Injury, substance abuse, verbal abuse, and emotional and behavioral issues among adolescents in Uttarakhand, India: A categorical principal component analysis of global school-based health survey

Abstract

Background:

Adolescents in low-middle-income countries face increasing physical and mental health challenges. The present study aimed to assess status of injury, verbal abuse, substance use, and emotional behavior of adolescents of Uttarakhand, India, and evaluate the importance of each component.

Methods:

A cross-sectional study was conducted among adolescents in 13 government schools in Uttarakhand using the Global School-based Health Survey (GSHS). Categorical principal component analysis (CATPCA) using Varimax rotation was performed to analyze principal components among two domains of GSHS (substance abuse domain and verbal abuse and emotional behavior domain). Factorability was assessed using Kaiser–Meyer–Olkin and Bartlett’s test. Variance Accounted For index was used to evaluate the importance of each component.

Results:

A total of 634 adolescents completed the questionnaire. 41.3% students suffered from serious injury with a significant difference (P < 0.0001) between both genders. Girls were more likely to report having felt lonely most of the time or always in the past 12 months (11.0% vs 4.6%, P = 0.018). Boys were more likely to miss classes on 3 or more days (9.9% vs 4.9%, P = 0.043). Initiation of smoking cigarettes (9.6% vs 1.2%, P <0.0001) and tobacco chewing (3.4% vs 0.3%, P = 0.001) was more likely in 12–15-year-old boys. One-third of the students reported male guardians to use either alcohol or some form of tobacco. CATPCA yielded an 11-factor model accounting for 58.26% of variances with the most important principal component named “Tobacco (Smoking and Chewing): Initiation, Frequency and Attempt to Stop” (eigenvalue: 4.109).

Conclusion:

Significant differences in various items of injury, verbal abuse, substance use, and emotional behavior were recorded between boys and girls. CATPCA revealed patterns among injury, verbal abuse, emotional behavior, and substance abuse domains of GSHS by categorizing them into 11 components. On the basis of these patterns, prioritizing and development of appropriate school-based interventions may be implemented by various stakeholders of Uttarakhand.

INTRODUCTION

One sixth of the global population is composed of adolescents (10–19 years of age), and their number is expected to rise further, especially in low- and middle-income countries such as India.[1] This period of transition between childhood and adulthood is characterized by rapid physical, cognitive, and psychosocial growth. Adolescents experience significant illness and injury with approximately 1 million dying each year due to preventable or treatable causes.[1]

A few studies report that unintentional injuries are responsible for almost half of all deaths in adolescents and cripple the survivors, resulting in a significant cost burden to the family.[2] The role of mental health has been increasingly recognized in the overall health of an individual and has therefore been included in Sustainable Development Goals.[3] Globally, about a billion people inclusive of the 14% adolescent population were reported to be living with a mental disorder.[4] Mental health, although in a complex manner, is closely related to injury, physical, verbal, or emotional abuse as well as substance abuse, especially among adolescents, as they are too young to handle their emotions and feelings.[5] A study reported that half of all lifetime cases of diagnosable mental illness in adults began by the age of 14.[6]

Substance abuse is another problem of major concern with the increasingly higher number of adolescents getting addicted to them.[7] Many studies have established the association between young age and exposure to substance use with various cognitive, behavioral, physical, and mental health problems, especially resulting in increased antisocial and risk-taking behaviors.[8,9]

Assessment of status of injury, verbal abuse, substance use, and emotional and behavioral issues of adolescents will help us develop interventions to control these problems at their inception so that the adolescents grow up to become healthy citizens of the country and contribute to the overall development. Dimension reduction techniques such as categorical principal component analysis (CATPCA) permit quick extraction of patterns and insights in the data.[10] CATPCA was applied specifically to analyze the components related to injury, verbal abuse, emotional behaviour, and substance abuse in order to identify patterns and assess their relevance to the study population. This will assist policymakers in priority identification among various items of the Global School-based Student Health Survey (GSHS) questionnaire and develop appropriate school-based health interventions. No such study has been conducted among school-going adolescents of Uttarakhand, which is a hilly state in North India and has its unique cultural and behavioral characteristics. Also, there is paucity of studies doing factor analysis and none have been done for the GSHS. Therefore, the first objective of the present study was to assess and compare health risk behaviors pertaining to injury, verbal abuse, substance use, and emotional behavior between adolescent boys and girls. The second objective is to detect the patterns among these various modules of the GSHS using CATPCA.

MATERIALS AND METHODS

This cross-sectional study was conducted among school-going adolescents in Class 8–11 of Government higher secondary schools of Garhwal division of Uttarakhand, North India. Inclusion criteria: Students studying from 8^th to 11^th class and those who received parental consent could participate in the study. Inability to obtain consent from the school/parent/children (anyone) was considered as an exclusion criterion. This study is part of a larger survey conducted in this region among these participants, the details of which are published with comprehensive methodology.[11] A school survey done by Sinha DN et al.[12] determined 40.1% prevalence of tobacco use among school-going children. Thus, taking prevalence at 40.1%, at 95% confidence interval, and with 10% relative error, the sample size calculated is 574, which was rounded off to 600. Multistage stratified random sampling was applied for recruitment of study participants, and the basis of selection of number of students from each class and also the selection of number of boys and girls was based on probability proportion to size. A total of three districts were randomly selected from each of the three zones based on altitude, that is, upper, middle, and lower. Random selection of four blocks was done from each district, and one school was randomly chosen from each block. Therefore, the total number of students recruited in the study was calculated as follows:

No. of students in each school X Number of schools in each district X Number of districts

=50 × 4 × 3 = 600 students

However, one of the schools selected was an “only girls” school; hence, another “only boys” school was selected to recruit the proportionate number of boys and girls from that block. Taking a 5% nonresponse, we recruited a final sample size of 634 students. A self-administered questionnaire, GSHS,[13] was used in this study. This questionnaire has been validated in India.[14] It includes validated survey items selected from ten core modules including alcohol use, dietary behavior, drug use, hygiene, mental health, physical activity, protective factors, sexual behaviors, tobacco use, violence, and unintentional injury. The present study assessed nine out of ten modules as questions related to sexual behavior were not culturally contextual. Both Hindi and English versions of the questionnaire were used for data collection after obtaining permission from World Health Organization (WHO). The questionnaire has been developed and validated by the WHO in collaboration with United Nations’ UNICEF, UNESCO, and UNAIDS, with technical assistance from the U.S. Centers for Disease Control and Prevention (CDC).[13] The present paper presents findings related to substance abuse, verbal abuse, injury, and emotional and behavioral issues. After providing written informed assent/consent (from the student/parents/both), the students completed the questionnaire during school hours under supervision of the field investigator.

Statistical analysis

Categorical variables were expressed in percentages (%) and proportions. Continuous variables were expressed as means and standard deviations. The significance of difference in proportions was inferred by Chi-square test, and P <0.05 was considered significant. The CATPCA utilizing Varimax with Kaiser normalization rotation method was performed to examine the factor structure. Nominal, numerical, ordinal, and categorical variables are transformed into quantitative variables using optimal quantification/optimal scaling for CATPCA.[10,15] Factors having loadings of 0.5 or higher were identified from the 32 questions assessed. The Kaiser–Meyer–Olkin (KMO) measure of sampling adequacy and Bartlett’s test of sphericity were used to assess the factorability of the data. Models with KMO values >0.60 and Bartlett test having P values <0.05 were accepted. All factors with an eigenvalue above 1 (Kaiser’s criterion) and Scree plot were used to determine the optimum number of components in each domain.[15] Variance Accounted For (VAF) was used to assess the importance of each component. Statistical Packages for Social Sciences (SPSS) (v23) (IBM SPSS Statistics version 23, SPSS South Asia Pvt Limited, Bangalore, India) was used for the data analysis.

Ethical considerations

The study was approved by the Institutional Ethics Committee (AIIMS/IEC/19/803). Parental consent and assent from the students were obtained. Also, permission from the administrative head of the school was obtained before data collection. The identity of participants was kept confidential by not disclosing their names at any point of the study, including reports.

RESULTS

A total of 634 adolescent students participated in the study, of which 310 were girls and 324 were boys. During the past 1 year, 41.3% of the students had suffered from serious injury, where involvement in sports activity (14.7%) was the major reported cause. There was a significant difference in injury-related characteristics between the two genders (P < 0.0001). 27.8% of the students were verbally abused by a teacher at least one time during the past 12 months. 15% of the students did not go to school at least once in a month as they felt unsafe, among which 2.0% students were absent for 4 or more days [Table 1].

Table 1.

Comparison of injury- and abuse-related characteristics among study participants according to gender

Characteristics	Boys (n=324)		Girls (n=310)		Total (n=634)		Chi square value, P
	No.	%	No.	%	No.	%
During the past 12 months, what were you doing when the most serious injury happened to you?
I was not seriously injured during the past 12 months	170	52.5	202	65.2	372	58.7	29.82, <0.001
Playing or training for a sport	66	20.4	27	8.7	93	14.7
Walking or running, but not as part of playing or training for a sport	23	7.1	17	5.5	40	6.3
Riding a bicycle, scooter, or bike	30	9.3	17	5.5	47	7.4
Riding or driving in a car or other motor vehicle	4	1.2	2	0.6	6	0.9
Doing any paid or unpaid work, including housework, yard work, or cooking	4	1.2	13	4.2	17	2.7
Nothing	9	2.8	14	4.5	23	3.6
Something else	18	5.6	18	5.8	36	5.7
During the past 12 months, how many times were you verbally abused by a teacher?
0 time	231	71.3	227	73.2	458	72.2	2.53, 0.95
1 time	38	11.7	38	12.3	76	12.0
2 or 3 times	28	8.6	27	8.7	55	8.7
4 or 5 times	12	3.7	7	2.3	19	3.0
6 or 7 times	4	1.2	3	1.0	7	1.1
8 or 9 times	3	0.9	1	0.3	4	0.6
10 or 11 times	1	0.3	1	0.3	2	0.3
12 or more times	7	2.2	6	1.9	13	2.1
During the past 30 days, on how many days did you not go to school because you felt unsafe?
0 day	271	83.6	268	86.5	539	85.0	3.52, 0.475
1 day	23	7.1	23	7.4	46	7.3
2 or 3 days	21	6.5	15	4.8	36	5.7
4 or 5 days	5	1.5	1	0.3	6	0.9
6 or more days	4	1.2	3	1.0	7	1.1

Girls were more likely to report having felt lonely most of the time or always in the past 12 months (11.0% versus 4.6%, P = 0.018). Although 16.4% of the students could not sleep as they were worried about something during the past 12 months, girls were more likely to report such sleeplessness most of the time or always than boys (9.0% vs 3.7%, P < 0.001). Approximately one quarter of the students stopped doing their daily activities as they felt sad or hopeless almost every day for 2 weeks or more in a row. 6.8% of the students reported not having even a single close friend. However, boys were more likely to have three or more friends than girls (5.2% vs 2.7%, P =0.007). Girls were more likely to report having felt disturbed due to the comments from their peers, family members, or teachers most of the time or always during past 12 months (39.2% vs 26.5%, P < 0.0001) [Table 2].

Table 2.

Comparison of emotions and friendship-related characteristics among study participants according to gender

Characteristics	Boys (n=324)		Girls (n=310)		Total (n=634)		Chi-square value, P
	No.	%	No.	%	No.	%
During the past 12 months, how often have you felt lonely?
Never	155	47.8	120	38.7	275	43.4	11.86, 0.018
Rarely	127	39.2	131	42.3	258	40.7
Sometimes	27	8.3	25	8.1	52	8.2
Most of the time	10	3.1	25	8.1	35	5.5
Always	5	1.5	9	2.9	14	2.2
How many close friends do you have?
No friend	24	7.4	19	6.1	43	6.8	19.82, <0.001
One friend	51	15.7	88	28.4	139	21.9
Two friends	122	37.7	121	39.0	243	38.3
Three or more friends	127	39.2	82	26.5	209	33.0
During the past 12 months, how often have you been so worried about something that you could not sleep at night?
Never	165	50.9	117	37.7	282	44.5	20.01, <0.001
Rarely	111	34.3	137	44.2	248	39.1
Sometimes	36	11.1	28	9.0	64	10.1
Most of the time	5	1.5	19	6.1	24	3.8
Always	7	2.2	9	2.9	16	2.5
During the past 12 months, did you ever feel so sad or hopeless almost every day for 2 weeks or more in a row that you stopped doing your usual activities?
Yes	77	23.8	79	25.5	156	24.6	0.252, 0.616
No	247	76.2	231	74.5	478	75.4
During the past 12 months, how often have you had a hard time staying focused on your homework or other things you had to do?
Never	127	39.2	129	41.6	256	40.4	2.05, 0.726
Rarely	154	47.5	148	47.7	302	47.6
Sometimes	24	7.4	19	6.1	43	6.8
Most of the time	12	3.7	11	3.5	23	3.6
Always	7	2.2	3	1.0	10	1.6
During the past 12 months, how often have you had a hard time answering questions or writing on the blackboard in front of your class?
Never	162	50.0	167	53.9	329	51.9	5.04, 0.281
Rarely	127	39.2	124	40.0	251	39.6
Sometimes	18	5.6	10	3.2	28	4.4
Most of the time	5	1.5	4	1.3	9	1.4
Always	12	3.7	5	1.6	17	2.7
During the past 12 months, how often have you felt disturbed due to the comments from your peers, family members, or teachers?
Never	189	58.3	180	58.1	369	58.2	13.61, 0.007
Rarely	95	29.3	103	33.2	198	31.2
Sometimes	31	9.6	11	3.5	42	6.6
Most of the time	5	1.5	13	4.2	18	2.8
Always	4	1.2	3	1.0	7	1.1

During the past 30 days, 2.8% students missed classes on 6 or more days, among which boys were more likely to miss classes on 3 or more days (9.9% vs 4.9%, P =0.043). Approximately two-third students reported that other students were never or rarely kind and helpful to them in the past 30 days. Girls were more likely to report having their guardians understand their problems and worries most of the time or always during the past 30 days (63.2% vs 54.3%, P = 0.008) [Table 3].

Table 3.

Self-reported experience regarding school and home by the study participants

Characteristics	Boys (n=324)		Girls (n=310)		Total		Chi-square value, P
	No.	%	No.	%	No.	%
During the past 30 days, on how many days did you miss classes or school without permission?
0 days	200	61.7	221	71.3	421	66.4	9.64, 0.043
1-2 days	92	28.4	74	23.9	166	26.2
3-5 days	21	6.5	8	2.6	29	4.6
6-9 days	6	1.9	3	1.0	9	1.4
10 or more days	5	1.5	4	1.3	9	1.4
During the past 30 days, how often were most of the students in your school kind and helpful?
Never	73	22.5	75	24.2	148	23.3	2.805, 0.591
Rarely	135	41.7	132	42.6	267	42.1
Sometimes	18	5.6	12	3.9	30	4.7
Most of the time	51	15.7	39	12.6	90	14.2
Always	47	14.5	52	16.8	99	15.6
During the past 30 days, how often did your parents or guardians check to see if your homework was done?
Never	35	10.8	47	15.2	82	12.9	3.86, 0.424
Rarely	115	35.5	108	34.8	223	35.2
Sometimes	22	6.8	19	6.1	41	6.5
Most of the time	57	17.6	43	13.9	100	15.8
Always	95	29.3	93	30.0	188	29.7
During the past 30 days, how often did your parents or guardians understand your problems and worries?
Never	26	8.0	30	9.7	56	8.8	13.67, 0.008
Rarely	86	26.5	71	22.9	157	24.8
Sometimes	36	11.1	13	4.2	49	7.7
Most of the time	61	18.8	62	20.0	123	19.4
Always	115	35.5	134	43.2	249	39.3
During the past 30 days, how often did your parents or guardians really know what you were doing with your free time?
Never	50	15.4	40	12.9	90	14.2	6.72, 0.151
Rarely	105	32.4	116	37.4	221	34.9
Sometimes	34	10.5	18	5.8	52	8.2
Most of the time	57	17.6	52	16.8	109	17.2
Always	78	24.1	84	27.1	162	25.6

Table 4 depicts the characteristics of substance abuse in the participants. In 12–15-year-old boys, initiation of smoking cigarettes (9.6% vs 1.2%, P < 0.0001) and tobacco chewing (3.4% vs 0.3%, P = 0.001) was more likely than girls. During the past 30 days, boys were more likely to smoke cigarettes (11.7% vs 1.9%, P<0.0001) and chew tobacco (8.6% vs 1.6%, P < 0.0001) than girls. Approximately 70% of students thought a man was ‘stupid’ when they saw them smoking. 70% students also reported being taught about the dangers of alcohol use in their classes during that school year. Almost one-third of the students reported that their father or male guardians used either alcohol or some form of tobacco. In the past 1 week, boys compared to girls were more likely to experience people smoking in their presence on 3 or more days (18.8% vs 10.6%, P = 0.024). Considering the role of media, boys compared to girls were more likely to always watch actors smoke (19.1% vs 11.3%, P = 0.011) and drink alcohol (15.7% versus 7.4%, P = 0.004), whereas girls compared to boys saw a lot of antismoking media messages during the past 30 days (52.3% vs 43.8%, P = 0.005). Attempts to quit smoking and tobacco were made by 4.6% and 6.2% boy and girl students, respectively, in the past 1 year, among which boys were more likely to quit smoking (7.7% vs 1.3%, P < 0.0001) and tobacco (9.9% vs 2.3%, P <0.0001).

Table 4.

Comparison of substance abuse-related characteristics among study participants according to gender

Characteristics	Boys (n=324)		Girls (n=310)		Total		Chi-square value, P
	No.	%	No.	%	No.	%
A. Characteristics related to substance abuse initiation
A.1. How old were you when you first tried a cigarette?
I have never smoked cigarettes	286	88.3	304	98.1	590	93.1	23.65, <0.001*
8 or 9 years old	0	0.0	1	0.3	1	0.2
10 or 11 years old	3	0.9	0	0	3	0.5
12 or 13 years old	12	3.7	2	0.6	14	2.2
14 or 15 years old	19	5.9	2	0.6	21	3.3
16 years old or older	4	1.2	1	0.3	5	0.8
A.2. How old were you when you first chewed tobacco?
I have never chewed tobacco	311	96.0	309	99.7	620	97.8	12.68, <0.001*
12 or 13 years old	1	0.3	1	0.3	2	0.3
14 or 15 years old	10	3.1	0	0.0	10	1.6
16 years old or older	2	0.6	0	0.0	2	0.3
A.3. Where were you the first time you had a drink of alcohol?
I have never had a drink of alcohol	299	92.3	298	96.1	597	94.2	12.92, 0.023
At home	12	3.7	7	2.3	19	3.0
At someone else’s home	3	0.9	2	0.6	5	0.8
At school	0	0	2	0.3	2	0.3
Out on the street, in a park, or in some other open area	0	0	1	0	1	0.2
At a bar, pub, or disco	2	0.6	0	0	2	0.3
In a restaurant	3	0.9	0	0	3	0.5
Some other place	5	1.5	0		5	0.8
B. Characteristics related to frequency of substance abuse
B.1. During the past 30 days, on how many days did you smoke cigarettes
0 days	286	88.3	304	98.1	590	93.1	24.28, <0.001
1-2 days	24	7.4	4	1.3	28	4.4
3-5 days	9	2.8	2	0.6	11	1.7
6-9 days	3	0.9	0	0.0	3	0.5
10-19 days	1	0.3	0	0.0	1	0.2
20-29 days	1	0.3	0	0.0	1	0.2
B.2. During the past 30 days, on how many days did you use any other form of tobacco, such as pan, masala, or gutka?
0 days	296	91.4	305	98.4	601	94.8	16.39, <0.001
1-2 days	25	7.7	5	1.6	30	4.7
3-5 days	2	0.6	0	0.0	2	0.3
6-9 days	1	0.3	0	0.0	1	0.2
B.3. During the past 12 months, how many times have you used drugs, such as inhaling any fluid, using Charas, or Ghanja?
0 times	316	97.5	309	99.7	625	98.6	4.81, 0.069
1 or 2 times	6	1.9	1	0.3	7	1.1
3 to 9 times	2	0.6	0	0.0	2	0.3
C. Characteristics related to knowledge and perception regarding substance abuse
C.1. During this school year, were you taught in any of your classes the dangers of alcohol use?
Yes	234	72.2	224	72.3	458	72.2	0.637, 0.727
No	48	14.8	51	16.5	99	15.6
Don’t know	42	13.0	35	11.3	77	12.1
C.2. When you see a man smoking, what do you think of him? select only one response
Stupid	218	67.3	223	71.9	441	69.6	5.49, 0.359
Loser	51	15.7	54	17.4	105	16.6
Successful	8	2.5	5	1.6	13	2.1
Intelligent	3	0.9	2	0.6	5	0.8
Macho	3	0.9	2	0.6	5	0.8
Others	41	12.7	24	7.7	65	10.3
C.3. Do you think smoking cigarettes is harmful to your health?
Definitely not	13	4.0	14	4.5	27	4.3	5.56, 0.062
Probably yes	21	6.5	8	2.6	29	4.6
Definitely yes	290	89.5	288	92.9	578	91.2
D. Role of guardians and surrounding environment in promoting substance abuse
D.1. Which of your parents or guardians use any form of tobacco?
None of them	154	47.5	172	55.5	326	51.4	7.11, 0.125
My father or male guardian	136	42.0	100	32.3	236	37.2
My mother or female guardian	3	0.9	5	1.6	8	1.3
Others in the family	10	3.1	13	4.2	23	3.6
I do not know	21	6.5	20	6.5	41	6.5
D.2. Which of your parents or guardians drink alcohol?
Neither	178	54.9	192	61.9	370	58.4	4.80, 0.284*
My father or male guardian	122	3737	104	33.5	226	35.6
My mother or female guardian	1	0.3	1	0.3	2	0.3
Both	3	0.9	1	0.3	4	0.6
I don’t know	20	6.2	12	3.9	32	5.0
D.3. During the past 7 days, on how many days have people smoked in your presence?
0 days	220	67.9	220	71.0	440	69.4	11.24, 0.024
1 or 2 days	43	13.3	57	18.4	100	15.8
3 or 4 days	32	9.9	18	5.8	50	7.9
5 or 6 days	15	4.6	5	1.6	20	3.2
All 7 days	14	4.3	10	3.2	24	3.8
E. Role of media
E.1. During the past 30 days, how many antismoking media messages have you seen?
A lot	142	43.8	162	52.3	304	47.9	10.45, 0.005
A few	119	36.7	115	37.1	234	36.9
None	63	19.4	33	10.6	96	15.1
E.2. When you watch television, videos, or movies, how often do you see actors smoking?
I never watch television, videos, or movies	20	6.2	26	8.4	46	7.3	14.93, 0.011
Never	10	3.1	16	5.2	26	4.1
Rarely	133	41.0	156	50.3	289	45.6
Sometimes	42	13.0	27	8.7	69	10.9
Most of the time	57	17.6	50	16.1	107	16.9
Always	62	19.1	35	11.3	97	15.3
E.3. When you watch television, videos, or movies, how often do you see actors drinking alcohol?
I never watch television, videos, or movies	26	8.0	28	9.0	54	8.5	17.19, 0.004
Never	29	9.0	19	6.1	48	7.6
Rarely	132	40.7	157	50.6	289	45.6
Sometimes	36	11.1	25	8.1	61	9.6
Most of the time	50	15.4	58	18.7	108	17.0
Always	51	15.7	23	7.4	74	11.7
F. Characteristics related to attempts to stop substance abuse
F.1. During the past 12 months, have you ever tried to stop smoking cigarettes?
I have never smoked cigarettes	286	88.3	303	97.7	589	92.9	21.97, <0.001
I did not smoke cigarettes during the past 12 months	11	3.4	3	1.0	14	2.2
Yes	25	7.7	4	1.3	29	4.6
No	2	0.6	0	0.0	2	0.3
F.2. During the past 12 months, have you ever tried to stop chewing tobacco?
I did not chew tobacco during the past 12 months	274	84.6	297	95.8	571	90.1	22.65, <0.001
Yes	32	9.9	7	2.3	39	6.2
No	18	5.6	6	1.9	24	3.8

CATPCA analysis of these 32 questions yielded an 11-factor model. The most appropriate number of factors/components for this domain was 11 as per Kaiser’s criterion. Also, the point where the slope of the curve in the scree plot is leveling off is at 11 [Supplementary File Figure ^{(503.2KB, tif)} ].

The fit for final model was adequate (KMO = 0.756; Bartlett’s test of sphericity, χ2 = 4992.285, df = 496, P < 0.0001). Table 5 summarizes the entire data into 11 components with their respective factor loadings given in detail in Supplementary File, Table A. These 11 components accounted for 58.26% of the total variation of the data, which is an acceptable amount of total variance. Six questions constituted the first and the most important principal component with the largest eigenvalue (4.109) and consequently the largest amount of the explained variance (12.84%). This component was named as “Tobacco (Smoking and Chewing): Initiation, Frequency and Attempt to Stop”. The second-most important component consisted of three questions and was labeled as “Emotional Disturbance and Impact on School Performance” (eigenvalue: 1.984; variance: 6.19%). The role of guardians was documented in two components, the third- and fifth-most important, accounting for 5.83% and 4.39% variance, respectively. The fourth-most important component was “Role of Actors in Substance Abuse” (eigenvalue: 1.634; variance: 5.108%) [Table 5].

Table 5.

Eigenvalues and variance explained by each component

Components	Variance Accounted For (VAF)
	Total (Eigen values)	% of Variance	Cumulative %
Component 1- Tobacco (Smoking and Chewing): Initiation, Frequency, and Attempt to Stop	4.109	12.841	12.841
Component 2- Emotional Disturbance and Impact on School Performance	1.984	6.199	19.040
Component 3- Role of Guardians in Emotional Behavior	1.866	5.830	24.870
Component 4- Role of Actors in Substance Abuse	1.634	5.108	29.977
Component 5- Role of Guardians in Substance Abuse	1.406	4.394	34.372
Component 6- Injury and Feeling of Unsafety	1.365	4.264	38.636
Component 7- Role of School and Media Messages	1.356	4.237	42.873
Component 8- Friendship and Feeling of Hopelessness	1.338	4.180	47.053
Component 9- Frequency of Intake of Inhalational Drugs	1.262	3.945	50.998
Component 10- School Absenteeism	1.167	3.647	54.645
Component 11- Perception of Cigarette Smoking	1.156	3.611	58.257

DISCUSSION

The present study assessed the injury, verbal abuse, substance use, and emotional behavior patterns among the adolescents of Uttarakhand. CATPCA was the most appropriate method to extract pattern and hidden relationships among these modules of the GSHS, especially considering the nominal nature of the data. Eleven components with considerable loading values accounted for 58.26% of the total variation in the data. This explained variance demonstrates the considerable ability of this model to summarize information.

The first and the most important component dealt with tobacco use in adolescents [Tobacco (Smoking and Chewing): Initiation, Frequency, and Attempt to Stop]. In the present study, both the initiation and frequency of either smoking or chewing of tobacco in past 30 days were reported more in boys as compared to girls. This was in concordance with ‘2007 Global School-based Student Health Survey - India (CBSE) Survey’ results,[16] wherein the percentage of boys smoking cigarettes (1.9% vs 0.2%) and chewing tobacco (4.3% vs 2.7%) in past 30 days was more than that of girls. However, these values were less than that of the present study, probably because the survey was conducted across India with a large sample size, whereas the present study is limited only to Uttarakhand. Other studies across various regions globally, be it the Eastern Mediterranean, South-East Asian, or the Western Pacific regions,[17,18,19] also reveal that boys were more likely than girls to misuse tobacco. Since tobacco addiction in adults has been largely initiated in adolescence,[20] it is of utmost importance to plan strategies to reduce its intake especially in male adolescents. Tobacco not only has deleterious effects on the physical body, but a few studies also highlight the significant impact of cigarette smoking on the emotional and behavioral problems (OR = 1.13, 95% CI: 1.08–1.18, P < 0.001).[21] Factor analysis of the present study also reveals that the second important component was the impact of emotional disturbances on the school performance of the adolescents during the past 12 months. It is responsible for 6.2% variance in the data. In the present study, approximately one-tenth of the students had a hard time staying focused on their homework, answering questions, or writing on the blackboard in front of the class and also felt disturbed due to the comments from their peers, family members, or teachers. This component highlights the connection between emotions and academic performance. Other studies across the globe also report strong relationship between adolescents’ emotions and academics, which was either negatively or positively associated, probably due to differences in cultures of those countries.[22,23]

The role of guardians has been explored in the third and fifth components. However, their role in the emotional behavior of the adolescents accounted for 5.83% variance in data, while their role in substance abuse accounted for 4.39%. In the present study, approximately 50% of the adolescents reported that their parents or guardians never or rarely checked their homework nor knew what they were doing with their free time. This was more than the ‘2007 India (CBSE) GSHS’, where 27.9% adolescents reported that their guardians never knew what they were doing in their free time.[16] Moreover, in the present study, one-third adolescents reported that guardians never or rarely understood their problems and worries and also reported their male guardians to be maximally using either alcohol or some form of tobacco. Jain S et al.[24] in their study on adolescents in India reported that guardians of 26.2% of the early adolescents (10–13 years) and 34.1% of the middle adolescents (14–17 years) never understood their problems/worries. Giannakopoulos G. et al.[21] in their study reported that if the father and mother were smokers, the risk in adolescents was almost twofold (OR = 1.94, 95% CI: 0.65–1.88) and 2.56 times greater (OR = 2.56, 95% CI: 1.49–4.39), respectively. Other studies also report the association between parent smoking behaviors and uptake of cigarettes by the adolescents and further explore the parent–child relations among other factors.[25]

The study’s implications are critical for shaping adolescent health strategies in Uttarakhand. By identifying 11 key components related to injury, verbal abuse, emotional behavior, and substance use, the present study offers a precise understanding of hidden patterns in the data. This component analysis combined with gender comparisons not only highlights gender-specific disparities—such as higher tobacco use among boys and the profound impact of emotional disturbances on academic performance—but also enables the prioritization of components that most significantly affect the local adolescent population. Such prioritization is crucial for developing for targeted, gender-sensitive, evidence-based interventions. The strategies may include educational programs, stricter tobacco regulation, and targeted support, especially for boys to reduce tobacco initiation and frequent use. Schools may implement mental health programs, with trained teachers and counselors to support students’ emotional well-being. The study also emphasizes the importance of increased parental involvement, educating parents on monitoring their children’s activities and addressing parental substance use. Although the present study was conducted with a well-designed schedule, a few limitations were inevitable. First, the data are limited to a few districts of Uttarakhand state and hence cannot be generalized to all of India. Second, the study population is composed exclusively of students from government schools, and as a result, the perspectives of adolescents from private schools have not been captured. This limits the generalizability of the findings to all adolescents in the study area. However, these gaps also provide an important scope for future studies. Third, even though CATPCA was used to overcome the limitations that could arise from principal component analysis (PCA) of nominal data, it also yields similar limitations to PCA. Moreover, even with this technique, no causal relationships can be established; only associations can be determined. Last, although the GSHS primarily captures data from the student’s perspective and is conducted with guardian consent, this focus is not inherently a limitation of the study. However, future research could benefit from including parental perspectives, offering a more comprehensive and holistic view of the issues surveyed and capturing insights that might be missed when relying solely on students’ viewpoints. Overall, this study highlights 11 components that are closely tied to both physical and mental health outcomes, which are of significant concern in school-aged populations. Understanding these risk factors allows for the development of focused, evidence-based interventions that address specific health behaviours and vulnerabilities. The study’s impact lies in its potential to provide a scientifically grounded framework for stakeholders in Uttarakhand to address the region’s most pressing health challenges and optimize adolescent health outcomes.

CONCLUSION

The study concluded that there was a significant difference in various items of injury, verbal abuse, substance use, and emotional behavior of adolescents between the boys and girls. CATPCA revealed patterns among the injury, verbal abuse, emotional behavior, and substance abuse domains in the form of 11 components. This not only enhanced the statistical capacity of the study but also improved the precision and accuracy with which hidden aspects of data could be analyzed. Hence, an understanding of these components may help in prioritizing and development of appropriate school-based interventions that may be implemented by various stakeholders in Uttarakhand, India. It is recommended to conduct similar studies on GSHS data of different places to compare their patterns.

Abbreviations

• CATPCA: Categorical Principal Component Analysis

• GSHS: Global School-based Health Survey

• KMO: Kaiser–Meyer–Olkin

• VAF: Variance Accounted For

• PCA: Principal Component Analysis

Financial support and sponsorship

Uttarakhand State Council for Science and Technology, Uttarakhand.

Conflicts of interest

There are no conflicts of interest.

APPENDIX/SUPPLEMENTARY FILE

Figure

Scree Plot depicting number of components

Table A.

Loading value of each question loaded into 11 major components

	Component
	1 Tobacco (Smoking & Chewing): Initiation, Frequency, and Attempt to Stop	2 Emotional Disturbance and Impact on School Performance	3 Role of Guardians in Emotional Behavior	4 Role of Actors in Substance Abuse	5 Role of Guardians in Substance Abuse	6 Injury and Feeling of Unsafety	7 Role of School and Media Messages	8 Friendship and Feeling of Hopelessness	9 Frequency of Intake of Inhalational Drugs	10 School Absenteeism	11 Perception of Cigarette Smoking
During the past 12 months, what were you doing when the most serious injury happened to you?	-0.011	-0.035	0.134	0.024	0.017	0.636	-0.293	0.054	0.061	-0.019	0.029
During the past 12 months, how many times were you verbally abused by a teacher?	-0.010	0.353	-0.027	0.104	-0.087	0.458	0.127	-0.052	-0.123	0.323	0.137
During the past 30 days, on how many days did you not go to school because you felt unsafe?	0.068	0.180	-0.002	-0.042	0.038	0.547	0.224	-0.246	0.020	0.033	-0.098
During the past 12 months, how often have you felt lonely?	0.071	0.389	-0.046	0.040	0.144	0.144	-0.274	-0.350	-0.008	0.140	0.004
During the past 12 months, how often have you been so worried about something that you could not sleep at night?	-0.033	0.373	0.087	0.061	0.268	-0.050	-0.128	-0.454	-0.035	-0.213	0.090
During the past 12 months, did you ever feel so sad or hopeless almost every day for two weeks or more in a row that you stopped doing your usual activities?	-0.034	-0.209	-0.076	-0.045	-0.113	-0.150	0.055	0.543	0.073	-0.060	0.074
How many close friends do you have?	0.017	0.258	0.042	0.069	0.072	0.061	-0.067	0.649	-0.137	-0.004	-0.042
During the past 12 months, how often have you had a hard time staying focused on your homework or other things you had to do?	0.008	0.678	-0.115	0.028	-0.109	0.018	0.028	0.003	0.072	0.017	0.081
During the past 12 months, how often have you had a hard time answering questions or writing on the blackboard in front of your class?	0.088	0.663	-0.030	0.065	0.030	0.038	0.071	0.038	0.091	-0.133	-0.053
During the past 12 months, how often have you felt disturbed due to the comments from your peers, family members, or teachers?	-0.070	0.628	-0.089	-0.051	0.076	0.026	-0.077	-0.050	-0.034	0.192	-0.011
How old were you when you first tried a cigarette?	0.937	-0.033	-0.079	0.071	0.030	0.003	-0.026	-0.037	-0.026	-0.051	0.050
During the past 30 days, on how many days did you smoke cigarettes	0.858	-0.026	-0.115	0.087	0.053	0.026	-0.028	-0.047	-0.044	-0.095	0.044
During the past 30 days, on how many days did you use any other form of tobacco, such as pan, masala, or gutka?	0.849	0.010	0.053	-0.052	0.012	-0.024	-0.011	0.084	0.086	0.065	-0.003
During the past 12 months, have you ever tried to stop smoking cigarettes?	0.932	-0.034	-0.078	0.071	0.031	0.039	-0.022	-0.041	-0.009	-0.038	0.060
During the past 7 days, on how many days have people smoked in your presence?	0.186	-0.010	-0.110	0.087	0.298	0.456	-0.074	0.248	0.188	-0.292	0.088
Which of your parents or guardians use any form of tobacco?	-0.009	0.054	-0.068	0.029	0.727	0.014	0.131	-0.141	-0.018	-0.060	-0.094
When you see a man smoking, what do you think of him? select only one response	0.110	0.026	-0.095	0.043	0.134	0.062	-0.028	0.110	-0.105	0.166	0.757
Do you think smoking cigarettes is harmful to your health?	-0.032	-0.024	-0.055	0.094	0.195	0.077	-0.100	0.163	-0.290	0.251	-0.630
During the past 30 days, how many anti-smoking media messages have you seen?	-0.006	0.031	0.042	-0.203	0.125	0.075	0.700	-0.020	0.124	-0.150	-0.033
When you watch television, videos, or movies, how often do you see actors smoking?	0.001	-0.009	0.003	0.871	-0.014	0.003	-0.094	0.025	0.084	0.021	0.007
How old were you when you first chewed tobacco?	0.530	0.167	0.090	-0.072	-0.111	0.064	0.024	0.034	0.254	0.028	-0.118
During the past 12 months, have you ever tried to stop chewing tobacco?	0.687	0.018	0.062	-0.099	-0.028	0.013	0.097	-0.006	0.074	0.154	0.096
Where were you the first time you had a drink of alcohol?	0.266	0.077	-0.020	0.026	0.099	0.075	-0.063	0.000	0.459	0.083	0.219
During this school year, were you taught in any of your classes the dangers of alcohol use?	0.031	-0.046	-0.064	0.070	-0.016	-0.083	0.718	0.061	-0.105	0.159	0.062
Which of your parents or guardians drink alcohol?	0.002	-0.027	-0.064	-0.002	0.697	0.024	-0.034	0.019	0.095	0.205	0.107
When you watch television, videos, or movies, how often do you see actors drinking alcohol?	0.003	0.085	0.107	0.842	0.055	0.024	-0.008	-0.021	0.011	-0.017	-0.018
During the past 12 months, how many times have you used drugs, such as inhaling any fluid, using Charas, or Ghanja?	0.026	0.037	-0.025	0.085	0.029	0.012	0.034	-0.029	0.836	0.080	-0.066
During the past 30 days, on how many days did you miss classes or school without permission?	0.069	0.060	0.017	0.000	0.127	0.007	0.003	-0.021	0.160	0.779	0.018
During the past 30 days, how often were most of the students in your school kind and helpful?	0.043	0.215	0.390	0.144	0.174	-0.370	-0.158	0.273	0.036	-0.022	0.038
During the past 30 days, how often did your parents or guardians check to see if your homework was done?	-0.028	-0.139	0.700	0.062	-0.106	0.044	-0.010	0.012	0.068	-0.054	-0.040
During the past 30 days, how often did your parents or guardians understand your problems and worries?	-0.044	-0.028	0.732	-0.012	0.004	-0.070	0.030	-0.009	-0.094	0.045	0.058
During the past 30 days, how often did your parents or guardians really know what you were doing with your free time?	0.007	-0.090	0.733	0.034	-0.062	0.102	-0.031	-0.083	-0.006	0.020	-0.088

Rotation Method: Varimax with Kaiser Normalization (Rotation converged in 11 iterations)