J Community Health DOI 10.1007/s10900-014-9938-3


Cardiovascular Risk Factors and Physical Activity Among University Students in Somaliland Mahdi Ali • Hassan Ismail Yusuf • Jens Stahmer Sibylle I. Rahlenbeck

Ó Springer Science+Business Media New York 2014

Abstract Physical inactivity is a well-known risk factor for the development of cardiovascular diseases and counts as fourth leading cause of death worldwide. The study aimed to elucidate to what extent cardiovascular risk factors exist in university students in Somaliland. In a cross-sectional survey, self-administered questionnaires were used to elucidate existence of cardiovascular risk factors in 173 university students (117 male, 56 female) in Hargeisa, Somaliland. Information elucidated included socio-economic and demographic data in addition to questions on coffee intake, on physical activity behavior, type of sport/activity and intensity and duration. Height and weight were taken, as was blood pressure (BP). Median age was 23 years in male and 20 years in female students. Mean BMI was 19.7 in male and 21.8 in female students. The prevalence rates of elevated BP and overweight (BMI C 25) in female and male students were, 0 versus 9 and 14 versus 7 %, respectively. Coffee consumption was reported by 39 % of students. None of the female students reported smoking cigarettes, while 5.1 % of the male students did. Physical inactivity was reported by 52 % of the female students and 27 % of the male students (p = 0.01). Overall, male students reported a higher degree and intensity of physical activity. The prevalence of cardiovascular risk factors is low in female and male university

M. Ali  H. I. Yusuf Faculty of Medicine, University of Hargeisa, Hargeisa, Somaliland J. Stahmer Internal Medicine, Reinbek Hospital, 21465 Reinbek, Germany S. I. Rahlenbeck (&) Epidemiology and Public Health, Afrika aktiv e.V., Berlin, Germany e-mail: [email protected]

students in Somaliland. However, the results demonstrate a high degree of physical inactivity and overweight might become a problem in the future. This issue should be addressed by increasing the motivation and opportunities for physical activity in students. Keywords Cardiovascular risk factors  BMI  Somalia  Physical inactivity  Sedentary life style  Blood pressure  Overweight

Introduction Somaliland, situated at the Horn of Africa, is the northern autonomous region of Somalia bordering Djibouti and Ethiopia. While it had declared its independence from Somalia in 1991, it has not been recognized internationally as yet. Somaliland has a population of about 3.5 million inhabitants, an under-five-mortality rate of 90/1,000 and a literacy rate of \45 % in young women, in 2011 [5, 16, 17]. Unlike the south, Somaliland has gained some stability by building up political and administrative structures. In addition, several universities have been created, among these two medical schools, one in Hargeisa and one in Borama. A lack of physical activity is a well-known risk factor for the development of cardiovascular diseases and counts as fourth leading cause of death worldwide [7]. Few studies have examined the prevalence of cardiovascular risk factors and physical inactivity in African countries, but some recent reports indicate overweight in adolescent is rising [2–4, 6, 8, 10–12, 14, 15]. Since the life styles associated with relevant risk factors are modifiable through political action, their extent should be known by public health authorities to enable them to take counteractive measures


J Community Health Table 1 Characteristics of the study population, Hargeisa, Somaliland 2013


Male students

Female students




Age (years)

23.3 (SD 2.1)

20.9 (SD 1.8)

Height (cm)

177.7 (SD 6.1)

165.0 (SD 5.4)

Weight (kg)

62.3 (SD 10.5)

59.1 (SD 10.0)





19.7 (SD 3.2)

21.8 (SD 3.8)

C25 (%)

7 (6.0 %)

6 (10.7 %)

C30 (%)

1 (0.9 %)

2 (3.6 %)

BP sys, mean

120 (SD 12.6)

107 (SD 10.0)

p = 0.0001

BMI p = 0.001

BP dia, mean

75 (SD 6.8)

67 (SD 6.1)

BP C 140/90 (%)

11 (9.4 %)


p = 0.0001

Family income p.m ($)

309 (SD 240)

548 (SD 263)

p = 0.0001



p = 0.001



p = 0.001

No schooling (%)



p = 0.001

College or university degree (%)



p = 0.001


29 (27.4 %)

29 (51.8 %)

C2 h per week

51 (43.6 %)

12 (21.4 %)

Parental education Mothers No schooling (%) % mothers with college or university degree Fathers

Physical activities p = 0.001

Watching TV Daily watching

80 (68.4 %)

44 (78.6 %)

C2 h/per day

22 (18.8 %)

25 (44.7 %)

6 (5.1 %)

0 (0 %)

p = 0.001

Other Smoking cigarettes (ever)

timely. With the aim of investigating the existence of risk factors in students, a study was carried out in Somaliland, in which 173 university students were investigated.

Methods A cross-sectional questionnaire study was carried out in which students from six classes of the University of Hargeisa were asked to fill in questionnaires (in English) anonymously. The study and its design had been submitted to and approved by the Ethical Review Board of the University of Hargeisa. As incentive to participate, students were offered a free BP measurement and calculation of their BMI. The participation rate was 91 % (173/190). The questionnaire had been pre-tested on March 23rd 2013 in a medical class. Questionnaires were distributed and completed voluntarily in six classes between March 25 and April 09, 2013. They captured socio-demographic data


(age, gender, birth place, family income, schooling of parents), eating habits and leisure time activities (sports, watching TV). Blood pressure (BP) was taken and weight and height measured; body mass index (BMI) was calculated as the ratio of weight (kg) to the square of height (m) with values between 25 and 29.9 being designated as overweight and those values equaling 30 or above as obese, respectively. In addition, attitude towards physical activity was asked for by offering statements, agreement to which were rated on a Likert-type scale of five choices ranging from complete agreement to complete disagreement. Yearly fees at the university were 400 US$ in 2013. Physical activity is defined as bodily movement that results in energy expenditure. Students were asked if and what type of sports and physical activities they engaged in regularly. Time spent on average hours per week was asked for as well. Walking and swimming were considered moderate activities, while playing soccer and/or basket ball were considered vigorous activities.

J Community Health

Fig. 1 Levels of physical activitiy in male and female university students in Hargeisa, Somaliland 2013

Data analysis was carried out using the SPSS system, version 12.0. Logistic regression models were specified to estimate factors influencing potential risk factors and leisure time activities. Independent variables offered included gender, age, family income, level of parental education, and selected variables. A backward elimination procedure was used for the selection of final models consisting of variables remaining significant at the p B 0.05. Continuous variables between males and females were compared by t test and ratios by Chi square test with ‘significance’ referring to a p value in two sided tests equaling or below 0.05.

Results Data from 117 male and 56 female students from six classes were included. The main characteristics of the participants are presented in Table 1: Age ranged from 18 to 29 years, with a median of 23.0 years in male and 20.1 years in females students. The majority (80.3 %) was born in Somaliland and/or Somalia, 10.5 % in Ethiopia and 5.8 % in Middle Eastern countries. All students followed the Islamic faith. Parental education was significantly higher amongst girls for both parents when compared to those of boys (Table 1). More than half of the girls’ parents (fathers and mothers) did at least have a college degree, while these figures were much lower in boys. Mean family income was 390 US$ (SD 274) and was significantly (p = 0.001) higher among the girls’ (548 US$) than the boys’ families (309 US$).

Systolic BP in boys ranged from to 90 to 160 mmHg, and dBP from 60 to 90 mmHg; median BPs was 117/74 mmHg. In girls, median BP was 104/66 mmHg (range: sBP 85–130 mmHg, dBP 60–80 mmHg). A BP exceeding 140/90 mmHg was found in eleven male students (9.4 %) but in none of the girls. Mean BMI was 19.7 in male students, while it was 21.8 in female ones. This difference was significant. Eight (6.9 %) male students were overweight (BMI C 25) as were eight female students (14.3 %). In multiple regression analysis BMI was the only significant factor of systolic BP in male students, explaining 8 % of the variability (p = 0.01). In female students, this was not significant. Half of the girls (52 %) reported not engaging in any physical activity, while only about one-forth (27 %) of the boys did so. Also, intensity of the physical activity was considerably higher in male students than in female ones (Fig. 1), with 42 % of the boys engaged in medium or intense sports compared to only 9 % of the girls, of whom none was performing sports in the vigorous (highest) category. Three quarters (73 %) of students reported watching daily TV, with more girls (79 %) than boys (69 %). Nearly half of the female students (45 %) reported watching TV at least two hours every day compared to only 19 % of the male students. Asked about their opinion of the availability of sport facilities, 85 % of male and 95 % of female students expressed the wish that the university should offer more sport opportunities; likewise the vast majority (95 %) supported the notion that government should be more active in promoting a healthy life style.

Discussion In this cross-sectional study of university students in Somaliland, the existence of cardiovascular risk factors in 171 university students in Somaliland was investigated. Limitations of this study include the low number of participants and the subjective assessment of physical activities. Nonetheless, some useful findings emerge. As expected, the percentage of students with elevated BP and/or overweight was small, but existing with seven percent of the male and fourteen percent of female students being overweight (BMI [ 25). It is noteworthy that the mean BMI index found in male students is the lowest reported from similar age groups in African countries (Table 2) [2, 4, 8, 12]. As expected a relationship between BMI and systolic BP was found [14]. Female BMI was found to be significantly higher than that in males, a common finding in Sub-Saharan Africa. While a relationship between BMI and parental income has been reported from other countries in Africa [12, 14] such a


J Community Health Table 2 Cardiovascular risk factors in male students in African countries % BMI [ 30

Mean SPB (SD)

BP [ 14/ 9 mmHg

Physical inactivity (%)

22.7 (3.8)


126 (12)

12.7 %

24 %, 55 %a

9.1 % [ 28

113 (10)

1.5 %

12.1 %

Country ref


Mean age, (years)

BMI, mean (SD)

Cameroon [4]


23.9 (2.9)

% BMI [ 25

Ethiopia [12]


20.8 (1.6)

20.7 (4.4)

Kenya [8]


21.4 (1.8)

20.8 (0.3)

114 (9)

17.5 %

Nigeria [9]



22.7 (3.8)

118 (18.3)

41 % (both sexes)

Nigeria [10]



24.4 %, 31.9a a

Somaliland, this study


23.3 (2.1)

19.7 (3.2)

6.9, 10.7

South Africa [11]



22.3 (0.5)

14.1, 44.1a

Tanzania [13]


16.6 (1.9)

20.8 (2.3)

Uganda [2]


19.0 (1.4)

22.6 (2.5)


In girls/women


Age range

120 (13)

9.4 %

27 %, 52 %a 37.5 % (50.7)a

123 (18) 3.3, 17.4a

relationship could not be found in this group. However, it should be noted that the average income of the students’ families exceeds more than twice the income in rural populations of Somaliland [1]. The fact that more female students than males ones were overweight is well-known in Africa [2, 15]. Being female and not engaging in sport were significant factors in Uganda for overweight [2]. Literature about physical activity in university students in Africa is scarce. Particularly for girls and women, access and availability to sport facilities is very limited in many African countries, but also knowledge about the utilization of other options (running, jogging) is existing only rarely. This holds also true in Somaliland. Half of the female students (52 %) and one quarter of the male ones (27 %) did not engage in any physical activity. These figures are very similar to the ones reported from students in Cameroon, where physical inactivity was prevalent in 55 % of females, but only 24 % of male students [4]. Lower figures have been reported from students in other African countries, with percentages between 12 and 24 % of male students not engaging in physical activities, respectively [8, 10, 12]. In the present study more females than male students were coming from affluent families. It is a well-known fact that in underprivileged sections of the society in developing countries, boys are often much longer sent to educational institutions than girls. To this end, policies aimed at discouraging physical inactivity and sedentary behavior are crucial for tackling the problem already in its infancy [3, 7, 8, 18]. The future success in preventing a rise in cardiovascular risk factors in Somaliland will depend on how the low physical activity in the young population will be addressed in the next years. This study showed that about half of female and one quarter of the male students are physically inactive and would gain


0.9, 3.6



health benefits from sport programs. Awareness among the students about the risks of physical inactivity should be put in place as should be efforts to increase physical activity. The vast majority of students expressed the wish that more facilities should be offered by the university. Relevant programs should focus on promotion of sports and programs that particularly target girls. Women’s lack of participation in sport and physical activity and their higher overweight and television viewing times is of concern. The implementation of more university-based sport programs and offering other physical exercises on campus for girls will be a move forward. All this will require substantial political advocacy and commitment by stakeholders alike. Acknowledgments We would like to thank all participating students of the University of Hargeisa for their active participation. This study was supported by Afrika aktiv e.V. and the Else-Kroener-Fresenius-Stiftung, Germany.

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Cardiovascular risk factors and physical activity among university students in Somaliland.

Physical inactivity is a well-known risk factor for the development of cardiovascular diseases and counts as fourth leading cause of death worldwide. ...
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