Presentation by Professor Candace Currie from the Health Behaviour in School-age Children programme (HBSC) gives a study overview; discussion of risk behaviours among adolescents across Europe and North America; discussion of social determinants of risk behaviours; evidence for policy makers; and a case study of HBSC in Scotland

1. CROSS NATIONAL
RESEARCH ON RISK
BEHAVIOURS:
CHALLENGES AND IMPACT
Experiences from the HBSC Study
Candace Currie, HBSC International Coordinator
Child and Adolescent Health Research Unit
University of St Andrews

2. 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

3. 1. HBSC study
overview

4. 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

5. 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
Collaborate with
partners with
advocacy role
Build research
network and
international
capacity

6. 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

7. 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

8. 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

9. 2013/14 RESEARCH PROTOCOL: Public Access
@ www.hbsc.org

10. HBSC SURVEYS: THE 2009/10 SURVEY DATA
More than 200,000 young people were surveyed
Over >60 topic areas with child indicators for:
• Health and wellbeing
• Health behaviours and risk behaviours
• Family, peers, school, neighbourhood, socioeconomic
conditions

11. HBSC SURVEYS: QUESTIONNAIRE
Set of HBSC mandatory items used by all countries
Selection of HBSC optional packages
National items
NATIONAL Q’AIRE

12. 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

13. 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

14. 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

15. HBSC’S LATEST RESEARCH FINDINGS
International
Report (2012)
Journal
Publications
Factsheets and
briefing papers
Data
visualisations

16. 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)

17. 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

18. COMPARATIVE DATA: FIRST AND FOREMOST
risk
behaviours
health and
wellbeing
social
contexts of
health
health
behaviours
Vital information for
national policy makers
benchmarking on:

19. 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:

20. 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

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

22. TOBACCO USE WEEKLY:
15-YEAR-OLDS
GENDER
 23 countries B=G
 10 countries B>G (mainly E and SE Europe)
 3 countries G>B (England, Wales, Czech Rep)

23. TOBACCO USE WEEKLY:
15-YEAR-OLDS
Girls:
range 1-61%
Boys:
range 8-53%
30% or more
25-29%
20-24%
15-19%
10-14%
Less than 10%

24. ALCOHOL USE WEEKLY:
15-YEAR-OLDS
GENDER
 32 countries B>G
 7 countries B=G
 0 countries G>B

25. ALCOHOL USE WEEKLY:
15-YEAR-OLDS
Girls:
range 5-34%
Boys:
range 6-44%
40% or more
30-39%
20-29%
10-19%
Less than 10%

26. DRUNK 2+ TIMES:
15-YEAR-OLDS
GENDER
 20 countries B>G
 13 countries B=G
 5 countries G>B (Greenland, Scotland,
Finland, Sweden, Spain)

27. DRUNK 2+ TIMES:
15-YEAR-OLDS
Girls:
range 8-56%
Boys:
range 15-57%
55% or more
45-54%
35-44%
25-34%
15-24%
Less than 15%

28. CANNABIS EVER USED*:
15-YEAR-OLDS
*no data for Sweden, Turkey
GENDER
 23 countries B>G
 14 countries B=G
 0 countries G>B

29. CANNABIS EVER USED:
15-YEAR-OLDS
Girls:
range 1-33%
Boys:
range 4-33%
30% or more
25-29%
20-24%
15-19%
10-14%
5-9%
Less than 5%

30. HAVE HAD SEXUAL INTERCOURSE*:
15-YEAR-OLDS
* no data for Belgium (Fr), Turkey, US
GENDER
 19 countries B>G
 11 countries B=G
 6 countries G>B (Greenland*, Scotland*,
Finland*, Germany)
*countries where drunkenness rates also higher
among girls than boys

31. HAVE HAD SEXUAL INTERCOURSE:
15-YEAR-OLDS
Girls:
range 3-71%
Boys:
range 15-46%
55% or more
45-54%
35-44%
25-34%
15-24
Less than 15%

32. PILL USE AT LAST INTERCOURSE*:
15-YEAR-OLDS
* no data for Belg (Fr), Czech Rep, Russian Fed, Turkey, US
GENDER
 0 countries B>G
 24 countries B=G
 10 countries G>B

33. PILL USE AT LAST INTERCOURSE:
15-YEAR-OLDS
Girls:
range 2-62%
Boys:
range 3-54%
55% or more
45-54%
35-44%
25-34%
15-24%
5-14%
Less than 5%

34. CONDOM USE AT LAST
INTERCOURSE*: 15-YEAR-OLDS
* no data from Belg (Fr), Czech Rep, Denmark,
Greenland, Russ Fed, Turkey & US
GENDER
 9 countries B>G
 23 countries B=G
 0 countries G>B

35. CONDOM USE AT LAST
INTERCOURSE: 15-YEAR-OLDS
Girls:
range 58-89%
Boys:
range 69-91%
85% or more
80-84%
75-79%
70-74%
65-69%
Less than 65%

36. 3. Social
determinants of
risk behaviour

37. HBSC FAMILY AFFLUENCE SCALE (FAS)
Summed to
produce FAS
score
Number of cars
Own bedroom Family holidays
Computers in the
home

38. FAMILY AFFLUENCE DISTRIBUTION BY
COUNTRY
Norway 2% low affluence
76% high affluence
USA 11% low affluence
54% high affluence
Turkey 62% low affluence
8% high affluence
Family affluence according to composite scores (all ages)

39. 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

40. KEY FINDINGS: Health and family affluence
Self-rated
health
+vely
associated
with higher
FAS
Life
satisfaction
Health
complaints
However
Medically attended injuries – higher
prevalence associated with affluence
Overweight and obesity - associated
with affluence in poorer countries
Gender effects
Differentials between poorer and
more affluent greater for girls in self
rated health and life satisfaction

41. KEY FINDINGS: FAMILY AFFLUENCE AND LIFE
SATISFACTION

42. SOCIAL CONTEXT and Family Affluence
Easy to talk
to mother
+vely
associated
with
higher FAS
Easy to talk
to father
Having 3+
close
friends
Good school
performance
Daily
electronic
media
contact
Gender effects
Both easy to talk to
mother and to father
show greater effects of
FAS for girls

43. KEY FINDINGS: FAMILY AFFLUENCE AND
PERCIEVED SCHOOL PERFORMANCE

44. KEY FINDINGS: FAMILY AFFLUENCE AND
WEEKLY TOBACCO USE

45. 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

46. DISCUSSION POINTS: GENDER AND
SOCIOECONOMIC ISSUES
Gender patterns vary between countries and
may 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

47. 4. Evidence for
policy decision
makers at
international
level

48. 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

49. 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

50. ELEMENTS OF BROADER COMMUNICATIONS
AND IMPACT PLAN:
BUILDING RELATIONSHIPS WITH DATA USERS
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

51. ELEMENTS OF BROADER COMMUNICATIONS
AND IMPACT PLAN:
BUILDING RELATIONSHIPS WITH DATA USERS
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

52. 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

53. IMPACT OF DATA AT NATIONAL LEVEL
Data can drive change in
policy and practice –
especially with
unfavourable
international comparisons
National
data
use:
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?

54. 5. National policy
case study -
HBSC in Scotland

55. 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)

56. INTERPRETING NATIONAL FINDINGS
How does
Scotland rank
compared with
other countries?
How can
international data
enhance our
understanding of
young people’s
health in Scotland?
Has rank
changed over
time?
How do national
trends compare
with
international
trends?
How does
prevalence
compare across
age and gender
groups?
What are the
levels of relative
socio-economic
inequality?
Are age and
gender
differences the
same as in other
countries?

57. INTERNATIONAL COMPARISON
HIGH
• Top ⅓ countries (rank = 1-13)
MEDIUM
• Middle ⅓ countries (rank =
14-26)
LOW
• Bottom ⅓ countries (rank =
27-39)

58. 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)

59. RELATIVE INEQUALITY: SEXUAL INTERCOURSE

60. RELATIVE SOCIO-ECONOMIC INEQUALITY
Soft drink
consumption
Scotland
has HIGH
relative
inequality
Sexual
intercourse
Classmate
support
Having
been
bullied
Self-rated
health
Communication
with mother
Tobacco
initiation
(girls
only)
Lifetime
cannabis
use (girls
only)
(girls only)

61. WHERE IS SCOTLAND DOING WELL?
High life satisfaction
Positive peer relationships
Low smoking rates
Low cannabis use
Good oral health

62. THREE KEY ELEMENTS OF IMPACT
Articulation of
the problem
through data
Policy based
solution
Political will

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

64. 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)

65. 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

66. ACKNOWLEDGEMENTS
Young people Funders
HBSC 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)