1. Background
Hunger is an individual-level physiological condition, which may result from food insecurity. Food insecurity is a household-level economic and social condition, associated with limited or uncertain access to adequate food (1). In member countries of the association of southeast asian nations (ASEAN), the prevalence of hunger or undernourishment has been estimated at 9.6%. The prevalence has been reported at 14.2% in Cambodia and Myanmar, 13.5% in the Philippines, 11.0% in Vietnam, 7.6% in Indonesia, 7.4% in Thailand, and < 5% in Malaysia (2).
In a previous study, according to the global hunger index, including undernourishment, child stunting, wasting, and mortality, serious hunger was reported in Cambodia, Indonesia, Myanmar, and Philippines (scores, 20.1 - 23.5) and moderate hunger was indicated in Malaysia, Thailand, and Vietnam (scores, 10.3 - 19.9) (3). In addition, among children under 5 years, chronic undernourishment or stunted growth was still prevalent in a number of ASEAN countries, including Myanmar (35.1%), Philippines (33.6%), Vietnam (23.3%), Malaysia (17%), and Thailand (16%) at different time points during 1993 - 2011 (2).
According to studies among adolescents in Asia, 1.3% of the population were often or always hungry in rural China (4), while in a small local study in Bangalore, India, 14.7% of the subjects experienced hunger (rarely, sometimes, often, or always) (5). Moreover, in rural Goa, India, 59.2% of the adolescent students experienced hunger due to inadequate food intake (6), and in a national study of adolescents in Taiwan, 10% reported experiences of hunger or thirst over the last year (7).
In 7 sub-Saharan countries, the prevalence of hunger in the past month (often or always) was the highest in Zambia (28.7%), followed by Kenya (14.7%), Botswana (13.9%), Malawi (12.5%), and Uganda (9.3%) (8-10). In the Americas, according to a study in Canada, 25.1% of the population sometimes, often, or always experienced hunger, while 3.8% were often or always hungry (11). Moreover, in another study in Canada, the prevalence of hunger among children was 5.7% (never, yes, or no) (12), while in Ecuador, 41.2 % of the students reported hunger (rarely, sometimes, mostly, or always) (13).
According to various studies, adolescents with hunger or food insecurity are at an increased risk of adverse emotional or behavioural outcomes, including reduced emotional and mental health, anxiety, sadness, loneliness, social isolation, depression, suicidal ideation, alcohol use, substance use disorders, drug abuse, bully victimization, involvement in physical fights, truancy, and arrogant behaviors at school towards teachers (antisocial behaviors) (8, 10-15).
Overall, there is a scarcity of research on hunger and its psychobehavioural correlates among adolescents in ASEAN countries. The purpose of this study was to examine the prevalence of hunger and its psychobehavioural correlates among adolescents in ASEAN member countries, including Cambodia, Indonesia, Malaysia, Myanmar, Thailand, Philippines, and Vietnam, which prompted this study.
2. Objectives
The objective of this study was to examine hunger and its psychobehavioural correlates among adolescents in ASEAN member countries.
3. Materials and Methods
3.1. Study Sample and Procedure
This study included a secondary analysis of cross sectional data from the global school-based student health survey (GSHS) in ASEAN member states, including Cambodia, Indonesia, Malaysia, Myanmar, Thailand, Philippines, and Vietnam during 2007 - 2013 (16). All ASEAN countries with publicly available GSHS datasets were included in the analysis. A 2-stage cluster sampling design was used to collect data for representing all students in grades 6 - 10 from each country (16).
In the first stage of sampling, schools were selected via probability proportional to size (PPS) sampling (16). In the second stage, classes in the schools were randomly selected, and all students in the selected classes were considered eligible to participate in the study, irrespective of their age (16). Students independently completed the questionnaires under the supervision of trained research assistants (16). The GSHS proposal has been approved by the world health organization, as well as the ministries of education and health in each country. In addition, informed consents were obtained from all the participants and their parents (16).
The sample size was determined, based on similar studies in this area. Among 7 countries, the prevalence of hunger (mostly or always) in the past month ranged from 28.7% in Zambia to 3.7% in Tanzania (8-10). Using Epi Info software for sample size calculation, the sample size was determined, considering a maximum prevalence of 30%, confidence interval (CI) of 1, a cluster of 7 ASEAN countries, and confidence level of 99.99% (sample, 30 821).
3.2. Measures
The instrument used in this study included GSHS (16), as described in Table 1. In a previous validation study, GSHS was reported to have acceptable validity. The average agreement between test and retest results was 77%, and the average Cohen’s kappa coefficient was 0.47 (17).
| Variables | Questions | Options |
|---|---|---|
| Hunger | During the past 30 days, how often did you go hungry because there was not enough food at home? | 1 = never, 2 = rarely, 3 = sometimes, 4 = most of the time, 5 = always |
| Psychobehavioural problems | ||
| Loneliness | During the past 12 months, how often have you felt lonely? | 1 = never to 5 = always (coded 1 - 3 = 0 and 4 – 5 = 1) |
| Suicidal ideation | During the past 12 months, did you ever seriously consider attempting suicide? | 1 = yes, 2 = no |
| Anxiety | During the past 12 months, how often have you been so worried about something that you could not sleep at night? | 1 = never to 5 = always (coded 1 - 3 = 0 and 4 – 5 = 1) |
| Current cigarette smoking | During the past 30 days, how many days did you smoke cigarettes? | 1 = 0 days to 7 = all 30 days (coded 1 = 0 and 2 – 7 = 1) |
| Current use of other tobacco products | During the past 30 days, how many days did you use any type of tobacco products such as tobacco leaves?” | 1 = 0 days to 7 = all 30 days (coded 1 = 0 and 2 – 7 = 1) |
| Current alcohol use | During the past 30 days, on how many days did you have at least 1 alcoholic drink? | 1 = 0 days to 7 = all 30 days (coded 1 = 0 and 2 - 7 = 1) |
| Truancy | During the past 30 days, how many days did you miss classes or school without permission? | 1 = 0 days to 5 = 10 or more days (coded 1 = 0 and 2 - 5 = 1) |
| Bully victimization | During the past 30 days, how many days were you bullied? | 1 = 0 days to 7 = all 30 days (coded 1 = 0 and 2 – 7 = 1) |
| Involvement in physical fights | During the past 12 months, how many times were you in a physical fight? | 1 = 0 times to 8 = 12 or more times (coded 1 = 0 and 2 – 8 = 1) |
| Injury | During the past 12 months, how many times were you seriously injured? (An injury is serious when it makes you miss at least 1 full day of usual activities such as school attendance, sports activities, or job or when treatment by a doctor or medical personnel is required.) | 1 = 0 times to 8 = 12 or more times (coded 1 = 0 and 2 – 8 = 1) |
| Protective sociofamilial factors | ||
| Peer support | During the past 30 days, how often were most of the students in your school kind and helpful? | 1 = never to 5 = always (coded 1 - 3 = 0 and 4 – 5 = 1) |
| Parental or guardian supervision | During the past 30 days, how often did your parents or guardians check to see if your homework was done? | 1 = never to 5 = always (coded 1 - 3 = 0 and 4 - 5 = 1) |
| Parental or guardian connectedness | During the past 30 days, how often did your parents or guardians understand your problems and concerns? | 1 = never to 5 = always (coded 1 - 3 = 0 and 4 - 5 = 1) |
| Parental or guardian bonding | During the past 30 days, how often did your parents or guardians really know what you were doing with your free time? | 1 = never to 5 = always (coded 1 - 3 = 0 and 4 – 5 = 1) |
Description of the Variables
3.3. Data Analysis
Stata version 13.0 (Stata Co., college station, Texas, USA) was used for data analysis. The study sample from each country was restricted to the age group of 13 - 15 years to facilitate comparisons among the samples from different countries. The associations between hunger and psychosocial indicators among school children were determined, based on odds ratios (ORs). Multivariate logistic regression analysis was employed to estimate the effect of independent variables (hunger, sociodemographic characteristics, and protective sociofamilial factors) on psychobehavioural outcomes (binary dependent variables) after adjusting for age, gender, country’s income, peer support, parental/guardian supervision, bonding, and connectedness. Regarding the multistage design of the survey, P value and 95% CI were adjusted.
4. Results
4.1. Sample Characteristics
The study sample included 30 197 students (age range, 13 - 15 years) from 7 ASEAN member countries. The overall response rate ranged from 82% in the Philippines to 96% in Vietnam. The sample size in the evaluated countries ranged from 1732 in Cambodia to 16 050 in Malaysia, including 14 696 (48.5%) males and 15 459 (51.5%) females (mean age, 14.1 ± 0.8 years).
The year in which GSHS was implemented in each country varied from 2007 in Indonesia and Myanmar to 2013 in Cambodia and Vietnam. The secondary school gross enrolment ratio was 71% in Malaysia, 83% in Indonesia, 85% in the Philippines, and 86% in Thailand, while no information was available for Cambodia or Myanmar (18). In terms of the overall prevalence of hunger in 7 ASEAN countries, 56.9% of the subjects experienced hunger rarely to always in the past month, while 4.2% felt hungry most of the time or always (high hunger status). The prevalence of high hunger status ranged from 0.9% in Vietnam to 7.9% in Cambodia (Table 2).
| Variables | Sample | The Percentage of Subjects Reporting Hunger in the Past 30 Days Due to Inadequate Food at Home | |||
|---|---|---|---|---|---|
| N | Never | Rarely | Sometimes | Mostly/Always | |
| All | 30197 | 43.1 | 25.3 | 27.3 | 4.2 |
| Cambodia | 1732 | 48.5 | 20.2 | 23.4 | 7.9 |
| Indonesia | 2864 | 35.3 | 27.0 | 31.8 | 5.8 |
| Malaysia | 16050 | 39.3 | 28.5 | 27.8 | 4.4 |
| Myanmar | 1974 | 64.7 | 6.6 | 26.1 | 2.6 |
| Philippines | 3625 | 35.5 | 26.5 | 31.8 | 6.2 |
| Thailand | 2219 | 47.7 | 23.5 | 25.8 | 3.2 |
| Vietnam | 1733 | 50.8 | 28.7 | 19.5 | 0.9 |
| Gender | |||||
| Female | 15459 | 45.3 | 24.8 | 26.6 | 3.3 |
| Male | 14696 | 40.9 | 25.9 | 28.1 | 5.2 |
| Age (years) | |||||
| 13 | 9102 | 42.6 | 21.6 | 30.9 | 4.9 |
| 14 | 10941 | 42.5 | 26.8 | 26.3 | 4.4 |
| 15 | 10154 | 44.2 | 26.4 | 25.9 | 3.6 |
| Country’s income | |||||
| Lowa/lower Middleb | 11928 | 42.8 | 25.3 | 27.6 | 4.4 |
| Upper middlec | 18269 | 44.4 | 25.3 | 26.6 | 3.7 |
| Parental supervision | |||||
| No | 21247 | 39.5 | 26.6 | 29.5 | 4.4 |
| Yes (mostly/always) | 7001 | 50.6 | 22.9 | 22.8 | 3.7 |
| Parental connectivity | |||||
| No | 18363 | 39.1 | 27.1 | 29.5 | 4.3 |
| Yes(mostly/always) | 9933 | 50.7 | 22.2 | 23.2 | 3.9 |
| Parental bonding | |||||
| No | 15608 | 37.3 | 26.8 | 31.1 | 4.7 |
| Yes (mostly/always) | 12642 | 50.8 | 23.5 | 22.3 | 3.4 |
| Peer support | |||||
| No | 16326 | 38.5 | 26.2 | 30.7 | 4.6 |
| Yes (mostly/always) | 11992 | 49.7 | 24.5 | 22.4 | 3.5 |
Descriptive Data of Hunger Status in School-Aged Students (13 - 15 Years)
4.2. Factors Associated with Psychobehavioural Problems
In bivariate and adjusted multivariate logistic regression analyses, increased frequency of hunger in the past month was associated with psychological distress (loneliness, suicidal ideation, and anxiety), substance use (tobacco and alcohol), behavioural problems (truancy, bully victimization, and involvement in physical fights), and serious injury in the last year (Table 3).
| Variables | Psychobehavioural Outcomes | Unadjusted Odds Ratio (95% CI) | Adjusted Odds Ratio (95% CI)a |
|---|---|---|---|
| Loneliness | |||
| Never | 7.0 | 1 (Reference) | 1 (Reference) |
| Rarely | 10.8 | 1.69 (1.45 - 1.96) | 1.52 (1.20 - 1.92)*** |
| Sometimes | 11.9 | 1.89 (1.64 - 2.16)*** | 1.68 (1.39 - 2.03)*** |
| Mostly or always | 17.8 | 2.80 (2.18 - 3.61)*** | 2.96 (2.16 - 4.04)*** |
| Suicidal ideation | |||
| Never | 8.6 | 1 (Reference) | 1 (Reference) |
| Rarely | 12.0 | 1.54 (1.36 - 1.74)*** | 1.25 (1.05 - 1.50)* |
| Sometimes | 10.8 | 1.44 (1.24 - 1.68)*** | 1.13 (0.95 - 1.36) |
| Mostly or always | 13.2 | 1.81 (1.44 - 2.26)*** | 1.51 (1.13 - 2.03)** |
| Anxiety | |||
| Never | 5.3 | 1 (Reference) | 1 (Reference) |
| Rarely | 7.4 | 1.53 (1.31 - 1.78)*** | 1.35 (1.11 - 1.65)** |
| Sometimes | 8.9 | 1.88 (1.61 - 2.19)*** | 1.59 (1.27 - 1.98)*** |
| Mostly or always | 16.8 | 3.54 (2.71 - 4.62)*** | 3.42 (2.54 - 4.62)*** |
| Tobacco use | |||
| Never | 6.4 | 1 (Reference) | 1 (Reference) |
| Rarely | 10.1 | 1.63 (1.41 - 1.88)*** | 1.44 (1.16 - 1.78)*** |
| Sometimes | 10.6 | 1.68 (1.43 - 1.97)*** | 1.42 (1.18 - 1.71)*** |
| Mostly or always | 14.1 | 2.24 (1.82 - 2.76)*** | 1.90 (1.34 - 2.41)*** |
| Alcohol use | |||
| Never | 10.4 | 1 (Reference) | 1 (Reference) |
| Rarely | 14.0 | 1.50 (1.31 - 1.71)*** | 1.27 (1.05-1.54)* |
| Sometimes | 11.4 | 1.24 (1.06 - 1.46)** | 0.96 (0.78-1.19) |
| Mostly or always | 18.4 | 1.50 (1.13 - 1.98)** | 1.76 1.32-2.35)*** |
| Truancy | |||
| Never | 18.8 | 1 (Reference) | 1 (Reference) |
| Rarely | 27.8 | 1.46 (1.30 - 1.65)*** | 1.52 (1.35-1.71)*** |
| Sometimes | 29.3 | 1.64 (1.46 - 1.85)*** | 1.61 (1.42-1.82)*** |
| Mostly or always | 40.4 | 2.40 (1.85 - 3.11)*** | 2.54 (1.94-3.32)*** |
| Bully victimization | |||
| Never | 26.6 | 1 (Reference) | 1 (Reference) |
| Rarely | 37.8 | 1.69 (1.50 - 1.90)*** | 1.57 (1.38 - 1.78)*** |
| Sometimes | 46.2 | 2.37 (2.16 - 2.59)*** | 2.10 1.85 - 2.40)** |
| Mostly or always | 48.4 | 2.99 (2.44 - 3.65)*** | 2.31 (1.77 - 3.01)*** |
| Involvement in physical fights | |||
| Never | 22.9 | 1 (Reference) | 1 (Reference) |
| Rarely | 33.4 | 1.57 (1.38 - 1.79)*** | 1.56 (1.37 - 1.79)*** |
| Sometimes | 35.8 | 1.84 (1.67 - 2.03)*** | 1.68 (1.51 - 1.88)*** |
| Mostly or always | 47.2 | 3.11 (2.56 - 3.78)*** | 2.57 (1.97 - 3.35)*** |
| Injury | |||
| Never | 30.3 | 1 (Reference) | 1 (Reference) |
| Rarely | 42.4 | 1.67 (1.49 - 1.87)*** | 1.60 (1.41 - 1.81)*** |
| Sometimes | 49.6 | 2.20 (1.99 - 2.45)*** | 2.06 1.82 - 2.34)*** |
| Mostly or always | 55.6 | 3.17 (2.53 - 3.96)*** | 2.61 (2.00 - 3.41)*** |
The Relationships Between Hunger and Poor Mental and Health Behaviours
5. Discussion
In the present study, the prevalence of hunger in the past month was high (rarely to always, 56.9%; most of the time or always, 4.2%) in 7 ASEAN countries with major differences; the lowest rate was reported in Vietnam and Myanmar and the highest was found in Cambodia and the Philippines. These findings are greatly comparable with previous studies among adolescents in Ecuador (13), India (6), Taiwan (7), and Canada (11, 12). On the other hand, the prevalence of hunger in this study was higher than previous studies performed in rural China (4) and Bangalore, India (5).
Nevertheless, the prevalence of hunger was significantly lower in this study, compared to rates reported among adolescents in 7 sub-Saharan countries (8-10). The differences in the prevalence of hunger among ASEAN countries agree with previous reports on the high prevalence of hunger or undernourishment in Cambodia and the Philippines (based on the Global Hunger Index) and the lower prevalence of hunger in only 2 upper-middle income countries (Malaysia and Thailand) (2, 3). Surprisingly, the present study reported a low prevalence of hunger in Myanmar, while previous studies have classified this country as having a serious hunger problem (based on the global hunger index) (3).
Concurrent with several previous studies (8, 10-15), the present study found an association between increased frequency of hunger in the past month and psychological distress (loneliness, suicidal ideation, and anxiety), substance use (tobacco and alcohol use), and behavioural problems (truancy, bully victimization, and involvement in physical fights). These findings raise some concerns, considering the high occurrence of hunger in the study sample.
Furthermore, this study reported an association between hunger and injury in the last year. Pickett et al. (20) found that hunger was positively correlated with specific injuries (due to street quarrels and physical fights). It is possible that adolescents who engage in an increasing number of risky behaviours also experience a higher risk of injury (21). In addition, stress (stress surrounding food security) may predict psychobehavioural problems among these adolescents (12).
In this regard, a model suggested that childhood development adversity, which may extend to hunger through different mechanisms (eg, attachment problems), can result in mental health problems in later stages of life (12, 22). Some evidence also suggests that low calorie intake may be associated with increased physiological and emotional reactivity and cause mental problems (23, 24). Therefore, to overcome hunger-related problems, it may be necessary to address social factors or stressors at home (eg, lack of control in life) with an integrated approach (11).
In the present study, the strength of GSHS administration was the utilization of a standardized method and questionnaire in 7 ASEAN countries. However, as the survey had a cross sectional design and only included school-aged children, no causal inferences or generalizations could be made for all the children. Moreover, hunger was only assessed with 1 question; therefore, assessment of this phenomenon was limited. Furthermore, socioeconomic status was not assessed, and in future studies, food insecurity and socioeconomic status should be examined.
In conclusion, the present study reported a high prevalence of hunger among school-aged adolescents in 7 ASEAN countries. Further quantitative and qualitative research is recommended to better understand the social circumstances, leading to hunger during adolescence in ASEAN member countries. Incorporation of food programmes (including school feeding programmes) and targeting hunger among ASEAN children may require the use of a more integrative approach incorporating care (eg, devoting time, support, and attention to a range of child developmental needs). Programmes to improve psychobehavioural health among ASEAN adolescents should consider the potential contribution of hunger or food insecurity.
