December 2001, Volume 51, Issue 12

Original Article

Urbanisation and Health related Knowledge and Attitudes of South Asian Children

R. Hakeem  ( Department of Food and Nutrition, RLAK Government College of Home Economics, Karachi. )
J. Thomas  ( Department of Nutrition and Dietetics, Kings College, London, UK. )
S. H. Badruddin  ( Department of Medicine/Community Health Sciences, The Aga Khan University, Karachi. )


Objective: To study the differences in health related knowledge and attitudes of less and more urbanised 10-12 year old South Asian school children.
Method: A total of 589 Asian children living in UK and in Pakistan were studied. Three groups of children were recruited from Punjab, Pakistan: rural (RrP n=100), middle income urban (MUP, n=148) and high income urban (HUP, n=1 59) and they were assigned urbanization rank (UR) 1 2 and 3. Another two groups of children were recruited from Slough, UK: British Pakistani (BrP, n=110) and British Indian (Brl, n=71) and they were assigned urbanization rank 4 and 5 respectively. Information about Cardiovascular Health (CVH) related knowledge, Health Locus of Control (HLC), smoking behaviour, self-perception of bodyweight and self-perception of activity level was collected through questionnaire. Actual weight status was judged by measuring body height and weight. Actual Physical Activity Level (PAL) was calculated from three day activity records kept by children.
Results: In general health related knowledge improved with urbanisation status. In all groups girls scored better on knowledge test than boys from the same group. HLC scores increased (indicate higher level of internal locus of control) steadily with urbanisation from UR 1-3. In most groups girls had slightly lower HLC scores. Smoking intentions were not related to UR. Validity of perceptions slightly improved with urbanisation rank only for activity level.
Conclusion: Due to lack of knowledge and belief in external health locus of control, behaviour modification is likely to harder in less urbanized Pakistani groups. For the prevention of disease, efforts are required not only to increase the children’s knowledge about health but also to increase awareness and understanding of healthy body weight, physical activity, hazards of smoking and to inculcate belief in internal control over own health (JPMA 51:437,2001).


In developed countries incidence of non- communicable diseases increased with urbanisation but was found to decline due to behaviour modification1. The health of future generations of South Asian countries, which are rapidly urbanising now, depends on the health-related behaviour of children today and tomorrow. Preventive check the spread of CHD epidemic in future. Positive results from early interventions have been noticed2-6. However, differences in demographic characteristics may necessitate designing culturally appropriate education. Studies in China have shown socio-demographic differences in nutrition knowledge and health locus of and they were assigned urbanization rank4 and5 control and indicate a need for specific nutrition education respectively (table 1). Assessment of dietary habits and for rural and urban population7-10. Assessment of of differences in knowledge and health-related beliefs of less and more urbanised South Asian groups can help in planning specific and effective educational campaigns.


Data was collected through questionnaires from five group of 10-12 year old school children, representing various urbanization catagories. Three groups of children were recruited from Punjab, Pakistan: rural(n=100), middle income urban (n=148) and high income urban (n=159) and they were assigned urbanization rank (UR) 1,2 and 3. Another two  groups of children were recruited from Sliugh, UK: British Pakistani (n=110), and British Indian (n=71) and they were assigned urbanization rank 4 and 5 respectively (table 1).
Assessment of dietary habits and exposure to Western culture conformed that ranking of Indian and Pakistanis in Britanin was correct11.
The data was collected through questionnaires filled by a total of 589 children. Students filled the questionnaires in their classrooms, in the presence of their teachers and the researcher. Proportion of adequately filled questionnaires ranged form 90-98% in various groups.
Data Collection and Analysis
CVH related Knowledge
The questionnaire contained questions about CVH related knowledge, belief in health locus of control, smoking intentions and presence of smoker in the family and self concept about bodyweight and physical activity level.
The cardiovascular nutrition knowledge questions were based on two nutrition teaching packages for primary schoolchildren in12 and cardiovascular nutrition knowledge questionnaire designed by White et aP3. The questions regarding health locus of control were adapted from Health related behaviour questionnaire used at the national level for British school children14.
Health Locus of Control
For determining health locus of control, children were asked to mention their agreement or disagreement with four statements regarding health locUs of control. The question were: i) “I am in charge of My Health”; ii) “If I Keep Healthy I Have Just Been Lucky”; iii) “If I take care I’ll stay healthy” and iv) “Even if I look after myself I can still fall ill”. The responses to these questions indicated the extent to which the children considered themselves responsible for their health (internal locus of control). These questions were used to generate a health locus of control score as used by Balding,14 For the first and the third question where agreement indicated internal control over health, a score of 1 was given for agreement and -1 for disagreement. For the second and the fourth question where agreement indicated external control over health, a score of-1  was given for disagreement and I for agreement. For all the four questions ‘not sure’ was given a score of zero. The sum of all the four scores generated a locus of health control score for each child, which could range from -4 to +4. Lower scores or more negative scores indicated that the child considered external factors to be responsible for their health.
Smoking intentions
Students were asked to mention whether any of their parents were regular smokers or not. They were also asked to indicate their own smoking behaviour, as well as future intentions.
Validity of Self-Perception of Body Weight
Children’s height and weight was measured in school. BMI was calculated and by comparing BMI values with international standards they were grouped into three categories of BMI: underweight, normal-weight and overweight. Children were asked to mention whether they wished to lose or gain weight or were happy with their bodyweight as it was. Validity of their concerns was judged by comparing their desires with their actual weight status.
Validity of Self-Perception of Physical Activity Level Children were asked to provide information about their daily activities (3 day-record) and on the basis of this information their Physical Activity Level (PAL) was calculated. The PAL value indicates multiples of BMR the subject spends in physical activity and thus higher values indicate more active lifestyle. Children were asked to mention whether they considered themselves to be physically very active, moderately active, or inactive. The validity of their perceptions regarding their activity level was judged by comparing their responses with thefr PAL calculated from their activity records.


Cardiovascular nutrition knowledge
Overall knowledge score increased with the urbanisation status (Figure 1).

Controlling for age and sex knowledge score had significant positive correlation with urbanisation rank (Spearman’s r = 0.2654, P<0.001). Overall difference in mean score of the five groups was also highly significant (ANOVA: P<0.001). However post hoc analysis of least significant difference (P<0.05) revealed the following pattern of inter group differences. Among the two groups of children residing in UK, there was no significant in the mean scores achieved. The two British groups had significantly higher scores than any of the three groups in Pakistan. And among those living in Pakistan the two urban groups were not significantly different from each other but both of them had significantly higher scores than the rural Pakistanis.
In all groups girls had higher mean scores than the boys. The gender difference was minimum among the British Pakistanis and reached statistical significance among less affluent urban Pakistanis (P<0.005), affluent urban Pakistanis (P<0.001) and British Indians (P<0.05).
Differences in responses to individual questions are presented in Table 2.

The less urbanised groups scored better than the urbanised groups in a few specific areas of knowledge. For example, the rural Pakistanis scored better than others did, in queries about saturated fat.
Health Locus of Control (Children’s perceptions of their control over their own health)
Overall HLC score increased with the urbanisation status (Figure 2).

Controlling for age and sex, HLC score had weak but significant positive correlation with urbanisation rank (Spearman’s r = 0.13, P <0.001). Overall difference in mean score of the five groups was also highly significant (ANOVA: P<0.001). HUP had highest mean score, which was significantly higher than that of RrP and MUP. Girls had slightly lower HLC scores in four of the six groups studied (UR 1,2,4 and 5). However the difference in the mean score of boys and girls was not significant in any group. Differences in responses to individual questions are presented in table 3.

Smoking intentions

Table 4 shows the responses of children, to the question asking them to mark the option, which described them, the best. Although the majority of the children from each group (63 to 96% of girls and 73 to 98% boys) selected the option: “do not smoke now and never will” the proportion varied according to group. However the rates of various responses were not necessarily associated with urbanization status.
Children were also asked to mention whether any member of their family smoked regularly. According to their responses the rates of smoking among family members of children did not have any consistent association with urbanization rank (Figure 3).

Children who did not select the option 1 (i.e. “do not smoke now and never will”) were considered to have likelihood of smoking in future. Families with smokers and proportion of children having likelihood of smoking were highest at UR1 (RrP) and lowest among British Indians UR5. Only among three groups from UR 2-4 the likelihood of children’s smoking in future increased steadily with urbanization rank.
Controlling for the effect of group and sex of the child, there was strong positive association between presence of smoker in the family (O=none, 1=one or more) and likelihood of child’s smoking in future (O=no, 1 =yes) (Partial Correlation Coefficients: r=0. 1871, P=.000, n=58 1).
Within each group the proportion of children showing likelihood of smoking in future was higher in the sub-group having any smoker in the family (Figure 3).
Validity of self-assessment of weight and physical activity level
Most of the children from each group had incorrect perception of their activity level. However degree of overestimation in most cases increased with UR. More than fifty percent of children assessed their weight status correctly. No particular association was observed between the degree of over or under estimation of weight status and urbanisation rank (table 5).


As observed in China15, in this study also the knowledge regarding cardiovascular health was lower among the less urbanised groups. Among the Pakistani groups (UR 1-3) the perceived control on health also decreased with urbanisation status. It indicates two things. Firstly, that coping with urbanisation related health problems, could be difficult for the less urbanised South Asian people, due to their lack of knowledge and their less likelihood of taking active measures for modifying their behaviour. Secondly that delivering information and increasing knowledge would not be enough to change the behaviour of these children. Serious attempts are required to modify the belief in external locus of control. Unless people think themselves to be responsible for their health and believe that their health status can change by taking positive measures, no amount of knowledge would help. It is a common attitude in South Asian cultures to hold luck or nature responsible for outcomes regardless of personal inputs. Paradoxically most people do not follow similar attitude while earnings of other material benefits are concerned. For example the people, who are found to be using any or every mean to earn money would have a very passive attitude towards health and would attribute ill health to God’s will even if they had been adopting unhealthy food and activity habits. It appears that belief in external sources of control is not uniformly held for various facets of life. Perhaps it is used as an excuse for not being able to adapt healthier habits. It is also possible that due to lack of knowledge, or methods of teaching followed in schools, even the educated people are unable to observe as concrete cause and effect relationship between health related behaviour and health as they do observe in endeavours to earn money and accumulation of wealth. Health educators need to find correlates of external health locus of control and devise strategies for instilling belief in internal locus of control to make people active in taking responsibility for their health. In many studies the healthier people are found to have a higher degree of internal health locus of control as compared to their less healthy counterparts15-18. As childhood aiid adolescence is the period when behaviour modification is relatively easier, efforts to modify beliefs should be focused on this age group.
Rural Pakistani children may not be at low risk for CHD and other NCDs in future because of their own and their parents’ smoking behaviour. Even as children they are exposed to secondary smoke due to parental smoking. Even those who do not adopt smoking in future significant harm might have been done due to parental smoking.
Lack of association between urbanisation and smoking, evident from this study, is also reported by a few other researchers17,18, According to the results of this study smoking among adults was deterniined by factors other than urbanization status. Those factors could be cultural and educational background of families. However, one thing is clearly evident that smoking behaviour of parents has significant impact on children’s intentions to smoke in future.
In terms of maintenance of healthy body weight, the children and particularly rural children needs to be guided both about the hazards of over, as well as underweight. Considering the long-term impact of pre-maternal and maternal nutrition on the health of the offspring, girls need to he cautioned about identifying, preventing and overcoming underweight also.
As maintenance of a particular level of physical activity is essential for the prevention of several diseases of urhanisation, children should be guided about kind and amount of activity desirable for the maintenance of health. Overestimation of PAL with increasing urbanisation indicates a need for particular guidance of more urbanised groups.
In conclusion the risk for non-communicable diseases can escalate quickly because of: lack of knowledge; neglecting health advice because of belief in external health locus of control; smoking history and inability to maintain healthy weight and adequate PAL because of improper assessment of weight status and activity level. These underlying factors could aggravate the detrimental effects of adopting urban life style in certain newly urbanised groups. Rural populations could be better prepared for healthy transition to urban life by educating and cautioning them about these factors.


Dr. R. Hakeem was recipient of Commonwealth Scholarship while doing PhD and additional financial support was provided by ISFE, Switzerland.


1.Popkin BM Nutrition Transition in Low income countries: an emerging crisis. Nutr, Rev., 1994; 52:285-98.
2.Badruddin SlI, Molla A, Khurshecd M, Vaz S. The impact of nutritional counselling on serum lipids, dietary and physical activity patterns of school children, J Pak Med, Assoe.,1993;43:235-7.
3.Feinstein JA, Quivers ES. Pediatric preventive cardiology’ healthy habits now, healthy hearts later. Curr Opin. Cardiol , 1997;12:70-7.
4.Friedman AG, Greene PG. Stokes T Improving dietary habits of children: effects of nutrition education and correspondence training. J Behav. Ther. Exp, Psychiatry. 1990; 21263-8.
5.Boreham C, Savage JM, Primrose D, Cran G. Strain J Coronary risk factors in schoolchildren Arch, Dis Child .1993. 68: 182-6.
6.Badruddin Sri, Molla A, Khursheed M, Vaz S, The impact of nutritional counselling on scnim lipids, dietary and physical activity patterns of school children. J. Pak. Med Assoc,,1993: 43:235-7.
7.Guldan GS, Zhang YP, Li ZQ, et al Designing appropriate nutrition education for the Chinese the urban and rural nutrition situation in Sichuan J. Trop Pediatr., 1991. 37:159-65.
8.Guldan GS, Fan HC, Ma X, Ni ZZ. et al. Culturally appropriate nutrition education improves infant feeding and growth in rural Sichuan, China. 1. Nutr,, 2000; 130.1204-11.
9.Wang RH The health locus of control and the relationship with the demographic characteristics of children from an elementary school of Kaohsiung City. Kao. Hsiung. I. Hsueh. Ku. Usueh. Tsa Chih.,1997.13:182­, 89.
10.Zhang YP, Guldan GS Li ZQ. IA survey of nutrition knowledge-attitudes-practices of Sichuan urban and rural adults]. Chung. Hua. Yu. Fang I. Hsueh, isa Chih., 1993, 27.22-25.
11.Hakeem R, Thomas J Exposure to Western culture and Acculturation infod Habits of South Asian Children. Eur. J. Clin. Nutr., S84. 1998.
12.Berkshire HEU, Food Busters: A nutntion teaching package to use with primary school children. 1991. Berkshire Health Authority: Helath Education Unit. Ref Type: Report.
13.White AA, Klimis-Tavantzis DJ. Dietary risk assessment for cardiovascular disease among central Maine adolescents. J. Sch. Health, 1992; 62:428-32.
14.Balding J. Young people in 1993. Exeter: Helath Education Unit, University of Exeter, 1994, Unit Ref Type: Report.
15.Gibson EL, Wardle J, Watts CJ Fruit and vegetable consumption, nutritional knowledge and beliefs in mothers and children. Appetite.,l998; 31205-28.
16.Bachanas PJ, Roberts MC. Factors affecting children’s attitudes toward health care and responses to stressful medical procedures. J. Pediatr. Psychol,1995: 20:26 1-75.
17.Riggs RS. Noland MP. Factors related to the health knowledge and health behavior of disadvantaged black youth J. Sch. Health.,1984;54:431-34.
18.Schlenk EA, Hart LK. Relationship between health locus of control, health value, and social support and compliance of persons with diabetes mellitus. Diabetes. Care, 1984:7:566-74.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: