Social determinants of health and
well-being among young people
Findings from the HBSC 2009/2010 HBSC Cross-National
Survey and evidence for policy at international and
national levels
Candace Currie
HBSC International Coordinating Centre
University of St Andrews
Outline of presentation
• The HBSC study: overview
• HBSC International Report 2009/2010
• Patterns of health among 11, 13 and 15 year olds in 39 countries
• Social determinants and health inequalities: family affluence, gender and age
• Evidence for policy at international level
• HBSC in Scotland case study – evidence for policy at national level
Key aim
To demonstrate development and implementation of HBSC communications
and impact plan:
• Achieving impact needs to be planned as a key goal from the outset of
research – not as an afterthought
• Data can be used at national and international levels in a large variety of ways
to inform and influence policy and practice
• Evaluating impact is still under development so range of evidence should be
gathered to gain a comprehensive picture
Background
History of the HBSC study
• HBSC initiated in 1983 in 3 countries and soon after became a World Health
Organization collaborative study – 30th anniversary in 2013
• Now 43 member countries in Europe and North America and a network of
more than 350 researchers
• Recent global development with linked projects in other regions of world (eg
China, Taiwan, Kuwait, Lebanon, Kosovo, India) using HBSC protocol and
instrument
• Works closely with NGOs and government organisations at national and
international levels to ensure widespread use of data to inform and influence
policy and practice
HBSC study background
Aim of the HBSC study (1)
• to increase knowledge and understanding of adolescent health and its
developmental, social and cultural determinants
• to gather cross-nationally comparable data on a range of health, behavioural
and social indicators on school children aged 11, 13 and 15 years
• to advance scientific field of adolescent health internationally
• to use data to inform and influence policy and practice for health
improvement of young people
HBSC study background
Aim of the HBSC study (2)
• to build a network of researchers across countries and develop research
capacity internationally in adolescent health
• to be a source of information and intelligence for stakeholders with a remit for
young people’s health
• to work in close collaboration with study partners with an advocacy role for
young people’s health improvement including WHO, UNICEF, OECD, EC
HBSC Surveys
Data collections to date
•
•
•
•
Surveys conducted every four years
8th cross-national surveys to date - next survey scheduled for 2013/2014
Nationally representative samples in each country
Sample size of 1,550 for each age group - 11, 13 and 15 year olds
• Standardised survey protocol and survey instrument – validated through
cross-national testing
2009/2010 survey:
• More than 200,000 young people were surveyed in 42 countries
• Data cover more than 60 topic areas with child indicators of:
• health and wellbeing
• health behaviours and risk behaviours
• family context, peer relations, school environment, neighbourhood,
socioeconomic conditions
HBSC national and international impact
Publications and knowledge exchange
• Over 150 national reports from successive surveys
• 6 international reports published by WHO - over 1000 citations (from past 2)
• 3 WHO/HBSC international policy forums – feeding into 3 European
Ministerial declarations to improve health
• 500+ peer reviewed journal articles
• International Journal of Public Health Supplement on HBSC in 2009;
• Journal supplement in preparation on international health and social trends
Latest HBSC International Report
WHO: Health Policy for Children
and Adolescents, No.6
Social determinants of health
and well-being among
young people
Currie, Zanotti, Morgan et al (eds) (2012)
Wider context of this report
Growing interest and global focus on adolescent health
“……there is an unprecedented momentum for young
people and adolescents. Young people,
after all, are our assets for the future”
Lancet Senior Executive Editor
Sabine Kleinert
Global focus on adolescent health
Recent evidence of data informing advocacy and policy (1)
•Lancet adolescent health series ‘Adolescents: From the Margins to the
Mainstream of Global Health’ launched in April 2012 in New York
•UNICEF published ‘Progress for Children: A report card on adolescents. No.10’,
April 2012
•UN Commission on Population and Development 45th Session - adolescents
and young people as their central theme, NY, 23-27 April 2012
Global focus on adolescent health
Recent evidence of data informing advocacy and policy (2)
•UNICEF report on ‘The State of the World’s Children 2011: Adolescence:
An Age of Opportunity’
•Unicef Report Card 9: ‘The Children Left Behind: A league table of inequality in
child well-being in the world's rich countries’ 2010
•Unicef Report Card 7: ‘Child Poverty in Perspective: An overview of child wellbeing in rich countries’ 2007
•WHO Europe has established a Commission on Social Determinants of Health
and adolescents feature as a key demographic group- informing new European
health policy, ‘Health 2020'
HBSC International Report content
Report focus
•Provides comprehensive, up to date comparative data on health and wellbeing
of young people growing up in almost 40 countries across Europe and North
America
•Examines social determinants of health – highlighting extent to which young
people’s health is shaped by inequalities related to age, gender and family
affluence
Information for action
•Indicates that adolescence is a critical developmental stage in the life course
•Helps to identify opportunities for health improvement and points for
intervention
•Shows need to strengthen efforts to build on early years investment
Key themes of report: comparing countries
First and foremost
provides key comparative data on health and wellbeing of young people: vital
information for national policy makers for benchmarking on:
• health outcomes: self-reported health, life satisfaction, health complaints,
body weight
• health behaviours: breakfast, fruit, physical activity, toothbrushing
• risk behaviours: tobacco use, alcohol, cannabis, sexual health,
fighting, bullying
• social contexts of health: family, peer and school connections
As well as descriptive data report provides scientific discussions and policy
reflections
Comparative data: value for policy makers
• Allows countries to see how they are doing on any particular measure
of health
• Ascertain whether the issue is common to all countries
• Or, whether there is evidence of strong cultural/ social differences
between countries
• Similarities between countries at one age may not be replicated at another
showing the importance of examining developmental trajectories
Country comparisons: MVPA (physical activity)
Girls:
range 5%-17%
Boys:
range 12%-33%
1%
Country comparisons: Weight-reduction behaviour
Girls:
range 8%-37%
Boys:
range 3%-14%
1%
Country comparisons: (physical activity) 11 &15 years
Austria (2)
USA (1)
USA (9)
Austria (21)
Key findings: Inequalities
Where do we see the greatest
inequalities related to family
affluence, gender and age?
•
•
•
•
In social contexts of health
In health outcomes
In health behaviours
In risk behaviours
FAMILY AFFLUENCE
(FAS) distribution by country
Norway 2% low affluence
76% high affluence
USA 11% low affluence
54% high affluence
Turkey 62% low affluence
8% high affluence
Key findings: Understanding FAS charts
ARMENIA*
Proportion of boys
taking soft drinks
daily higher among
those from higher
affluence families
*
SCOTLAND*
Proportion of girls
taking soft drinks
daily higher among
those from lower
affluence families
*
Key findings: family affluence
Health outcomes
Many aspects of health affected by family affluence -> better outcomes
generally* associated with better material conditions:
• Self-rated health
• Life satisfaction
• Health complaints
• *Medically attended injuries – higher prevalence higher affluence
• Overweight and obesity – higher prevalence associated with lower affluence
(but opposite in some poorer countries*)
Gender effects
• Larger FAS differences for self-rated health and life satisfaction among girls than
boys
Key findings: family affluence
Family affluence and life satisfaction
Key findings: family affluence
Health behaviours
Positive health behaviour tends to be associated with better material conditions:
• Eating fruit daily
• Eating breakfast on school days
• Toothbrushing more than once a day
Gender effects
• For daily fruit greater effect of FAS for girls
• For toothbrushing greater effect of FAS for boys
Key findings: family affluence
Family affluence and brushing teeth more than once a day
Key findings: family affluence
Social context
Positive social contexts and connections associated with better material
conditions:
• Easy to talk to mother
• Easy to talk to father
• Having 3+ close friends
• Daily electronic media contact
• Good school performance
Gender effects
• Both easy to talk to mother and to father show greater effects of FAS for girls
Key findings: family affluence
School: Family affluence and perceived school performance
Key findings: gender
Gender differences
&
Gender equalisation
Gender differences: overweight/ obese
Girls:
range 5%-27%
Boys:
range 11%-34%
Gender differences: multiple health complaints
Girls:
range 25%-65%
Boys:
range 14%-54%
Key findings: gender differences
Girls do better:
• injuries, overweight/ obese, fruit, soft drinks, oral health
• early tobacco initiation, weekly drinking, drunkenness,
sexual health, fighting, bullying
• electronic media communication with friends, liking school, perceived school
performance
Boys do better:
• self-rated health, life satisfaction, health complaints, body image, breakfast,
physical activity
• Easy communication with father, 3+ close friends, evenings out with friends,
feel less pressured by schoolwork
Gender differences: electronic media communication
Girls:
range 48% - 81%
Boys:
range 25% - 66%
Key findings: gender differences
Gender equalisation
•
Where we see equalisation it is in girls adopting ‘male patterns’ of risk,
seen in a few countries, for example:
• smoking in Czech Republic, Spain, Wales, England
• drunkenness in Denmark, Wales, Greenland, Scotland and Finland
• sexual intercourse by 15 in Greenland, Wales, Scotland, England,
Germany
•
But we do not see corresponding equalisation in health perceptions ie girls
improved well-being/ body image; or increase in physical activity
Key findings: age changes
Health outcomes: all worsen with age especially for girls
•
Fair/poor health
•
Life satisfaction
•
Health complaints
•
Body image: worsens in girls (not boys)
•
Weight control: increases in girls (not boys)
Health fair/poor: 11, 13 and 15 years
Key findings: age changes
Health behaviours: worsen in boys and girls*
•
•
Breakfast
Fruit
•
•
Physical activity
Toothbrushing: increases in girls*/ decreases in boys
Risk behaviours: worsen in boys and girls
•
Smoking, drinking and drunkenness
Social contexts and connections: critical changes
•
•
family and school support declines
peer support increases
Drink alcohol weekly: 11, 13 and 15 years
Discussion points: age
• Health compromising behaviours increase especially between ages 13 and
15 but extent and pattern of change varies across countries suggesting that
social, cultural, economic and legislative factors play an important role
• Important changes in social contexts are experienced by young people as
they transition through puberty, changing relationships and new social
structures (e.g. school systems) – programmes need to focus on helping to
build assets in order that adolescents can negotiate healthy pathways
• Patterns of change commonly differ for girls and boys with evidence that
during transition girls are susceptible to poorer health and well-being
Discussion points: gender
• Gender differences in patterns of health and social relations vary from
country to country and are related to cultural differences in gender
socialisation. Social expectations and social restrictions have a role to play
as do gender roles in adult society.
• Underlying girls’ poorer self-rated health and wellbeing may be higher levels
of stress which may be linked to physical changes at puberty as well as
perceived pressure to do well in different spheres
• Patterns of risk taking are also changing – traditionally males had higher
rates but in some western countries girls have overtaken rates among males
which have seen a decline
• Equalisation however is not seen around mental health where boys maintain
better self-perceptions
Discussion points: family affluence
• Evidence that affluence impacts on social contexts as well as health and wellbeing with advantage for those growing up in more affluent families
• Various explanations have been proposed relating to family affluence
conferring social status, economic power to purchase healthy foods and
activities, or being linked to higher levels of education/ occupation. Material
capital may translate to social capital.
• Risk behaviours are less influenced by family affluence than healthy
behaviours, being susceptible to other social factors (eg friendship group),
wider cultural norms
• Positive experiences of education and schooling, as well as support of key
adult figure, are known to reduce the impact of low family affluence on a
young person’s school achievement
• Inequalities within a country as well as at family level are known to affect
adolescent health and well-being
Adolescence a critical period for intervening
• no other period in lifecourse where health, behaviour and social
environment are all changing so rapidly
• at same time, important neurological, cognitive, hormonal, and
physical changes occurring
• critical time for positive inputs to support, and set on track, health of
young people for best current and future outcomes
What can such an international report achieve to make
use of data
HBSC provides a rich source of data that can be translated into useful
intelligence:
•
to inform and guide policy and practice
•
to improve the health of all young people
•
to limit the impact of social inequalities
•
and invest sufficiently to build on early years
Elements of broader communications and impact plan
Engaging with wide range of stakeholders:
• considerable investment into creation and continual updating of
stakeholder database to enhance engagement with end users of data
through accurate targeting with information
• development of online systems for knowledge exchange e.g. using
social media technology – attractive to wide range of users and
increasingly popular – challenge is to reach all constituencies
including young people
• use of traditional media
• launch of international report accompanied by a media strategy
at national and international levels – highly successful
• importance of ongoing media coverage at national level through
‘trickle’ of news on latest findings
Elements of broader communications and impact plan
Building relationships with data users (1):
World Health Organisation - longstanding partnership with WHO over
almost thirty years has led to many opportunities for data use:
• for reports (HBSC international reports and special reports e.g.
‘Snapshot of Young People’s Health in Europe’)
• for specific events (WHO-HBSC Forums and other meetings e.g.
WHO Youth Friendly Health Policies and Services Conference)
• Child and Adolescent Health Strategy in Europe – HBSC as a tool
to create an evidence base from national survey data
Elements of broader communications and impact plan
Building relationships with data users (2):
UNICEF Innocenti Research Centre (Florence) and HQ (New York):
• provided data for Report Card 7: ‘Child Poverty in Perspective: An
overview of child well-being in rich countries’ 2007
• produced background paper including HBSC data analysis for
Report Card 9: ‘The Children Left Behind: A league table of
inequality in child well-being in the world's rich countries’ 2010
• Regular consultations about future work of HBSC and UNICEF and
opportunities for partnership activities (eg HBSC consulting
UNICEF about future of study; discussions about potential to
survey younger and hard to reach children)
Elements of broader communications and impact plan
Building relationships with data users (2):
UNICEF Innocenti Research Centre (Florence) and HQ (New York):
• provided data for Report Card 7: ‘Child Poverty in Perspective: An
overview of child well-being in rich countries’ 2007
• produced background paper including HBSC data analysis for
Report Card 9: ‘The Children Left Behind: A league table of
inequality in child well-being in the world's rich countries’ 2010
• Regular consultations about future work of HBSC and UNICEF and
opportunities for partnership activities (eg HBSC consulting
UNICEF about future of study; discussions about potential to
survey younger and hard to reach children)
Elements of broader communications and impact plan
Building relationships with data users (3):
OECD:
• provided data for OECD reports including: ‘Doing Better for
Children’ ; ‘Doing Better for Families’; ‘Health at a Glance’
• presented invited papers based on HBSC data to OECD
international conference on Education, Social Capital and Health
in Oslo, 2010
• participated two high level conferences ‘UNICEF/ OECD/ EC
consultations on Child Wellbeing’ contributing evidence from
HBSC study on children indicators and data
• contributed input to OECD/EC review of child surveys in Europe
Impact of data at international level
• How to measure this is complex as policy impact will probably
first occur at national level
• International policy change would be through, for example,
European legislation and hard to trace process by which data
could be said to have effected change
• Many countries following same legislative or policy change would
be a more likely route
Value of international data
HBSC provides a rich source of data that can be translated
into useful intelligence:
• to inform and guide policy and practice
• to improve the health of all young people
• to limit the impact of social inequalities
• and invest sufficiently to build on early years
Impact of data at national level
National data use:
• Data can drive change in policy and practice – especially unfavourable
international comparisons (example of poor eating habits, low
physical activity, poor sexual health)
• Power of time trends – e.g. in Scotland 20 years of data – change and
lack of change
• Analysis of relationship between trends in health and policy
environment – can we trace impact of policy and practice change
Need for policy action on teen smoking indicated by
increasing rates in 1990s
Evidence of impact indicated by
decreasing trends in 2000s (including
smoking in public places ban 2006)
Evidence of impact of improved schools food environment:
Education (School Meals) (Scotland) Act 2003
Interpreting national findings
How can international data enhance our understanding of young people’s
health in Scotland?
•
How does Scotland rank compared with other countries?
•
Has rank changed over time?
•
How do national trends compare with international trends?
•
How does prevalence compare across age and gender groups?
•
Are age and gender differences the same as in other countries?
•
What are the levels of relative socio-economic inequality?
International comparison
Ranking:
HIGH
Top ⅓ countries (rank = 1-13)
MEDIUM
Middle ⅓ countries (rank = 14-26)
LOW
Bottom ⅓ countries (rank = 27-39)
Sexual health (15 year olds)
Sexual intercourse
• 27% boys and 35% girls report having had sexual intercourse
• HIGH ranking = 7th (out of 36)
Condom use
• 72% boys and 70% girls report using a condom at last
intercourse
• LOW ranking = 27th (out of 32)
Pill use
• 14% boys and 21% girls report use of contraceptive pill at
last intercourse
• MEDIUM ranking = 18th (out of 34)
Relative inequality: sexual intercourse
Relative socio-economic inequality
Scotland has HIGH relative inequality compared to other
HBSC countries for:
• Soft drink consumption
• Sexual intercourse
• Classmate support
• Having been bullied
• Self-rated health
• Tobacco initiation (girls only)
• Lifetime cannabis use (girls only)
• Communication with mother (girls only)
Where is Scotland doing well?
• Life satisfaction
• Peer relationships
• Smoking
• Cannabis use
• Oral health
Future challenges
• Physical activity
• Sexual health
• Alcohol consumption
• School experience
• Family communication
Three key elements to impact
• Articulation of the problem through data
• Policy based solution
• Political will
Further acknowledgements
• Young people who responded to surveys in 39 countries and schools and
education authorities who supported HBSC
• Funders, especially NHS Health Scotland who support HBSC International
Coordination and the Norwegian Institute of Public Health who support the
HBSC Data Management Centre
• HBSC network members for devising the study, fund raising at national level,
collecting the data, publishing findings
• WHO – HBSC study partner
• University of St Andrews (hosts HBSC International Coordinating Centre)
• University of Bergen (hosts HBSC Databank Management Centre)
• University of Southern Denmark (hosts HBSC Support Centre for Publications)
• Ludwig Boltzmann Institute (coordinated development of HBSC international
research protocol 2009/2010)