social determinants of health and well-being among … of presentation • the hbsc study: overview...

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

Social determinants of health and well-being among young people

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 well-being 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)

Austria (21)

USA (9)

USA (1)

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


Family affluence and life satisfaction


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


Family affluence and brushing teeth more than once a day


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


School: Family affluence and perceived school performance

Gender differences & Gender equalisation

Key findings: gender

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


• 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 well-being 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


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



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)



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

HIGH Top ⅓ countries (rank = 1-13)

MEDIUM Middle ⅓ countries (rank = 14-26)

LOW Bottom ⅓ countries (rank = 27-39)

Ranking:

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?


• 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)

social determinants of health and well-being among … of presentation • the hbsc study: overview...

Documents