CROSS NATIONAL RESEARCH ON RISK BEHAVIOURS:

Experiences from the HBSC Study

CHALLENGES AND IMPACT

Candace Currie, HBSC International CoordinatorChild and Adolescent Health Research UnitUniversity of St Andrews

OUTLINE OF PRESENTATION

HBSC study overview

Risk behaviours among 11 -15 year olds across Europe and North America

Social determinants of risk behaviour

Evidence for policy decision makers at international level

National policy case study - HBSC in Scotland

1. HBSC study overview

HISTORY OF HBSC STUDY

HBSC started in 1983 in 3 countries; World Health Organization Collaborative study

Now 44 countries in Europe and North America; network of > 350 researchers

Adaptation and use of HBSC Protocol in other regions - HBSC ‘linked projects’

Works with NGOs and government departments at national/ international levels

AIMS OF THE HBSC STUDY

Raise awareness of adolescent health

internationally

Gather cross-nationally comparable data

Advance scientific field of adolescent health

Encourage use of data in policy and

practice

Build research network and international

capacity

Collaborate with partners with advocacy role

HBSC SURVEYS: DATA COLLECTION

School based surveys every four years; self-complete questionnaire in classroom under ‘exam’ conditions

8 surveys completed to date, 9th in 2013/2014 – countries currently submitting data to international databank

Nationally representative samples – 1550 pupils aged 11, 13 and 15 years

Standardised survey protocol and survey instrument – validated through cross-national testing

HBSC SURVEY: CHALLENGES

To maintain quality standards as study grows in size and diversity

To innovate and improve in context of limited financial resources

To meet the need for trend data while developing questionnaire content each survey cycle

To meet differing requirements of scientific and policy audiences

HBSC SURVEY PROTOCOL

Produced by network for each survey cycle – 2.5 year process

Work of topic area ‘focus groups’

Brought together by Scientific Development Group

Input from Policy and Methodology Development Groups

2013/14 RESEARCH PROTOCOL: Public Access @ www.hbsc.org

HBSC SURVEYS: THE 2009/10 SURVEY DATA

More than 200,000 young people were surveyed

• Health and wellbeing

• Health behaviours and risk behaviours

• Family, peers, school, neighbourhood, socioeconomic conditions

Over >60 topic areas with child indicators for:

HBSC SURVEYS: QUESTIONNAIRE

Set of HBSC mandatory items used by all countries

Selection of HBSC optional packages

National items

NATIONAL Q’AIRE

HBSC SURVEYS: METHODOLOGICAL CHALLENGES OF STUDYING ADOLESCENTS

Permission: from education authorities and schools;

Consent: young people and parents; implications of active v passive consent

Administration: methods and settings

Questions: age appropriate in content and vocabulary

Ethical considerations: ethics approval

HBSC SURVEYS: METHODOLOGICAL CHALLENGES OF CROSS-NATIONAL RESEARCH

Translation

Variation in guidelines for consent

Different school systems

Cultural relevance, acceptability or understanding of specific concepts

Ethical approval - not all countries have such systems in place

HBSC SURVEYS: METHODOLOGICAL CHALLENGES OF STUDYING RISK BEHAVIOURS

Cultural acceptability in some countries

Ethical considerations – asking young people about illegal activities

Accuracy of self-reports

Non-response

Skip or filtering instructions can be hard to understand

HBSC’S LATEST RESEARCH FINDINGS

International Report (2012)

Journal Publications

Factsheets and briefing papers

Data visualisations

HBSC INTERNATIONAL REPORT (2012)

Social determinants of health and well-being among young people

WHO Report Series: ‘Health Policy for Children and Adolescents’(6; 2012)

HBSC INTERNATIONAL REPORT CONTENT

Report focus:

comparative data on health and wellbeing of young people in 39

countries

highlights risk behaviours and how these vary across countries

examines inequalities related to age, gender and affluence

Information for action:

adolescence a critical developmental stage in life course

opportunities for intervention and health improvement

value of building on ‘early years’ investment

COMPARATIVE DATA: FIRST AND FOREMOST

risk behaviours

health and wellbeing

social contexts of

health

health behaviours

Vital information for national policy makers benchmarking on:

COMPARATIVE DATA: current and future policy issues

tobacco use, alcohol,

cannabis, sexual behaviour,

fighting, bullying

self-rated health, life satisfaction,

health complaints, body image and BMI

family, peers, school,

socioeconomic conditions

breakfast, fruit, physical activity, toothbrushing

Comparative data on:

COMPARATIVE DATA: VALUE FOR NATIONAL POLICY

Countries can see how they are doing on any particular health/social

Can ascertain whether issue is common to all countries or particular to theirs

Evaluate evidence of strong cultural/ social differences between countries

Importance of examining developmental trajectories

2. Risk behavioursamong 11 -15 year olds across Europe and North America

23 countries B=G 10 countries B>G (mainly E and SE Europe) 3 countries G>B (England, Wales, Czech Rep)

GENDER

TOBACCO USE WEEKLY:15-YEAR-OLDS

Boys: range 8-53%

TOBACCO USE WEEKLY:15-YEAR-OLDS

Girls: range 1-61%

30% or more

25-29%

20-24%

15-19%

10-14%

Less than 10%

32 countries B>G 7 countries B=G 0 countries G>B

GENDER

ALCOHOL USE WEEKLY:15-YEAR-OLDS

Boys: range 6-44%

ALCOHOL USE WEEKLY:15-YEAR-OLDS

Girls: range 5-34%

40% or more

30-39%

20-29%

10-19%

Less than 10%

20 countries B>G 13 countries B=G 5 countries G>B (Greenland, Scotland,

Finland, Sweden, Spain)

GENDER

DRUNK 2+ TIMES:15-YEAR-OLDS

Boys: range 15-57%

Girls: range 8-56%

DRUNK 2+ TIMES:15-YEAR-OLDS

55% or more

45-54%

35-44%

25-34%

15-24%

Less than 15%

23 countries B>G 14 countries B=G 0 countries G>B

GENDER

CANNABIS EVER USED*:15-YEAR-OLDS*no data for Sweden, Turkey

Boys: range 4-33%

Girls: range 1-33%

CANNABIS EVER USED:15-YEAR-OLDS

30% or more

25-29%

20-24%

15-19%

10-14%

5-9%

Less than 5%

19 countries B>G 11 countries B=G 6 countries G>B (Greenland*, Scotland*,

Finland*, Germany)

GENDER

HAVE HAD SEXUAL INTERCOURSE*:15-YEAR-OLDS* no data for Belgium (Fr), Turkey, US

*countries where drunkenness rates also higher among girls than boys

Boys: range 15-46%

Girls: range 3-71%

HAVE HAD SEXUAL INTERCOURSE:15-YEAR-OLDS

55% or more

45-54%

35-44%

25-34%

15-24

Less than 15%

0 countries B>G 24 countries B=G 10 countries G>B

GENDER

PILL USE AT LAST INTERCOURSE*:15-YEAR-OLDS* no data for Belg (Fr), Czech Rep, Russian Fed, Turkey, US

Boys: range 3-54%

Girls: range 2-62%

PILL USE AT LAST INTERCOURSE:15-YEAR-OLDS

55% or more

45-54%

35-44%

25-34%

15-24%

5-14%

Less than 5%

9 countries B>G 23 countries B=G 0 countries G>B

GENDER

CONDOM USE AT LAST INTERCOURSE*: 15-YEAR-OLDS* no data from Belg (Fr), Czech Rep, Denmark, Greenland, Russ Fed, Turkey & US

Boys: range 69-91%

Girls: range 58-89%

CONDOM USE AT LAST INTERCOURSE: 15-YEAR-OLDS

85% or more

80-84%

75-79%

70-74%

65-69%

Less than 65%

3. Social determinants of risk behaviour

HBSC FAMILY AFFLUENCE SCALE (FAS)

Summed to produce FAS

score

Number of cars

Own bedroom Family holidays

Computers in the home

FAMILY AFFLUENCE DISTRIBUTION BY COUNTRY

Norway 2% low affluence76% high affluence

USA 11% low affluence54% high affluence

Turkey 62% low affluence 8% high affluence

Family affluence according to composite scores (all ages)

UNDERSTANDING FAS CHARTS

ARMENIAProportion of boystaking soft drinks daily higher among those from higheraffluence families

SCOTLANDProportion of girls taking soft drinks daily higher among those from lower affluence families

KEY FINDINGS: Health and family affluence

+vely

associated with higher

FAS

Self-rated health

Life satisfaction

Health complaints

Medically attended injuries – higher prevalence associated with affluence

Overweight and obesity - associated with affluence in poorer countries

However

Gender effects

Differentials between poorer and more affluent greater for girls in self rated health and life satisfaction

KEY FINDINGS: FAMILY AFFLUENCE AND LIFE SATISFACTION

SOCIAL CONTEXT and Family Affluence

+velyassociated

with higher FAS

Easy to talk to mother

Easy to talk to father

Having 3+ close

friends

Daily electronic

media contact

Good school performance

Both easy to talk to mother and to father show greater effects of FAS for girls

Gender effects

KEY FINDINGS: FAMILY AFFLUENCE AND PERCIEVED SCHOOL PERFORMANCE

KEY FINDINGS: FAMILY AFFLUENCE AND WEEKLY TOBACCO USE

FAMILY AFFLUENCE AND RISK BEHAVIOURS

Risk behaviours associated with

FAS in only a minority of countries

Smoking associated with low affluence

Weekly alcohol use associated with high affluence among boys

Cannabis use generally associated with low affluence among boys

Mixed picture for sexual behaviour

DISCUSSION POINTS: GENDER AND SOCIOECONOMIC ISSUES

Gender patterns vary between countries andmay be explained by cultural differences in gender socialisation

Social expectations and social restrictions have a role to play as do gender roles in adult society

Patterns of risk taking are changing - in some western countries girls show higher rates of risk behaviour than males which have seen a decline

Risk behaviours are less influenced by family affluence than healthy behaviours

4. Evidence for policy decision makers at international level

VALUE OF INTERNATIONAL REPORT: PROMOTING USE OF HBSC

HBSC provides a rich source of data that can be translated into action:

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:

World Health Organization

Longstanding partnership with WHO has led to

many opportunities for data use:

HBSC international reports and

special reports

WHO-HBSC Forums

Child and Adolescent

Health Strategy in Europe

BUILDING RELATIONSHIPS WITH DATA USERS

ELEMENTS OF BROADER COMMUNICATIONS AND IMPACT PLAN:

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

BUILDING RELATIONSHIPS WITH DATA USERS

ELEMENTS OF BROADER COMMUNICATIONS AND IMPACT PLAN:

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

BUILDING RELATIONSHIPS WITH DATA USERS

IMPACT OF DATA AT INTERNATIONAL 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

How to measure this is complex as policy impact will

probably first occur at national level

IMPACT OF DATA AT NATIONAL LEVEL

National data use:

Data can drive change in policy and practice –

especially with unfavourable

international comparisons

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 –trace impact of policy and

practice change?

5. National policy case study -HBSC in Scotland

NEED FOR POLICY ACTION ON TEEN SMOKING INDICATED BY INCREASING RATES IN 1990’S

Evidence of impact indicated by decreasing trends in 2000s (including smoking in public places ban 2006)

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 relativesocio-economic

inequality?

INTERNATIONAL COMPARISON

HIGH

• Top ⅓ countries (rank = 1-13)

MEDIUM

• Middle ⅓ countries (rank = 14-26)

LOW

• Bottom ⅓ countries (rank = 27-39)

SEXUAL HEALTH: SCOTLAND V INTERNATIONAL

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

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?

High life satisfaction

Positive peer relationships

Low smoking rates

Low cannabis use

Good oral health

THREE KEY ELEMENTS OF IMPACT

Articulation of the problem through data

Policy based solution

Political will

6. New WHO Collaborating Centre for Child and Adolescent Health Policy

ACHIEVING RESEARCH IMPACT: HBSC COMMUNICATIONS AND IMPACT PLAN

Achieving ‘impact’ has been planned as a key goal of HBSC Study from outset (written into study Terms of Reference 30 years ago)

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

Role of new WHO Collaborating Centre in Child and Adolescent Health Policy at St Andrews School of Medicine is to better understand process of policy impact through research communication (www.whoccstandrews.org)

CURRENT ACTIVITIES (year 1)

• SYSTEMATIC REVIEW (July to Dec 2014) Does the involvement of children and young people improve programme effectiveness?

• 3rd POLICY EVENT (27TH Oct)Educational session: What are New Psychoactive Substances (‘Legal Highs’)? Expert speaker: Professor Fabrizio Schifano, University of Hertfordshire.

Round table discussion: with key stakeholders including school and university students, teachers and student services

ACKNOWLEDGEMENTS

Young people FundersHBSC network

members

WHO – HBSC study partner

University of St Andrews

(International Coordinating Centre)

University of Bergen (Data Management

Centre)

University of Southern Denmark (Support Centre for

Publications)

Ludwig Boltzmann Institute (supports

protocol production)