12 and 13).

For example, the number of students who reported being bullied were almost three

times (e.g. in Bhutan and Nepal) to five times more likely to report attempting suicide in past

12 months than students who were not bullied. The relationship was significant among both

boys and girls in most countries (see Part III – Table 12).

Similarly, students who reported being bullied in the past 30 days were almost two to

four times more likely to smoke cigarettes, two to seven times more likely to use alcohol

and two to seven times more likely to use marijuana. The relationship was significant among

both boys and girls (see Figure 3 and Part-III – Table 13).

Figure 4: Unadjusted odds ratios with 95% confidence interval showing association

between being bullied (dependent variable, reference group= no bullying) and selected

mental health problems and substance use indicators among students 13–17 year olds in

the South-East Asia Region.

Source: Authors’ calculations from Global School-based Student Health Survey 2014–2016

Notes: An odds ratio of 1 implies or 95% CI inclusive of 1 implies no association.

*In Myanmar, instead of current cigarette smoking, current tobacco smoking is used. For current

alcohol use, in Maldives, it refers to ‘ever’ use of alcohol rather than current use. For marijuana use,

in India and Myanmar it refers to ‘any drug use’.

3.4 Co-existence of mental health problems and substance use

Almost in all Member States, the presence of a mental health problem (suicide ideation,

loneliness and anxiety used as dependent variable with reference group=no mental health

problem) substantially increased the likelihood of cigarette smoking, alcohol use and drug

(marijuana) use (see Part III – Table 14 to 16). The relationship was observed for both girls

Mental health status of adolescents in South-East Asia: Evidence for action 9

and boys with few exceptions. However, based on results from these cross-sectional surveys,

it is not possible to comment or direction of causality, as substance use may increase the

likelihood of mental health problems, as well as mental health problems may increase the

vulnerability of adolescents to indulge in substance use.

4 Conclusions and way forward

The results confirm the previous literature on high prevalence of mental health problems and

substance use among adolescents in the WHO South-East Asia Region and emphasize the

public health and development importance of the adolescent mental health.

Adolescent suicide behaviour seems to be a serious problem in all Member States of

the Region. Suicide is the second most common cause of death among the 15–29 year

age group. Almost one in eight adolescents in the age group 13–17 years of age reported

attempting suicide one or more times in the past one year. Measures can be taken to

prevent suicide by observing the factors significantly linked to suicidal behaviour. Steps can

then be taken to identify adolescents who have serious suicidal ideation so that intervention

can be taken to reduce the suicidal rate.

While almost all the countries in the Region with few exceptions legally restrict the

supply (including sale) of tobacco and alcohol to people under a certain age ranging from18

years to 21 years of age and completely ban the supply and sale of drugs such as marijuana

and amphetamines, the results show their use remains high among 13–17 year olds. The

evidence presented shows that almost one in 10 and almost one in 12 adolescents in the

age-group 13–17 years of age smoked cigarettes and used alcohol, respectively. The actual

prevalence may even be higher, as the current estimate is based only on school-going

adolescents, and the non-school-going adolescents may smoke or drink alcohol more often.

The Bhutan case is especially interesting, given the complete ban on domestic tobacco sales

in the country. The reported drug use was also disturbingly high, especially in some countries

such as Bhutan, Maldives, Thailand and Timor-Leste. The evidence shows the age of initiation

of use of alcohol and tobacco is decreasing in SEA. This is of great concern from the public

health point of view, as the lower the age of initiation, more the risk of developing addiction

and dependence on these substances.

High substance use among adolescents despite underage laws and complete ban (e.g.

for drugs) in most of the countries calls for more efficient implementation of strategies

known to reduce consumption of these substances such as price and taxation, controls on

availability, restrictions on advertising and promotions as well as exploration of alternative

strategies to control substance use. Co-existence of substance use and mental health

disorders calls for combined strategies and programmes to deal with both the issues and an

acknowledgement of the fact that adolescents using substances may be highly vulnerable

to developing mental health disorders and vice versa.

From the program managers and policy makers perspective, the results related to adverse

relationship between bullying and mental health problems and the protective relationship

with parental engagement suggest that schools and families may be the important entry

points for programmes and interventions aiming to improve adolescent mental health

problems.

Mental health status of adolescents in South-East Asia: Evidence for action

The high level of bullying in the Region ranging from almost one fifth of students to

almost half the students along with the strong adverse association between bullying and

poor mental health and substance use in all the countries examined emphasizes the need

to develop and implement strategies for reducing bullying among children and adolescents.

The adverse association between being bullied and mental health problems and substance

use seen in the WHO South-East Asia Region is consistent with the relationship seen in

other Regions and countries such as China (Cheng, Newman et al. 2010), Ghana (Owusu,

Hart et al. 2011), Caribbean countries (Abdirahman, Bah et al. 2012) and low- and middle-

income countries (Fleming and Jacobsen 2010) as well, where such relationship has been

investigated.

The results in this study are also consistent with previous literature that suggests that

victims of bullying have increased stress and a reduced ability to concentrate and are at

increased risk for substance abuse, aggressive behaviour and suicide attempts (Abdirahman,

Bah et al. 2012, Wilson, Bovet et al. 2012).

Schools in most of the Member States place great emphasis on academic achievement,

perhaps at the expense of the social climate of the school. It may be necessary to implement

changes to the school climate to reduce the extent of bullying in schools and to create a

positive school environment.

A higher level of parental engagement was found to be consistently protective against

both mental health problems including suicidal behaviours as well as substance use. The

relationship observed in the SEA Region is also consistent with similar relationship reported

elsewhere outside the region (Cheng, Tao et al. 2009, Hasumi, Ahsan et al. 2012, Peltzer

and Pengpid 2012).

Unfortunately, a troublingly high proportion of adolescents reported low level of parental

engagement in the Region. The public policies, the youth programmes and schools should

involve parents and emphasize the need for them to better engage with their adolescent

children in meaningful ways.

Action is imperative to reduce the burden of mental health problems in future generations

and to allow for the full development of vulnerable children and adolescents worldwide.

More research may be required to further understand the dynamics of circumstances

surrounding mental health issues and initiation of substance use. The results also warrant

better experience sharing among member states in furthering the knowledge base of what

works and what does not.

Mental health status of adolescents in South-East Asia: Evidence for action 11

References

1. Cheng Y, Tao M, Riley L, Kann L, Ye L, Tian X, et al. Protective factors relating to decreased risks of

adolescent suicidal behaviour. Child Care Health Dev. 2009 May;35(3):313-22.

2. Abdirahman HA1, Bah TT, Shrestha HL, Jacobsen KH. Bullying, mental health, and parental involvement

among adolescents in the Caribbean. West Indian Med J. 2012 Aug;61(5):504-8.

3. Cheng Y, Newman IM, Qu M, Mbulo L, Chai Y, Chen Y, et al. Being bullied and psychosocial adjustment

among middle school students in China. J Sch Health. 2010 Apr;80(4):193-9.

4. World Health Organization. Global School-based Student Health Survey (GSHS). Geneva, 2016.

http://www.who.int/chp/gshs/en/ - accessed 15 March 2017.

5. Fleming LC, Jacobsen KH. Bullying among middle-school students in low and middle income countries.

Health Promot Int. 2010 Mar;25(1):73-84.

6. Hasumi T, Ahsan F, Couper CM, Aguayo JL, Jacobsen KH. Parental involvement and mental well-being of

Indian adolescents. Indian Pediatr. 2012 Nov;49(11):915-8.

7. Kieling C, Baker-Henningham H, Belfer M, Conti G, Ertem I, Omigbodun O, et al. Child and adolescent

mental health worldwide: evidence for action. Lancet. 2011 Oct 22;378(9801):1515-25.

8. World Health Organization. Preventing suicide: a global imperative. Geneva, 2014.

9. Owusu A, Hart P, Oliver B, Kang M, et al. The association between bullying and psychological health among

senior high school students in Ghana, West Africa. J Sch Health. 2011 May;81(5):231-8.

10. Peltzer K, Pengpid S. Suicidal ideation and associated factors among school-going adolescents in Thailand.

Int J Environ Res Public Health. 2012 Feb;9(2):462-73.

11. Ranasinghe S, Ramesh S, Jacobsen KH. Hygiene and mental health among middle school students in India

and 11 other countries. J Infect Public Health. 2016 Jul-Aug;9(4):429-35.

12. Wilson ML, Bovet P, Viswanathan B, Suris JC. Bullying among adolescents in a sub-Saharan middle-income

setting. J Adolesc Health. 2012 Jul;51(1):96-8.

13. United Nations, Department of Economic and Social Affairs, Population Division. World population

prospects: the 2015 revision. 2015

Mental health status of adolescents in South-East Asia: Evidence for action Bangladesh

Part II

Country Profiles

Bangladesh Mental health status of adolescents in South-East Asia: Evidence for action 13

Current alcohol users

(had at least one alcoholic drink on

one or more days in past 30 days)

Boys: 2% Girls: <1%

Drunkenness

(drank so much alcohol to be

really drunk)

Boys: 2% Girls: 0%

Problem from drinking

(got into trouble with family/friends,

missed school, or got into fights as a

result of drinking alcohol)

Boys: 2% Girls: 0%

Current marijuana users

Boys: 2% Girls: 1%

Multiple substance use

Total population:a

161.0 million

Adolescentb (13-17 years) population: 10.2% of total population

Total:16.4 million Boys: 8.4 million Girls: 8.0 million

Suicidal behaviour in past 12 months:

Estimated suicide rates per 100 000 (aged 15–29 years, 2012) c : 8.1

Boys: 5.5

Girls: 10.8

Suicidal ideation

(considered attempting suicide)

Boys: 4% Girls: 6%

Suicidal ideation with a plan

(made suicide plan)

Boys: 8% Girls: 7%

Attempted suicide

(one or more times)

Boys: 7% Girls: 6%

Warning signs of mental health problems in past 12 months

Anxiety

(could not sleep because of

being worried)

Boys: 4% Girls: 5%

Loneliness

(felt lonely most of times

or always)

Boys: 12% Girls: 9%

Had no close friends

Boys: 7% Girls: 11%

Substance use

Bangladesh (2014)

11%

10%

Substance use among users

Any substance use

Tobacco only

Alcohol only

Marijuana only

Multiple substance

use

Current tobacco users

(used any tobacco product – smoked and/or

smokeless on one or more days in past 30 days)

Boys: 14% Girls: 2%

Current cigarette smokers

(on one or more days in past 30 days)

Boys: 11% Girls: 2%

Yes, 10%

No, 90%

4% 2%

81%

13%

Mental health status of adolescents in South-East Asia: Evidence for action

Mental health status of adolescents in South-East Asia: Evidence for action Bangladesh

Protective and risk factors for mental health and substance use

Perceived parental engagement

Parents understood their

problems and worries

(most of times or always)

Boys: 43% Girls: 55%

Parents really knew what they

were doing with their free time

(most of times or always)

Boys: 40% Girls: 49%

Parents checked if their

homework was done

(most of times or always)

Boys: 53% Girls: 56%

Parental engagement as a predictor of mental health problems and substance use

School experience

Being bullied as a predictor of mental health problems and substance use

Mental health problems as predictors of substance use

Percentage of students

Attempted

suicide

Attempted

suicide

Anxiety

Loneliness

Cigarette

smokers

Cigarette

smokers

Alcohol users

Marijuana users

Low Medium High

Not bullied Bullied

% of cigarette smokers

% of alcohol users

% of marijuana users

Suicidal ideation Suicidal ideation Suicidal ideation

Anxiety Anxiety Anxiety

Loneliness Loneliness Loneliness

No Yes

Perceived other students to be kind and helpful

(most of times or always)

Boys: 56% Girls: 57%

Bullied by other students

(one or more times in past 30 days)

Boys: 28% Girls: 18%

47% 43% 54%

56% 25%

Specific mental health indicator by level of parental engagement Index of parental engagement d

2122 2 2

11 10

Bangladesh Mental health status of adolescents in South-East Asia: Evidence for action 15

Among students aged 13–17 years Overall % Boys % Girls %

(95% CI) (95% CI) (95% CI)

Suicidal behaviour in past 12 months

Attempted suicide one or more times 6.7

(5.2–8.7)

6.9

(5.0–9.5)

6.0

(4.2–8.6)

Made a plan about how they would attempt suicide 7.5

(5.5–10.1)

7.5

(4.8–11.3)

7.3

(5.7–9.2)

Seriously considered attempting suicide 4.9

(3.6–6.6)

4.4

(2.8–7.0)

5.8

(4.1–8.2)

Warning signs of mental health problems in past 12 months

Worried about something that they could not sleep at

night most of times or always

4.7

(3.6–6.2)

4.4

(2.9–6.6)

5.1

(3.9–6.7)

Did not have any close friends 8.2

(6.4–10.5)

6.7

(4.5–9.9)

11.4

(8.9–14.3)

Felt lonely most of times or always 11.0

(8.7–13.8)

11.7

(8.8–15.4)

9.4

(7.1–12.4)

Substance use on one or more days in past 30 days

Current tobacco users (smoked and/or smokeless) 9.8

(6.3–15.0)

13.8*

(8.4–22.0)

2.0

(1.2–3.6)

Current cigarette smokers 7.7

(4.4–13.1)

11.0*

(5.9–19.6)

1.5

(0.7–3.1)

Current alcohol users 1.6

(0.8–3.2)

2.4*

(1.2–4.7)

0.1

(0.0–0.5)

Current marijuana users 1.7

(0.8–3.6)

2.2*

(0.9–5.3)

0.5

(0.1–1.5)

Ever drank so much alcohol that they were really drunk 1.3

(0.5–3.4)

2.0*

(0.8–5.0)

0.0

(–)

Ever got into trouble with family or friends, missed

school, or got into fights as a result of drinking alcohol

1.2

(0.5–3.0)

1.9*

(0.8–4.4)

0.0

(–)

Perceived parental engagement in past 30 days

Parents or guardians understood their problems and

worries most of times or always

47.2

(42.1–52.4)

43.3

(36.2–50.7)

54.8

(48.5–61.0)

Parents or guardians really knew what they were doing

with their free time most of times or always

42.9

(38.7–47.3)

39.9

(34.0–46.0)

48.7

(42.6–54.8)

Parents or guardians checked to see if their homework

was done most of times or always

54.0

(48.6–59.3)

52.9

(46.5–59.2)

56.2

49.8–62.4)

Social relationships with peers in past 30 days

Students in their school were kind and helpful most of

times or always

56.1

(51.5–60.6)

55.6

(49.7–61.4)

57.0

(49.8–63.9)

Bullied on one or more days 24.6

(21.0–28.5)

28.1

(23.5–33.3)

17.5

(14.2–21.5)

Mental health status of adolescents in South-East Asia: Evidence for action Bangladesh

Technical notes:

Data source: The data reported in this profile comes from latest round of Global School-based Student Health Survey (GSHS). For more

information on survey, please visit www.who.int/chp/gshs

(a) The data for both the total and 13-17 year old population are from World Population Prospects: The 2015 Revision, DVD Edition

published by United Nations, Department of Economic and Social Affairs, Population Division (2015).

(b) An adolescent is typically defined as a person in the age group 10 to 19 years of age. However, in this publication we report data

for adolescent population 13 to 17 years of age only, as this was the age group included in GSHS surveys.

comparability, and may not be the same as official national estimates. The estimates are rounded to the appropriate number of

significant figures. For further information on these estimates, please refer to WHO publication: “Preventing suicide: A global

imperative, 2014 World Health Organization, Geneva” accessible at

http://www.who.int/mental_health/suicideprevention/world_report_2014/en/

(d) Index of parental engagement: A set of 3 to 12 questions with 5 response options (never, rarely, sometimes, most of the times

always) were asked in GSHS survey to elicit respondents’ perception of the connectedness and engagement of their parents with

them in the past 30 days. A set of 3 questions which were common across the countries were used in this report. A binary variable

for each of these 3 is created with a value of 1 if respondent reported ‘most of the times’ and ‘always’ for a particular question, and

value of 0, otherwise. A summative parental engagement index was created using those 3 question, which was categorized as ‘low’

if score of 0, ‘medium’ if score of 1, and ‘high’ if score of 2–3.

(e) An odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome

will occur given a particular exposure, compared to the odds of the outcome occurring in the absence of that exposure. All the odds

ratios represented here are unadjusted or based on univariate logistic regression, not checking for any potential confounders..

* Differences between male and female students are statistically significant at 95% level.

# Missing standard errors because of stratum with single sampling unit.

NS – Not significant at 95% level.

Odds ratio e

Overall Boys Girls

Predictors of suicide, mental health problems, and substance use

Perceived parental engagement (ref=high engagement)

Attempt to suicide 1.69 1.65 1.88

Anxiety 1.22 NS 1.25 1.33

Loneliness 1.15 NS 1.06 1.42

Current cigarette smokers 1.22 NS 1.12 1.58

Current alcohol user 1.07 NS 1.02 #

Current marijuana users 1.10 NS 1.15 1.10

Bullying (ref=not bullied)

Attempt to suicide 3.45 3.57 3.05

Anxiety 3.36 3.21 3.61

Loneliness 3.17 3.22 2.68

Current cigarette smokers 3.77 3.25 4.51

Current alcohol users 6.81 5.47 #

Current marijuana users 4.91 4.87 #

Mental health as predictor of substance use

Suicidal ideation (ref=no suicidal ideation)

Current cigarette smokers 2.22 NS 2.14 7.43

Current alcohol users 7.20 8.79 #

Current marijuana users 4.04 NS 5.93 #

Anxiety (ref=no anxiety)

Current cigarette smokers 2.08 NS 2.06 5.67

Current alcohol users 10.27 11.35 29.79

Current marijuana users 8.54 8.48 #

Loneliness (ref=no loneliness)

Current cigarette smokers 1.92 1.62 6.63

Current alcohol users 7.89 8.04 #

Current marijuana users 9.26 8.47 3.37

Bhutan Mental health status of adolescents in South-East Asia: Evidence for action

Current alcohol users

(had at least one alcoholic drink on

one or more days in past 30 days)

Boys: 33% Girls: 16%

Drunkenness

(drank so much alcohol to be

really drunk)

Boys: 33% Girls: 15%

Problem from drinking

(got into trouble with family/friends,

missed school, or got into fights as a

result of drinking alcohol)

Boys: 15% Girls: 6%

Current marijuana users

Boys: 21% Girls: 4%

Multiple substance use

Total population:a

775 000

Adolescentb (13-17 years) population: 9.4% of total population

Total:73 000 Boys: 37 000 Girls: 36 000

Suicidal behaviour in past 12 months:

Estimated suicide rates per 100 000 (aged 15–29 years, 2012) c : 15.7

Boys: 18.0

Girls: 13.1

Suicidal ideation

(considered attempting suicide)

Boys: 10% Girls: 13%

Suicidal ideation with a plan

(made suicide plan)

Boys: 11% Girls: 16%

Attempted suicide

(one or more times)

Boys: 10% Girls: 12%

Warning signs of mental health problems in past 12 months

Anxiety

(could not sleep because of

being worried)

Boys: 6% Girls: 9%

Loneliness

(felt lonely most of times

or always)

Boys: 10% Girls: 14%

Had no close friends

Boys: 7% Girls: 10%

Substance use

Bhutan (2016)

12%

25%

24%

12%

14%

12%

27%

11%

29%

10%

Substance use among users

Any substance use

Tobacco only

Alcohol only

Marijuana only

Multiple substance

use

Current tobacco users

(used any tobacco product – smoked and/or

smokeless on one or more days in past 30 days)

Boys: 43% Girls: 18%

Current cigarette smokers

(on one or more days in past 30 days)

Boys: 38% Girls: 13%

Yes, 36%

No, 64%

25%

17%

57%

Mental health status of adolescents in South-East Asia: Evidence for action

18 Mental health status of adolescents in South-East Asia: Evidence for action Bhutan

Protective and risk factors for mental health and substance use

Perceived parental engagement

Parents understood their

problems and worries

(most of times or always)

Boys: 40% Girls: 47%

Parents really knew what they

were doing with their free time

(most of times or always)

Boys: 36% Girls: 38%

Parents checked if their

homework was done

(most of times or always)

Boys: 28% Girls: 26%

Parental engagement as a predictor of mental health problems and substance use

School experience

Being bullied as a predictor of mental health problems and substance use

Mental health problems as predictors of substance use

11 9

Percentage of students

Attempted

suicide

Attempted

suicide

Anxiety

Loneliness

Cigarette

smokers

Cigarette

smokers

Alcohol users

Marijuana users

Low Medium High

Not bullied Bullied

% of cigarette smokers

% of alcohol users

% of marijuana users

Suicidal ideation Suicidal ideation Suicidal ideation

Anxiety Anxiety Anxiety

Loneliness Loneliness Loneliness

No Yes

Perceived other students to be kind and helpful

(most of times or always)

Boys: 41% Girls: 42%

Bullied by other students

(one or more times in past 30 days)

Boys: 26% Girls: 26%

43% 37% 27%

42% 27%

12 10

32 32

29 28 15

24 24 12

23 23 11

Specific mental health indicator by level of parental engagement Index of parental engagement d

14 13

Bhutan Mental health status of adolescents in South-East Asia: Evidence for action

Among students aged 13–17 years Overall % Boys % Girls %

(95% CI) (95% CI) (95% CI)

Suicidal behaviour in past 12 months

Attempted suicide one or more times 11.3

(10.0–12.7)

10.3

(8.8–12.0)

12.1

(10.5–13.7)

Made a plan about how they would attempt suicide 13.7

(12.6–14.8)

11.2*

(10.0–12.5)

15.8

(14.3–17.6)

Seriously considered attempting suicide 11.6

(10.4–12.9)

9.8*

(8.4–11.4)

13.1

(11.6–14.8)

Warning signs of mental health problems in past 12 months

Worried about something that they could not sleep at

night most of times or always

7.6

(6.8–8.6)

6.2*

(5.7–7.3)

8.8

(7.7–10.0)

Did not have any close friends 8.7

(7.7–9.8)

7.4

(6.3–8.7)

9.8

(8.6–11.1)

Felt lonely most of times or always 12.4

(11.1–13.8)

10.0*

(8.6–11.6)

14.4

(12.7–16.3)

Substance use on one or more days in past 30 days

Current tobacco users (smoked and/or smokeless) 29.4

(26.8–32.0)

42.9*

(39.6–46.2)

17.6

(15.2–20.2)

Current cigarette smokers 24.7

(22.4–27.1)

38.0*

(35.0–41.1)

13.1

(10.9–15.6)

Current alcohol users 24.2

(22.0–26.5)

33.4*

(30.4–36.6)

16.1

(13.9–18.6)

Current marijuana users 12.0

(10.7–13.4)

21.0*

(18.7–23.6)

4.1

(3.2–5.3)

Ever drank so much alcohol that they were really drunk 26.9

(23.5–30.7)

33.3*

(29.0–37.8)

15.0

(11.3–19.6)

Ever got into trouble with family or friends, missed

school, or got into fights as a result of drinking alcohol

10.1

(9.2–11.1)

14.5*

(13.2–15.9)

6.1

(5.2–7.3)

Perceived parental engagement in past 30 days

Parents or guardians understood their problems and

worries most of times or always

43.3

(41.1–45.6)

39.8*

(37.5–42.1)

46.6

(43.8–49.3)

Parents or guardians really knew what they were doing

with their free time most of times or always

37.2

(34.1–40.3)

35.8

(32.2–39.6)

38.4

(35.3–41.6)

Parents or guardians checked to see if their homework

was done most of times or always

26.7

(24.8–28.8)

27.5

(25.3–29.9)

26.1

(23.9–28.4)

Social relationships with peers in past 30 days

Students in their school were kind and helpful most of

times or always

41.8

(39.6–44.0)

41.4

(38.8–44.1)

42.2

(39.8–44.7)

Bullied on one or more days 26.5

(23.1–30.1)

26.3

(22.8–30.2)

26.3

(22.7–30.2)

20 Mental health status of adolescents in South-East Asia: Evidence for action Bhutan