SUBJECTIVE HEALTH AND HEALTH BEHAVIOUR OF FIRST-YEAR STUDENTS OF JSC NATIONAL MEDICAL UNIVERSITY IN ALMATY, KAZAKHSTAN

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1 LITHUANIAN UNIVERSITY OF HEALTH SCIENCES

ACADEMY OF MEDICINE FACULTY OF PUBLIC HEALTH

Dinara Zhumanbayeva

SUBJECTIVE HEALTH AND HEALTH BEHAVIOUR OF

FIRST-YEAR STUDENTS OF JSC NATIONAL MEDICAL

UNIVERSITY IN ALMATY, KAZAKHSTAN

Master thesis (Applied Public Health)

Student

Dinara Zhumanbayeva

Supervisor Accos. Prof. Vilma Kriaučionienė

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ACKNOWLEDGMENT

Foremost, I would like to express my sincere gratitude to my supervisor Assoc.Prof.Vilma Kriaučionienė for the continuous support, for her patience, motivation, enthusiasm, and immense knowledge. Her guidance helped me in all the time of study investigation and writing this Master Thesis. I could not have imagined having a better supervisor and mentor for my research.

Besides my supervisor, I would like to thank Commission for Preparation of Master Thesis: Chairman Prof.dr. Petkevičienė, Prof.dr.Aušra Petrauskienė, Prof.dr.Daila Lukšienė, Prof.dr.Rūta Ustinavičienė, and Doc.dr.Vaclovas Šveikauskas for their encouragement and insightful comments.

My sincere thanks also goes to Vice-dean of Public Health Faculty at JSC National Medical University, Tussupbekova Sandugash Kairatovna, for helping me with organization and performing of the survey among first-year students.

I thank my classmates Ikenna Charles Ujuagu and Nitika Minender Singh, and former classmate Gyeong Won Jang, for the motivational discussions, sharing opinions, and for the two years, we were working hard together. Also, I thank my friends Zhuldyz Duisebayeva, Nazerke Abdesheva, and Malik Fahaid, for the support they give and objective critics on my work.

Last but not the least, I would like to thank my family: my mother Svetlana Ospangaliyeva, father Abdugali Zhumanbayev, brother Arsen and sister Zeine for supporting me spiritually throughout my life.

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SUMMARY

Study programme: Applied Public Health

Topic: Subjective health and health behavior of first year students of JSC National Medical University in Almaty, Kazakhstan. Cross-sectional study. Kaunas; 2020, 107 p.

Student: Dinara Zhumanbayeva

Supervisor: Accos. Professor Vilma Kriaučionienė, Faculty of Public Health and Health Research Institute, Medical Academy, Lithuanian University of Health Sciences.

Aim. To evaluate subjective health and health behaviour of first year students of JSC National Medical University in Almaty, Kazakhstan.

Objectives. To evaluate subjective health of first year students. To analyze anthropometric parameters of first year students. To evaluate nutrition habits and associations with

anthropometric parameters. To analyze physical activity, smoking and alcohol consumption of first year students and associations with subjective health and nutrition habits.

Methods. Cross-sectional survey was performed among first-year students in JSC National Medical University. A standardized anonymous questionnaire was used in this study. There were 200 participants, 132 females and 68 males. Health behavior was measured with questions on socio-economic parameters, general health behavior, anthropometric parameters, nutrition habits (breakfast, fresh fruits and vegetables, meat and cheese, cereals, sweets, fast food, and soft drinks), and harmful habits (tobacco, alcohol , and drugs use). Statistical data was analyzed using SPSS/24.0 program for Social sciences for data accumulation and analysis.

Results. Major part of first year students subjective health is good and reasonable good (72%), while approximate half of participants take care about their health at least at some extent. Around 25% of students visited doctor once a 12 month, with the main reasons - sickness. Females’ visits were more often for preventive checkup. The most common complaints were headaches, nervousness, diarrhea and depression. More than 70% of males and female have normal BMI. The number of underweight females was more prevalent than males (23.5% and 1.5%), while number of overweight or obese males was prevailing females (22.1% and 3.8%). More than 80% of underweight females evaluated their weight as normal. Majority (62%) of all study participants consider eating healthy as important or very important. One-third of females and slightly above 22% of males eat breakfast every day, average fruits consumption is 2±0.98 servings a day, more common among girls. Most of first year students do not follow dietary recommendations. Females are more likely to eat healthy than males. 27.3% of women and 23.5% of men had a diet index that

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4 corresponds to a healthy diet. Approximately 50% of first year students performed physical active at least several times a week. Students spent in average 9.4±3.4 sitting hours, and 7.4±1.7 hours sleeping. 87.5 % of all study participants never smoked cigarettes; proportion of daily smokers was 2.5%. Most of first-year students never used alcohol in the last three months, however 7% of them drank alcohol one or more times a month. The most common drinks were beer and wine.

Conclusions. Majority of students evaluated their health as good or reasonable good, but their lifestyle habits are not healthy: part of students do not follow nutrition recommendations, are not enough physically active, do not sleep enough time, have high sedentary behavior level. However just minority of them use tobacco and alcohol.

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ABBREVIATIONS

BMI – body mass index

CDC – Center for Disease Control and Prevention CVD – cardiovascular diseases

DALY – disability-adjusted life year DI – diet index

HIV/AIDS – Human immunodeficiency virus / Acquired Immune Deficiency Syndrome JSC – Joint-stock company

NCD – non-communicable diseases SB – sedentary behavior

SDG – Sustainable Development Goals UN – United Nations

WC – waist circumference

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CONCEPT OF TERMS

Health behavior - is an activity to keep up, achieve, or recover great wellbeing and to prevent disease. Some basic health behaviors include regular exercises, eating a healthy food, and getting vital immunizations.

Anthropometric parameters – quantitative measurements of the human body: weight, height, BMI, and body circumferences

Dietary habits – series of human decisions regarding food consumed

Harmful habits – negative behavioral pattern, which destroy individual’s mental or physical health

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INTRODUCTION

One of the key factors affecting health is healthy behavior. Health behaviors are the activities, which are performed by persons for the goal of managing and improving their health, to avoid health issues, or to maintain certain body image. It is not only related to healthy people, but also includes people with chronic diseases, persons at risk, or physically disabled people through proper diet, regular physical activity, and avoiding negative habits.

Adolescence is determined as the stage from the beginning of youth to the completion of growth and reaching the final adult height and attributes that appear during the next decade of life. It is defined by fast physical growth, considerable physical and cognitive changes, and elaboration of private relationships. This period may have significant effects on the health of young adults due to the major changes in their lifestyle [1].

Actuality of the problem. Young adults often find it difficult to manage their health. They face many changes after leaving their home and starting university life. A lot of surrounding stress, new area, people, and academic changes can affect their choices and might be unfavorable for their lifestyle behaviors. It is important to be aware of healthy behavior, and reduce the possibility of developing risky behavior. Moreover, positive health behavior is considered as a path to success in academic life [2]. Some of the patterns, such as eating behavior, become established in early childhood, and may have an impact on healthy behavior in adolescent years. Most of the health behaviors and habits, such as hygiene, nutrition preferences, awareness of physical activity, and communication skill are fundamental part of family education.

Hence, family, school and companion settings and connections should be investigated, as does the financial condition where youngsters grow up, in the event that we are to see completely the examples of wellbeing found in the youthful populace.

The main focus of this thesis was on socio-demographic factors, such as age, education, income, living conditions; and health behaviors, such as diet, physical activity, smoking and alcohol consumption. For this reason, information about youngsters moving through adolescence, and general factors, which may have an effect on their success and problems during this period of life, should be taken into account health background of the person.

For instance, understanding of health, self-esteem and satisfaction with life may have an impact on stress and anxiety, which young adolescents may face. Shortages in the fields of healthy behavior might lead to the failures in later life.

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10 Furthermore, young people are more likely to align themselves towards their mates. Cigarette smoking and alcohol drinking usually is a part of interrelationship among youngsters. So, absence of these behaviors, especially under the pressure and fear of not being accepted may influence physical and physiological health of individuals.

Novelty of the problem. Social differences in subjective health of first-year JSC National Medical University students in Almaty (Kazakhstan) was performed for the first time and it can be useful for students, universities, and local public health departments.

Theoretical and practical significance of the performed research. By the identification of socio-demographic factors, nutrition behaviors, level of physical activity, this study might be helpful for establishment of health promoting program for young adults.

Young people should be aware of psychological and physical factors, which are impactful for their health condition. They need to have knowledge about health values, control over their behaviors and health, benefits of healthy lifestyle and disadvantages of harmful habits. All of the personal principles mentioned above may be significant in enhancing general health and diminishing hazardous health behaviors.

However, all of these determinants may vary according to the circumstances such as demographic situation, anthropometric measures, social support, and conditional factors.

Numereous factors contribute in the subjective health of university students and their health behaviors, but the roles of socio-demographic factors, dietary behavior, physical culture, as well as tobacco and alcohol consumption are main purpose of this thesis.

Personal input. Personally, I performed a cross-sectional study among first-year JSC National Medical University students in Almaty (Kazakhstan), using student lifestyle anonymous survey.

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11 1. AIM AND OBJETIVES OF THE STUDY

Aim of the study. To evaluate subjective health and health behaviour of first year students of JSC National Medical University in Almaty, Kazakhstan.

Objectives:

1. To evaluate subjective health of first year students

2. To analyze anthropometric parameters of first year students

3. To evaluate nutrition habits and associations with anthropometric parameters

4. To analyze physical activity, smoking and alcohol consumption of first year students and associations with subjective health and nutrition habits.

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2. REVIEW OF THE LITERATURE

2.1. First-year students

First-year students experience freedom, self-determination, society pressure and less parental control in the study period that lead to the involvment in healthy and unhealthy lifestyles. The current evidence shows the participation of young adults in different high-risk behavior including cigarette smoking, alcohol consumption , drug abuse, risky sexual behavior, unhealthy nutritional habits, and low physical activity [3]. Transition period from high schools into tertiary institutions is an urgently important period for young adults. There was also mentioned, that mental vulnerability among youngsters is relatively during their first year than in later years of studies, and reasons for that are not only because of scholastic or psychological factors, but also due to adaptation conditions of environment. Researchers characterized it as a need in certainly determined life goals, an imbalance with university culture, or feeling of aloneness [4]. First-year students usually suffer from colossal amount of stress during an adjustment to an unfamiliar academic, new social, and unique cultural surrounding at university and many school graduates described their first year as a time of a fresh self-sufficient growth.

Young adults, who can manage a developing of sufficient academic base and build constructive relationships with mates and university society during their first year, are more likely to endure to a prosperous achievement. Community surrounding and study stress may influence force medical students' to change the lifestyle behavior, which has a weight to their influencing their enlargment and achievement. Academic habitat factors create a crucial origin of strains that can lead to stress, such as long duration of study, pressure from teachers, struggle overburden and distitute physical function. The first-year student anxiety with the scholastic infidelity, object injustice has been associated with the drop of empathy and altruistic characteristics [5].

The students of Kazakhstan constitute a very impressive number of the population and are the most important reserve of the labor and intellectual potential of our country. In Almaty, students make up the majority of the population, thus being one of the main representative groups of the city. According to the Statistics Committee of the Ministry of National Economy of the Republic of Kazakhstan in 2018, 542,458 people were registered in Kazakhstan as students of higher educational institutions. Of these, 143,860 of them study in the city of Almaty, 84,813 - in the city of Shymkent, and 54,419 in the capital of Kazakhstan - Nur-Sultan [6].

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13 The environment for residents of Almaty is typical climatic and geographical features - low airing, high dustiness, pollution of the atmosphere with harmful chemicals, which has a pronounced effect on the course of a number of diseases. Considerably, less attention is paid to the study of the state of the systems of a practically healthy person, including students. Compared to other students, the JSC National Medical University's youth differ in terms of lifestyle, values, and behavioral standards. Receiving medical education is a combination of increased mental and emotional stress, which can negatively affect the functional state of the body, mental performance, and the quality of education. During the period of study, the student is forced to adapt to a complex of factors: climatic, environmental conditions, psychological. A change in the diet also plays an important role in the formation of subjective health and a tendency towards the development of chronic diseases [7].

During the period of study, students are at the stage of formation of physiological, social and psychological health. Being at the stage of adaptation to the factors of social and natural environment, students are at high risk of disruptions in their health. It should be noted that the socio-demographic factors, to a greater extent, are the parents of the person, since health is particularly dependent on the environment in which the person lives. The family institute defines and forms the attitude of a person to their health, instills behavioral stereotypes that influence a person’s lifestyle in the future [8]. However, the majority of students studying in Almaty are representatives of other cities and regions. In accordance with this, the way of life, biological rhythm, environment are subject to change. Due to changes in students' habitual living environment, factors that make up a lifestyle and affect its health can change: presence/absence of bad habits, involvement in sports, changing diet patterns, attitudes towards the prevention and treatment of diseases, a look at all other components of healthy lifestyle [9].

2.2. Health and health problems among first year students

2.2.1. Health definition

The concept of health as a harmony between a human being and the surroundings, the wholeness of spirit and body, and the natural basis of disease, was described as the understanding of health in ancient Greece. By the theory of Hippocrates, environmental factors and human lifestyle were explained as an inherent part of health. Hippocrates created the concept of “positive

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14 health”, and it was relied on the fundamental human genetics, nourishment, and activity. By his opinion, the complex of proper food and movement was vital for health. In addition, Hippocrates thought, that during the winter, people were more likely to have respiratory tract diseases, and during the summer – digestive tract diseases, and those seasonal climate shifts had an intense power on the mentality and organism [10]. Otherwise, current perceptions of health acknowledge it as not only the absence of disease, but also an ability of the individuals to realization and self-fulfillment. It plays a role of an equilibrium for the person‘s mental capabilities and opportunities with the awareness of amusement or anxiety in their connection with the habitat [11].

The approach of public health and social medicine promotes that researchers should observe the health of the groups and communities, not only individuals‘, due to the connection of the individuals with the external environment. On the other hand, health is verbalization of integrity. It is proportionate condition, in which people have well-functioning physical, social, mental, and spiritual parts of health to precise the entire spectrum of their exclusive potentials for the development within their lifestyle atmosphere. Each person is placed on a specific measured scale or endless range, which starts from well-being and excellent functioning in every prospect of one‘s life, and ends at illness and death [12].

Moreover, a theory of salutogenesis, unlike a theory of pathogenesis, has a distinct approach to human health and its factors, and studies these factors-origins of health, which create a good environment for health and welfare, not those ones, which cause disease and illness [13; 14].

The key challenges in the modern society and present time are establishment of a social welfare, encouragement of individuals, and a dignity of human being. The World Health Organization created the recognizable understanding of health in 1948, when it was established along with its Constitution. Dr Andrija Štampar, a well-known professor of social medicine and public health, and one of the founders of WHO suggested this definition. He described the health as a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity [15]. This definition was the first advocating of a belief, that social welfare is an essential part of overall health together with physical and mental health, in behalf of link of the health and the social environment, living conditions, and working circumstances. During the past few decades, the definition of health has been progressively modified and complemented by the spiritual health, the fourth element. Overall, spiritual health associates with a feeling of accomplishment and pleasure of person with one‘s life, principles, self-assurance and self-respect,

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15 calmness and tranquility, ethics and honesty, humanity and empathy, maturity and trustworthiness, and lucrative handling of daily-life issues and needs in injunction with social stress [16].

2.2.2. The most prevalent non-communicable diseases, and it’s relation to the lifestyle

The United Nations (UN) proposes and follows elemental ways to the Sustainable Development Goals (SDGs), which focus on actual global health inequalities by extensive, complete approaches. The established goals for the SDGs contain the industrial, informational, substantial, and public backbones of sustainable development along with a distinct target on equity beyond all aims both national and international levels [17].

Five SDGs set explicit targets that relate to the reduction of health inequalities both nationally and worldwide. The SDGs, which relate to the decrease of health inequalities at worldwide level, such as poverty decline, health and well-being for all, impartial access to education, gender equality, and decrease of inequalities within countries and between them [18].

Globally, non-communicable chronic diseases lead to more than half of deaths. In addition, most of those arise in low- and middle-income countries and one-third of deaths from NCDs influence young adults [19]. There was noted, that people in low-income status in high economic countries are more likely to have a risk for the development of chronic diseases than population with high income [20]. Researches on the relationship of the socioeconomic status and chronic diseases in low- and middle-income countries are comparatively rare, and the systematic evidence of it is insufficient in order to prove this connection between socioeconomic status and health in low- and middle-income countries. Women in low- and middle-income countries are more likely to develop obesity. People, who live in poverty, usually are limited in possibility to evolve healthy behaviors. These restriction lead to the low health promotion level and late diagnosis of diseases, in case of the development of it. The opposite trend is also logical, because chronic disease may lead to poverty due to many expenses and decline of work rate [21]. Another study reported that people from the poor community do not have the opportunity to pay for treatment of chronic diseases. Issues connected with NCDs may provoke declines because of salary loss, education skipping, or huge expenditures for health care [22]. Extended medical care and repeated usage of health care services generally include pricey diagnostic procedures. Persist disability and continuous acute diseases, related to chronic during practical efficient years of life, may block ordinary domestic productivity, principally in the lack of social security nets. These processes

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16 perform a wrong cycle of health-related behaviors and hazards in population with low economic status, and escalate the risk of NCDs [23].

The report of WHO 2018 announced, that an approximate 41 million of deaths appeared as a result of non-communicable diseases, giving the reason for 71% of the total 57 million deaths worldwide. The most of these deaths were induced be the four main chronic diseases, such as cardiovascular diseases – 17.9 million deaths; all types of cancer - 9.0 million deaths; chronic respiratory diseases - 3.8 million deaths; and diabetes - 1.6 million deaths. In 2016, a possibility for dying from non-communicable disease before the age of 70 for a 30-year-old man was higher than for a 30-year-old woman. These indexes were 22% and 15% respectively. People in low- and middle-income countries had the highest burden in comparison with people in high-income countries. However, the risk of death due to one of the four NCDs in the ages from 30 to 70 declined from 22% in 2000 to 18% in 2016 [24].

The burden of non-communicable diseases causes the death of 41 million people annually, which is about 71% of all deaths worldwide. The WHO reports, that every year approximately 15 million people die due to chronic diseases between the age of 30 and 69 years. The four groups of diseases such as cardiovascular diseases, cancers, respiratory diseases, and diabetes account for the main non-communicable diseases in the world, by the percentage of 80% of overall death globally.

Non-communicable diseases present image of the considerable hamper of mortality and morbidity within the European Region. The factors involving individuals to develop chronic non-communicable diseases are genetic, biological, behavioral and environmental. Studies showed, that a human‘s genetic predisposition is important to determine the possibility of progressing these particular diseases. Nevertheless, the decrease and monitoring of behavioral and environmental risk factors endure the keystone of process to reduce the incidence and reshape the flow of chronic diseases. Specific diseases are usually linked to the behavioral factors such as tobacco smoking, alcohol drinking, obesity, a fatty nutrition, lack of physical activity, and high stress levels. In addition, these diseases are caused by power, which includes rapid and unplanned urbanization, globalization, developing of unhealthy lifestyles among adults, and population ageing. Unhealthy dietary behaviors and lack of physical exercises may expose in people increased blood pressure, raised level of blood glucose, boost of blood lipids and obesity. All these mentioned may be called as metabolic risk factors, which lead to cardiovascular disease [25].

Risk factors for the occurring of NCDs can be modifiable and metabolic. Modifiable behaviors, such as tobacco smoking, physical inactivity, poor diet, and alcohol consumption, all

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17 increase the risk of non-communicable diseases. Only tobacco smoking accounts for more than 7.2 deaths annually, including the effects of exposure to second-hand smoke. It is projected, that it will increase over the next few years. The 4.1 million deaths connected with high sodium intake are reported each year. In addition, about the half of the 3.3 million deaths globally attributed to NCDs, including cancer due to harmful alcohol consumption. Moreover, insufficient physical activity lead to the 1.6 million death every year. On the other hand, there are metabolic risk factors, which also contribute to four main NCDs such as increased blood pressure, overweight and obesity, hyperglycemia (high blood glucose levels), and hyperlipidemia (high levels of fat in the blood).In case of attributable deaths, the dominant metabolic risk factor world widely is high blood pressure, which is followed by overweight and obesity and raised blood glucose [26].

The socioeconomic impacts of NCDs are reported in the 2030 Agenda for Sustainable Development, which contributes to reduce the premature deaths from NCDs by one-third by year 2030. They described poverty as a closely connected with the burden of chronic diseases. The accelerated climb in NCDs was concluded to cut off poverty reduction measures in low- and middle-income countries, especially by increasing domestic costs linked with health care services. Socially weak and disadvantaged people are getting more sick and are more likely to die sooner than people in higher social status, particularly because they are at bigger risk to be exposed to hazardous behaviors, such as tobacco use, or unhealthy nutrition practices, and limited access to health care. A few non-communicable diseases are thoroughly considered beneath. Cardiovascular illnesses incorporate coronary artery, cerebrovascular diseases, and hypertension. They remain the leading causes of disease, and are more likely to occur in the former socialist than in established market economies. They are considered as the main causes of death in population worldwide. A large number of people suffer from the short- or long-term obstacles such as physical disability, less advantageous employment position, or psychological and cognitive problems. Health-attached behaviors such as cigarette smoking, unhealthy diet, overweight and obesity, and lack of physical activity have a great impact on the development of cardiovascular diseases. Mortality and morbidity might be reduced in case of treatment for some conditions, especially for artery disease. The second in the list of main NCDs is cancer. The particular most crucial risk factor for cancer developing is smoking, which is accounting for about one-third of all cancers in the WHO European Region. Nutrition, especially deficiency in fruit and vegetables in diet, and high fat intake, was noted as a valuable risk factor for some types of cancer. Additionally, breast cancer in women persists the most significant cause of cancer deaths in the WHO European Region, and the

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18 prognoses admit that in west part of European region around one in twelve women will be afflicted, with incidence rates increase. There are narrow possibilities for prevention, but X-ray mammography during the screening at specific age groups has been profitably made acquainted in some countries, followed by a decline in mortality rates. These approaches have also been popularized to disclose pre-invasive cervical cancer in some countries. Worldwide cancer mortality did not fall much, regardless of the extensive resources committed to uncovering, identification of diagnosis and treatment program. In addition, lack of management in case of terminal cancer prevails an urgent problem – for most of people pain regulation persist poor, with redundant discomfort, which reduces the quality and dignity of the final years of life. The type 2 diabetes affects 25–40 million people in the WHO European Region annually. It can cut down the lifespan and have significant impacts on human health, when it not treated adequately. The effects are loss of vision, kidney diseases, amputations, acute blood glucose crises etc. Mortality rates from type 2 diabetes display stable or decreasing tendencies in central and Eastern Europe and in Western Europe. Diabetes during the pregnancy period arranges a considerable risk to the mother and her child. From the year of 1989, the WHO Regional office in Europe together with the European branch of the International Diabetes Federation have been cooperatively working on a St Vincent movement, which merges practically Member State with an creative way to essentially scale down severe health problems for people with diabetes. In addition, the prevalence of chronic pulmonary diseases in many countries was proclaimed to be around 2–7%. These diseases have a primary influence on the life quality, developing of disability, health care cost and work skipping. Ingenious risk factors contain tobacco smoking, air pollution and uncovering to allergens in the house, work or external environment. Satisfactory oral health strengthens not only to the quality of life but also prevents serious diseases and maintains general health. The first concern addressed to avoidance of dental caries, especially in childhood, signifies that oral health services nowadays need less resource than earlier, therefore dispensation of resources for oral health problems of other target groups, as the elder population, is needed [27].

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19 2.2.3. The most prevalent non-communicable diseases in Kazakhstan

The ischemic heart disease, cerebrovascular disease and self-harm were recorded as a prevalent mortality cases in Kazakhstan. In 2013, nutrition habits, high blood pressure and high BMI were reported as the consequential risk factors for the developing of disease in Kazakhstan, which are related to years of life, lived with disability. Diabetes type 2 increased from eighth rank in 1990 to fourth rank in 2013 as the cause of disability-adjusted life years. Moreover, situation across the Kazakhstan showed meaningful differences among males and females in mortality rates from CVD. The mortality rates were marked as highest in the northeastern part of Kazakhstan and the as lowest in the southwestern part of the country, besides the cities of Almaty and Nur-Sultan. Also, analogous pattern was established for self-reported alcohol drinking and alcohol purchase, and indicated, that increased mortality rates from CVD might be associated with the predominance of alcohol drinking among ethnic Russians, who located mostly in the north-east of the Kazakhstan [28]. In Kazakhstan, the reported comprehensive morbidity rate by the cause of cerebral stroke was 3.7 per 1000 person, with 52% due to acute stroke. Likewise, stroke is the leading cause of long-term disability in Kazakhstan, disabling consequences involves approximately 105 individuals per 100 000 population [29].

By the report of International Agency for Research on Cancer, lung, stomach and colorectal cancers for men and breast, cervix uteri and colorectal cancers for women were announced as the cancers with the highest incidence and mortality rates [30]. As in the rest WHO European Region, the outcomes of chronic diseases, risk factors for the development of it, and the tendency of NCDs are diverse among males and females in Kazakhstan. There is spreading evidence worldwide, which conveys that the gap between men and women is due to the power of gender standards and attitudes on the burden of NCDs and to the gender-specific preference that might affect the acknowledgment of health care services. Despite the fact, that many data researchers collected and analyzed throughout the survey, they presented the most important highlights. Researchers were not able to supervise the impact of sex and it‘s connection with factors such as income, education level, household condition and the place of residence. Nevertheless, they determined evidence and divergence that may direct the policies and actions. Gender is recognized with reproductive and maternal health, and gender assessment was not distinctly assumed as a vehicle of upgraded access to health care and reduced impact of NCDs [31].

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20 In Kazakhstan, the effective political engagement to reducing the gender inequalities has not been completely maintained by the public health care sector. The Gender Equality Strategy 2006–2016 was implemented and monitored by the President of the Republic of Kazakhstan – Nursultan Nazarbayev and National Commission on Women’s Affairs, Family and Demographic Policy served as an advisory committee for it. The main health priorities established in that strategy were mostly for the improvement of reproductive health, even though there was assertion of premature death among males due to cardiovascular diseases. The Gender Equality Strategy also recognized risky health-attached behaviors among males and the low priority of males’ health in health care facilities. The most significant for females’ health was reproductive health status, with confirmation that unsatisfactory access to health care services was a boundary [32].

2.2.4. Prevention and control of non-communicable diseases

According to the WHO, around 80% of cardiovascular diseases, type 2 diabetes, and more approximately one-third of all cancers, occurring globally, can be inhibited by defeating of risky-behavior factors, which are primarily tobacco smoking, an unhealthy nutrition, lack of physical exercises, and the hazardous drinking of alcohol. An outstanding action to monitor and control non-communicable diseases is to aim attention at contacting the risk factors related to these diseases. Low-expenditure clarification endures for ministries and other stakeholders to decrease the frequent risk factors, which are modifiable. The progress in monitoring and tendencies of chronic diseases and factors for their developing is significant for guiding policy and priorities. For the decline of the affects, that caused by NCDs, on a person and population, there is a need in an overall approach, with the requiring all sectors, such as health, education, finance, transport, and agriculture, to cooperate for the deterioration of the risky behaviors associated with NCDs, and promotion of the measures to prevent and control them. Financial investments for the upgraded and renewed management of chronic non-communicable diseases are urgently important. Management and monitoring of non-communicable diseases include disclosing, screening and curing these diseases, and supporting the accessibility to palliative care for needy people. High effect key-intervention in the relation to NCDs can be conveyed through a primary health care way to sustain immediately detection and timely treatment. Studies show, that those interventions were exquisite commercial contributions due to the early providing to patients, which might decrease the obligation for much more high-priced treatment [33].

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21 Some countries with poor health insurance are unconceivable to afford universal access to fundamental NCD interferences. Management measures for NCDs are indispensable to enact the global aim of a 25% proportionate decline of the premature mortality from chronic diseases by 2025, and the Sustainable Development Goals target is a reducing by a one-third of premature deaths from NCDs by 2030. The NCDs are admitted as a dominant challenge for continuous development by the 2030 Agenda for Sustainable Development. The aims came from the High-level Meetings of the UN General Assembly on NCDs in 2011 and 2014, and they prolonged the WHO’s initiative and regulation role in advertising and controlling global action against chronic non-communicable diseases. The United Nations General Assembly gathered a third High-level Meeting on NCDs in 2018 to reconsider advancements and counterfeit consensus on the way forward containing the period 2018-2030 [34].

2.2.5. Students moving from parents to new environment.

The skills of young people in decision-making about health attitudes is better when they are able to be involved in it. They can influence their psychological, physical and university. Students’ cognitive health and wellbeing, is attentively connected with the quality of parent-child relationships, classmates and friends. For those who are in protective and benevolent relationships with their parents, understanding and supportive friends, and other more or less important people in their surroundings is much easier to develop healthy lifestyle and positive reputation. Good and valuable self-image and ability to solve problems, including different type of conflicts, are important part of the daily life. More and more academics work on analysis on correlation of the psychological health of young adolescents, relationship between parents and children, the connection between public encouragement and spiritual condition, psychological health and individual behavior, mental health and abandoned background, school and health behavior. The theory of Elder demonstrates that the modifications of the circumstances in the family life course of the adults after leaving their families, and changing the childhood regime to adulthood have particular consequences on personal advancement [35].

Young adults who live apart from their family, compared with those who do not have this experience, as a result of the exceptional development surroundings during the educational process, would have an effect on their behavior and changes may occur because of the pressure in the new environment. Numerous studies have indicated that living with parents has an effect on the

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22 cognitive attitudes and behavior of the youngsters [36]. Inadequate amount communication have a tendency to disorganize parent–child connection, which causes young people to experience diverse issues due to the missing of family attention, help, orienteering and connection [37]. Another study also indicated that children should receive proper control and support for their families in order to develop right personality, especially in the critical period of their growth – teen ages. Children who did not get enough attention and parental guidance are more likely to hide their emotions, facing problems without sharing with family, and due to the lack of family judgment, they are in the risk of developing bad habits [38]. Generally, after separating from the family young students have less contact with their families due to the distance, overloaded curriculum and new environment. Parents are more likely to pay attention on their children physical health and educational achievement, and less attention is usually paid to their psychological health and moral condition, which may cause diverse mental health issues, for instance, melancholy, vulnerable relationships with people, and public nervousness [39]. Zhang‘s study summarized that the there were differences in the effect between males and females who lived apart from family. Girls are more concerned about secure challenges than boys are.

At the same time, the interview‘s results showed that girls are more responsible because they were taking care of their siblings while they were at home. For instance, some of them were much more independent and more careful of others emotions [40]. According to Sigmund Freud, an Austrian neurologist and the founder of psychoanalysis, if person‘s cognitive demands are not satisfied during youth, pessimistic feelings are stored and kept in the mind, which may impact their mental health [41]

2.2.6. Students health

Indicators of living standards are one of the main determinants of health. The size and form of income - the majority of students face financial difficulties, due to lack of sufficient skills in the management of the budget and their own earnings (students, who live separately from their parents, families). The quality of housing and the provision of them - as noted earlier, students of the city of Almaty come for higher education from other cities and regions, so they are forced to live in dormitories or rented accommodation; working and rest conditions - the first year of study is more intensive compared to the level of workload in school; state of the environment; educational and cultural level of the population; health and life expectancy [42].

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23 Constant socio-demographic differences may be related to behaviors that promote health, such as physical activity or the consumption of fruits and vegetables. A higher socioeconomic level was associated more frequently with physical activity and the frequency of higher consumption of fruits and vegetables [43]. Socio-economic and socio-demographic factors can result in constructive health outcomes, but sometimes teachers, parents and other adults might overlook them.

There are several explanations for the influential factors to the students ‘behavior: socio-cultural background; socio-economic status of family; health-related behaviors of parents of the student. Differences in the socio-cultural background of students have a greater likelihood of influencing attitudes toward health and its subjective state. In the case of health-related behaviors of family members, there is a huge impact on person‘s views on life and shape the child’s lifestyle in the future. The concept of lifestyle is usually formed in childhood and adolescence, when children tend to copy the behavior pattern of the older generation. In consequence, socioeconomic status can be associated with the level of the education of parents and has more strongly impression with health-enhancing behaviors of student. On backwards, health-related behaviors such as smoking are usually deep-rooted more thoroughly in adolescence when the ascendancy of parents is less noticeable and the influence from society is growing [44].

As another sociological factor, could serve the absence of mental anguish, physical illness or disease – human wellbeing. It commonly demonstrates the success of physical fitness and subjective psychological stability. Individuals are tending to feel themselves good and stable in the state of well-being. Human beings have persistent self-image as long as they take pleasure in high levels of well-being. Young adults, especially university students, are at the maximum of their intelligent capability. For this reason, the wisdom and knowledge they have provides young people numerous upsides to specify their own risk factors and risk factors for their peers. Nevertheless, the overall well-being, which adults experience during their early ages, might mislead them in thought of the maintaining the way without any ill effect due to the privileges in age, only to later phase of the consequences of the involvement to those risky attitudes. Along with that, the exposure of the negative impact of the mass media, society pressure, and overall unspiritual cultures can later exacerbate the situation. Therefore, their capability to psychologically rationalize situations, their comprehensive insufficient experience together with cognitive vulnerability and rebellious behaviors can place them at risk. The severe lifestyles and stress at higher academic environments, absence or lack of family support, dissatisfaction in personal life, and unhealthy attitudes may also

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24 lead to the decreasing of wellbeing and enlarge in the engagement rates in health-risk behaviors [45].

The routine life of young people extremely changes after enrolling to the university. As soon as they start living separately, they enter the one of the intensive period of their lives. This experience help young adults to grow as a mature human being. However, youth is the part of population, which is weaker to start risky and unhealthy lifestyle, such as smoking, alcohol consumption, drug-addiction, and behaviors of unprotected sexual contacts. Among the young adults, unprotected sexual contact leads to undesirable pregnancies, high abortions and sexually transmitted diseases. The lack of knowledge and sex education, especially in Kazakhstan, where people are not use to talk and explain about sexual life and its consequences, create pointless visceral stress. Young people in Kazakhstan are confused when it comes to understanding of sexuality, changes in body and hormones, and sentimental feelings. Along with that, low level of physical activity and harmful eating behaviors increase obesity levels among young population throughout the world. The development of the communication technologies, social media, and huge flow of the information, make young adults being influenced to diverse messages and values, which sometimes are inappropriate. Advertisement and mass media are not just type of entertainment; they also have an impact on youth, their ideas and beliefs, which can bring either pros or cons to the health.

For instance, high exposure of tobacco and alcohol in movies, series and some computer games can affect young adults to involve these behaviors to their lifestyle.

First, health is meaningful for young people if they are aware of its meaning, and if they have enough resources to manage it, such as mental, financial, physical and cognitive resources to meet their demands. Young adult’s understanding of health can be significantly strengthened by the content of the proper university curriculum. It should pay attention on youth monitoring, interventions in their physical activity, awareness of the food with micronutrients, regular and adequate food portions. It can improve youngsters’ physical, cognitive and social wellbeing. Sports clubs, youth associations, and other social activities, such as marathons can be beneficial for healthy lifestyle development, and social media interaction should be particularly involved in this process. Because youth is suspected to be attracted to social advertising, and marketing industry can serve as a significant partner for healthy behavior development in this age group.

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25 2.3. Nutrition habits and anthropometric measurements.

2.3.1. Healthy nutrition habits

In general, routine eating behaviors are important for people lives. Apart from food consumption, thoughts about food take a key part in human lives. People are likely to make around 200 decisions during the day and less than a half of daily wishes of person take food desires [46]. Due to survival competitions, people evolved to enjoy eating process itself [47]. In addition, food consumption might be considered as a major public and cultural entertainment which society likely to delight for aesthetic purposes [48] On the other hand, food is not only a single source of enjoyment presently, but also a reason for the development of food-related diseases. The most significant cause for this concern is growing levels of overweight throughout the world, which is result of obesogenic surroundings with lots of cheap, available and fatty foods everywhere and at any time [49]. A healthy behavior is considered as eating habits, which has advantageous impact on health or at least no hazardous and harmful impact. Poor diet is mostly can be described by high consumption of processed food, sugar sweetened drinks, trans fats, added salt, and very low intake of fresh fruits and vegetables, absence of nuts and whole grains. Generally, fruits and vegetables are beneficial and low in calories. Overall, fruits and vegetables are a great replacement of fatty food with a poor nutritional value (e.g. processed meal, sweet beverages, and other junky food) [50]. However, the type of food or nutrients and vitamins may differ according to the countries, but most of them have relative nutritional recommendations [51].

According to the official dietary guidelines of 83 countries, healthy diet is consist of high intake of vegetables and fruits, and low level of fat, sugar and salt. Polyunsaturated fatty acids, whole grains, fiber, and omega-3 products also should complete balanced diet. However, guidelines can vary concerning to the intake of red and processed meat, alcohol drinking and eating of dairy food, possibly due to the cultural differences in food behavior, as well as suggestions on food safety and maintainable food preferences [52]. Also, the way of the connection among guidelines are different. Some of the countries offer just short and simple messages, whereas other provide very detailed recommendations, such as portion sizes and frequencies, or guidelines for a specific group of population (e.g. pregnant women, children, elder people and etc.) [53].

It is significant to be aware of healthy nutrition not only because of its impact on health, but also because various external factors can have an effect on it. It is very important to understand the

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26 fact, that different groups of society are not able to have an access to food rich in nutrients, healthy eating education, or habits which an improve their wellbeing. Proper eating behavior and healthy balanced diet are essential for young adults during the growth as a path to the healthy development. A good healthy diet during the adolescence can be helpful to set up a beneficial model of strong and correct eating behaviors to bring through into adulthood [54]. A poor diet can be considered as one of the major risk factors of obesity, cancer diabetes, heart diseases development etc. Thus, to develop healthy eating behaviors, first of all its necessary to know the factors influencing on it, and then its impact on the quality of diet [55].

Nowadays, globalization and urbanization have a huge influence on farm industry, which is the most appropriate source of fresh vegetables and fruits. Due to the easy access to fast food, the popularity of it have become higher among both children and adolescents [56].

Despite the fact that the quality of nutritional habits usually strengthens with age, a decrease is mostly noticed in the period of transition from youth to adulthood. It is disturbing, that some eating behaviors are common among youngsters; they often skip meal, frequently enjoy snacking, and prefer prepared meals due to the commercials. Poor diet quality can be associated with takeaway food, delivered food or quick cooked conserved food. The problem of this food-related behavior is that development of it in childhood may have a long lasting impact on nutritional habits in later life.

2.3.2. Students nutrition habits

First year university students are usually reported as group of population with unhealthy lifestyle behavior including hazardous eating behaviors such as high consumption of fast food , consumption of processed food , high intake of sugar-sweetened drinks, and deficient uptake of fruit and vegetables. Therefore, students nourished in these behaviors might be at increased risk of weight gain and future development of NCDs. Adequate consumption of fruit and vegetables is relevant as the nutritional content of dietary fiber, vitamins, and minerals. Fruits and vegetables in daily nutrition are associated with a reduced risk of cardiovascular disease and type II diabetes [57].

Despite the fact that nutrition quality commonly develops with age, a decline is repeatedly noticed in the time of the changeover cycle from adolescence to adulthood. Critically, some food-associated attitudes established by first year students including erratic meal arrangements, such as

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27 breakfast skipping and incessant snacking, persistent intake of commercially prepared meals, takeaway food, store or restaurant ready meals. An affixed burden is that these conceivably unfavorable behaviors evolved in earlier life and possible to take a place in later life, having a long-lasting effect on the permanent health of students [58]. Nutrition-related behavioral factors such as customers’ mindset to the quality of food, buying of grocery, and ways of cooking, ways of shopping have been used to assess the probable elements of food intake and food-associated diseases. Nonetheless, food purchasing and meal preparation as food-related behaviors can be a more direct determinant of nutrition quality and have been investigated previously in students [59]. Students at their first year of university life face to transition period that can be a result in poor nutrition and weight gain. Tolerable food cooking skills may have an impact on a diet quality and be help to avoid development of chronic diseases. Students who live away from their parental home for less than one year have been reported as significantly low in total food skills. Results of the study indicated that students' food skills might vary by gender, level of education, and household condition [60]. Young adults determine diverse negative behaviors, rest of them usually because unsuitable diet, which becomes demonstration called ‘diseases of civilization’. It is typically acknowledged that medical students start their studies with lack of an awareness of health issues [61].

Recent study showed that high intake of hazardous food during period of stress has been has been attributed the choice and intake of unhealthy foods to the express availability of these foods. In this study mentioned that healthy foods (i.e., salads, cereals) might take lengthy time to prepare. Thereupon, the convenience of fast food can be estimated as a nutrition-valued food during periods of distress. In the study, the correlation between stress level and junky food selection habit, especially processed food, was associated with the issue of accessibility of food cooking and purchasing. First year students are likely to have very narrow time during the academic year, and this pressure can be a strong reason of store food selection among them [62].

Young adults tend to have vulnerability to the components of the nutrition habitat: the price of food products and portion size of food due to lower disposable incomes and perceived value for money. Students are in the list of population who have attitude to energy-dense, nutrient-poor foods, drinks, fried potatoes, pizza, hamburgers compared with older adults [63].

The study, conducted in Germany in 2009, reported that students from first or second semesters of the studies had higher scores of dietary restraint than students from the higher semesters of university education. The Public Health Research Group mentioned that healthy food

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28 choices were done in a less obsessive fashion by higher semester University students, and their food behaviors became slightly, but significantly more healthy. In the results of the research increased knowledge of University students was associated with a more healthy nutrition choice and eating behavior. Though, they assumed in their conclusion part interesting results: students, related to the public health area of education (nutrition students) were more likely more to reduce their food intake in order to discipline their body weight, using possibly uncertain harsh control behaviors along with supportive and healthy soft behaviors; and that the developed nutrition awareness was associated more upgraded food choice and eating behavior [64].

Another study on students’ nutritional behavior showed that, students who had even small knowledge in nutrition field were more likely to improve their eating habits and had more healthy food in. They reported that a single course of nutrition was efficient to develop the nutrition knowledge of the undergraduate students. They also discussed on the Canadian study, which was performed among around 270 students, and in that, particular research was found that the broader level of nutritional education the less fatty and energy-dense food students consumed. Those students were contributed to intake lower amounts of total fat, saturated fat, trans fats and cholesterol per day compared with students with low nutrition knowledge scores [65].

Appropriate nutrition education would be advantageous in enhancing dietary habits, and students might be encouraged when they have the fundamental nutrition knowledge and skills to achieve better health-related habits.

2.3.3. Students anthropometrics parameters

Malnutrition in the early ages, especially during the first year of a human life, decreases the head circumference, which is one of the most sensitive physical indicator of adjustment in undernutrition circumstances. One research conducted among high school graduates have associated absolute head circumference and brain volume, which were measured by magnetic resonance imaging with health outcomes. Those results were corresponding with findings of few previous studies, which stated that head circumference is the most admissible anthropometric parameter strongly associated with scholastic achievement.

One of the new studies on brain development threw aside brand-new vision on the impressible power experience in early childhood time. At the beginning of life, every single second a creation of 700 to 100 new neural connections, a motion that declines later; by the end of the first

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29 year of life 70% human brain has been already formed [66]. By reason of importance of the first year of a human's brain development, these years propose a demanding possibility to avoid an inequity in environmental factors that have an influence on human’s psychological development, nutrition habits, peer choices, and future parental-child relationship [67].

Nutrition attitudes has been investigated in condition of the connection with anthropometric parameters, recognition of body structure, and the passion for skinniness. From this perspective, dysfunctional cognitive food eating was undoubtedly affiliated with body weight, BMI, waist circumference, and free fat mass [68].

In case of female students, bound diet was indubitably corresponding with BMI and body shape frustration. This behavior was linked to the increased BMI, waist circumference, and level energy intake. On another note, alimentary obstruction is undeniably matched with overvaluing and mania with body weight and shape. Japanese study showed that female students in one particular university, in spite of their slimness or underweight, were indicated to reveal a stronger willingness to be thin than male students, and the wish to be very slim was absolutely connected with restricted diet [69].

In addition, it is important to mention that young girls are more likely to be motivated to nutrition restricts due to their mothers behavior. Those researches put forward that eating habits is closely related to not only anthropometric parameters, but also self-estimation of body shape and body satisfaction. Regardless, it was not properly authenticated the idea the gender makes difference on these dependencies [70].

2.4. Physical activity

2.4.1. Physical activity recommendations

Physical activity is a term, which may include numerous definitions that describe. The term physical activity encompasses a number of definitions that describe any body movement with the energy expenditure in result. Some scientists divide physical activity into two groups – sport and exercises. Besides exercise and sport, physical activity may also include active leisure, which means voluntary and spontaneous activity with the energy expenditure [71]. However, this kind of physical activity such as exercises, participation in any sports, or hobbies are not considered as part of usual job responsibilities, domestic activities or usage of transport [72].

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30 Physical activity is a component of a healthy well-being and brings advantageous effects to the health condition throughout several age groups, ethnics, nationalities and people with different health status. It is broadly acknowledged that physical activity in regular terms can decrease mortality levels, prevents significant non-communicable diseases, and improves cognitive condition [73]. According to Blair, among the people who were more physically active, the mortality rates were lower, in comparison with those who were less active. Even though first group included smokers, high cholesterol level participants, or the results of their examination were more or less satisfactory [74].

Prevention of overweight and obesity are closely linked with physical activity as well as with the prophylaxis of diseases. It is easier to improve psychological wellbeing towards regular physical activity and prevent the risk of being ill (Biddle et al., 2010). There is a difference active and inactive child in their future life, because the habits, which formed during this period of life, are likely to last the whole life [75].

According to the longitudinal study of Telama in 2005, the higher physical activity person has during the childhood in the age of 9 until 18, the ore active person in later 20 years. Also, the skill of problem solving and good memory can be improved due to the development of the frontal lobe-mediated cognitive processes by regular physical activity of the human (Brown and Vaughan, 2009). Furthermore, enhanced scholastic abilities and developed mental processes are related to the level of physical activity. Variety of diseases, including psychological ones can be reduced by the combination of physical activity and healthy diet and promotion of this kind of lifestyle may have a huge influence on non-communicable diseases [76].

The recommendation for children and young adults according to the WHO states that at least 60 minutes of moderate intensity physical activity should be included in daily routine. Regular physical activity consist of playing games, doing sports, transportation (e.g. bicycles), house chores, and physical exercises. In addition, the recommended 60 minutes can be divided into the shorter periods and performed in multiple times [77].

World Health Organization recommends to pay attention on routine physical activity such as aerobic one, for example walking or cycling. For the strengthening muscles and bones, more intensive and energetic activity should be included into the weekly schedule, people should consider running, jogging or sport activities at least three times a week.

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31 2.4.2. Students physical activity

The tremendous change in developing countries over the past decades caused the drop of the people necessity to undertake physically active lifestyle. Physical activity constitutes any movement of human body generates by skeletal muscles that causes in an escalation in the metabolic rate over inactive energy expenditure. In the book “Physical activity and health” of Bouchard and Blair was described the concept of importance of considering leisure-time activity, sport exercises, car or bus transportation, job-related activity, and house routine. The authors wrote that the energy output, which is associated with physical activity, is the single elective component of the total energy expenditure in daily life. They mentioned that energy expenditure of activity is usually around 25% of daily energy expenditure in a person with sedentary lifestyle, while it can be higher in an active athletes during the training (50%) or in a person doing heavy job (labor) for a whole working day. Also, it can be mentioned that people used to have three to four hours of leisure, free time after he or she completes the work, transportation, house chores, and personal hygiene as a shower or bath-taking [78].

However, in case of first-year students of JSC National Medical University this variation may be less wide, depending on absence of work – usually in the first year of studies young adults do not have a job; the dimension of labor at home – rest of students of Almaty city live in university dormitories; the decreased need for self-sufficiency activities – students tend to have a narrow budget that restrict their involvement in sport clubs, and daily commuting time – as it was mentioned above; first-year medical students tend to have a high level of stress due to the pressure during the first and second semesters of bachelor degree.

In journal of school health, Taras’s article named “Physical activity and student performance at school” physical activity was linked to young adults’ performance at schools. He pointed out that sufficient amount of physical activity develops general lymph circulation, increases blood flow to the brain, and boosts level of norepinephrine and endorphin, all of that are keys to decrease stress, improve mood, have a calming impact after studies, and probably could be a result better success in goals achievement. Taras associated the existence of physical activity in a daily behavior as a positive result in academic field. In this research mentioned that youth involved in-group physical activities learn to cooperate, communicate, share and tend to challenge themselves in areas apart from sports. On the other hand, physically inactive adolescents are more likely to commit suicide, risky behaviors, and random sexual habits [79].

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32 The team of researcher from University of Kentucky, USA in their pilot-study discussed on the health outcomes, and its physical advantages; moreover, they quoted that young adults who involved in physically active life had a powerful and beneficial effect on their psychological health and academic progress. American researchers theorized that young adults receive cognitive advantages from the participation in physical activity through an amount of mediation. They also described the physiological effects as a huge inspiration and increased level of neurotrophins, which stimulates neurons in hippocampus or learning center of youth’s brains. In addition to this, they commented that psychosocial factors were also connected to a level of students’ self-esteem and relations in schools [80].

Another recent research described that young adults’ opportunities are closely related to their income and socio-economic status, thus they can be disadvantaged in diverse areas of life activities, more in academics and physical health .They admitted that ability to participate in physical activities are more connected to unfortunate circumstances such as low paying capacity, and absence of own financial resources. Students at low socioeconomic status were put in the risk group for negative health outcomes because of the diverse barriers to health-promoting behavior, including physical activity. Ullrich-French, McDonough, and Smith in their research linked physically active lifestyle with success in academic studies and subjective health of students. Physically activity behaviors were are interpreted as entangled, collective, and cognitional resources and tools for the improvement of social opportunities, conflict situations avoidance, and cooperation with surrounding people, team building, life goals setting, and leadership skills. Although, sport and physical activity background was described as a vehicle for relaying important life skills and belongings such as group communication, social skills, positive self-estimation, and outdoor relationships. However, the pros of physical activities was not accomplished without willful action to particularly promotion of students skills: involvement in organized sport was more associated with low moralistic reasoning, affirmation of destructive behaviors, and misconduct; still well constructed, hypothetically founded sport and physical activity programs enlarged advantageous developmental results [81].

Aside from a low intensity of physically active exercises, one of the researches has shown that habits of a sedentary behavior: watching television, playing video games (e.g. PlayStation), spending rest of the free time in front of computers, laptops, and the most popular – usage of smartphones during the whole day.