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Section II

Scientific Rationales for focus areas

Content
II.1 Demographic factors: Age, sex and grade................................................................................ 4 II.2 Social contexts of health and health behaviour........................................................................ 8 II.2.1 Social Inequality ...................................................................................................................... 8 II.2.2 Family Culture ....................................................................................................................... 35 II.2.3 School setting........................................................................................................................ 56 II.2.4 School-level questionnaire.................................................................................................... 80 II.2.5 Peer culture........................................................................................................................... 89 II.2.6 Leisure Time Activities ........................................................................................................ 109 II.3 Developmental context of health and health behaviour .......................................................117 II.3.1 Pubertal status and timing................................................................................................... 117 II.4 Health and wellbeing ...........................................................................................................128 II.4.1 Self-rated Health ................................................................................................................. 133 II.4.2 Life Satisfaction ................................................................................................................... 138 II.4.3 Health Complaints............................................................................................................... 144 II.4.4 Physical Disability and Chronic Conditions (Optional package).......................................... 150 II.4.5 Global well-being (KIDSCREEN) (Optional package) ........................................................... 159 II.4.6 Strength and Difficulties Questionnaire (SDQ) (Optional package).................................... 168 II.4.7 Oral health .......................................................................................................................... 172 II.4.8 Body Mass ........................................................................................................................... 178 II.4.9 Body Image ......................................................................................................................... 190 II.5 Health related behaviours....................................................................................................201 II.5.1 Eating habits......................................................................................................................... 201 II.5.2 Weight reduction behaviour................................................................................................ 218 II.5.3 Physical Activity ................................................................................................................... 227 II.5.4 Sedentary behaviour............................................................................................................ 239 II.5.5 Tobacco use ......................................................................................................................... 249 II.5.6 Alcohol use........................................................................................................................... 262 II.5.7 Illicit drug use....................................................................................................................... 277 II.5.8 Medicine use (Optional package) ........................................................................................ 286 II.5.9 Sexual health........................................................................................................................ 293 II.5.10 Injuries ............................................................................................................................... 307 II.5.11 Violence and Bullying......................................................................................................... 316

II.1 Demographic factors

II.1 Demographic factors: Age, sex and grade


Inchley, J

Compared with other age groups, adolescents are considered to be relatively healthy. However, despite being the stage of life during which mortality and morbidity are lowest, adolescence is a key period for the development of health inequalities. Health inequalities have been defined as measurable differences in health experience and health outcomes between different population groups (Whitehead / Dahlgren 2006), including age, gender and socio-economic status. Young peoples behaviours, lifestyles and social context change dramatically as they grow and develop through their adolescent years. Important changes are observed in terms of the health and risk behaviours in which they engage the social influences that surround them and the health outcomes they experience. It is important to understand these patterns and transitions, as many of the inequalities that emerge during childhood translate into ongoing health problems during the adult years. Many serious diseases in adulthood have their roots in adolescence and poor behavioural habits established in adolescence can lead to increased risk of morbidity and premature mortality in later life. Life-course approaches to health interventions highlight the adolescent period as critical in determining adult behaviour in relation to issues such as tobacco use, dietary behaviour, physical activity and alcohol use, and recognise that health inequalities in adult life are partly determined by early life circumstances (Graham / Power 2004).

Gender
Previous HBSC reports have consistently reported clear gender differences in health behaviours and health outcomes. The evidence points to different issues of concern for boys and girls, rather than one gender being more or less healthy than the other. Developing a better understanding of such differences is fundamental to the improvement of young peoples health and is necessary to better guide appropriate policy and practice responses. Examining gender differences in health and wellbeing can also contribute to the understanding of how well boys and girls cope with the developmental challenges associated with the adolescent years. The relationship between gender and health undergoes a marked change during adolescence (Sweeting 1995). In childhood, boys experience higher mortality and experience more physical and mental problems. Post-puberty, however, girls are more likely to report poor health (Kolip / Schmidt 1999, Cavallo et al. 2006). Both biological and psychosocial factors are thought to contribute to this
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effect (Sweeting / West 2003). In addition, some have argued that different externalising and internalising patterns may account for some of the observed differences in health, with girls at greater risk of internalising problems and boys more likely to exhibit externalising behaviours (e.g. Raty et al. 2005). Previous HBSC research (Currie et al. 2008) has also highlighted a number of important gender differences in relation to health behaviours. For example, boys are more likely to be overweight or obese, but girls are more likely to perceive themselves as too fat and to engage in weight loss behaviours. Girls are more likely to consume healthy food but are more likely to skip breakfast and less likely to be physically active. Boys are more likely to engage in risk behaviours on an experimental or regular basis. In the majority of countries, this is the case for alcohol and cannabis consumption, early sexual activity, bullying and fighting. Furthermore, gender differences are evident in relation to the social context in which young people grow and develop (Currie et al. 2008). For example, girls report more positive school experiences than boys, particularly in relation to perceived academic achievement, support from classmates and school satisfaction. In relation to peers, boys are more likely to report having multiple friendships and have more face-to-face contact with their friends, whereas girls are more likely to use electronic media to communicate with their friends.

Age
The transition from childhood to adolescence represents a period of significant biological, psychological and social changes (see chapter II.3.1), and in many countries also coincides with school transition. The HBSC study focuses on young people attending school aged 11, 13 and 15 years. These age groups represent the onset of adolescence, the challenge of physical and emotional changes and the middle adolescent years when important life and career decisions are beginning to be made (Roberts et al. 2007). Data on the health and health behaviours of young people at these different stages during adolescence can help to determine the most effective types of interventions as young people travel through adolescence and into adulthood. Adolescence is also a time of increasing independence and changes in the relative influence of parents and peers. Indeed, Coleman and Hendry (1999) suggest that the development of independence, or autonomy, in respect of family relationships is one of the key tasks for adolescents. Children report poorer communication with both parents as they get older and spend more time with their friends, both face-to-face and through electronic media (Currie et al. 2008).

II.1 Demographic factors

Previous HBSC findings have demonstrated important age-related differences in health behaviours and health outcomes (Currie et al. 2008). Younger children are more likely to engage in healthpromoting behaviours, report more favourable relationships with parents and more positive experiences of school. During the adolescent years, however, young people increasingly engage in more health-damaging behaviours such as poor diet, physical inactivity and substance use. At the same time, reporting of physical and emotional symptoms increases, perceptions of poor health increase and life satisfaction decreases.

School grade School grade is included in the HBSC survey because it is distinct from age. Schools have an important influence on young peoples health and wellbeing and the position of young people within the school system is also significant (see section II.2.3). School transition occurs at different stages in different countries. In some countries, each age group corresponds to a single school grade, while in others children of the same age may be found in different grades. The desired mean age for each of the three age groups included in the HBSC study is 11.5, 13.5 and 15.5. In order to achieve this, survey administration may take place at different times in different countries, depending on the national school system. In countries where there is significant holding back and/or advancement of students, sampling may involve more than three grades.

Instruments
Gender Item box 1
MQ1 Are you a boy or a girl?
1 2

Boy Girl

Grade Item box 2


MQ2 What class are you in?
1 2 3

Country specific Grade (11 year old) Country specific Grade (13 year old) Country specific Grade (15 year old)

II.1 Demographic factors

Age Item box 3


MQ3 Jan
1

What month were you born? Feb


2

Mar
3

Apr
4

May
5

June
6

July
7

Aug
8

Sept
9

Oct
10

Nov
11

Dec
12

Item box 4
MQ4 1991 What year were you born? 1992 1993 1994 1995 1996 1997 1998 1999 2000

References
Cavallo, F., Zambon, A., Borraccino, A., Raven-Sieberer, U., Torsheim, T. Lemma, P. and the HBSC Positive Health Group (2006). Girls growing through adolescence have a higher risk of poor health. Quality of Life Research, 15(10), 1577-1585. Coleman, J.C. & Hendry, L.B. (1999) The Nature of Adolescence, 3 Edition. London: Routledge. Currie, C., Nic Gabhainn, S., Godeau, E. et al. (Eds) (2008). Inequalities in young peoples health. HBSC International Report from the 2005/2006 survey. Copenhagen: WHO Regional Office for Europe. Graham, H. & Power, C. (2004). Childhood disadvantage and adult health: a lifecourse framework. London: Health Development Agency. Kolip, P. & Schmidt, B. (1999). Gender and health in adolescence. WHO Policy Series Health policy for children and adolescents Issue 2. Copenhagen: WHO Regional Office for Europe. Raty, L.K.A., Larsson, G., Soderfeldt, B.A. & Wilde Larsson, B.M. (2005). Psychosocial aspects of health in adolescence: the influence of gender and general self-concept. Journal of Adolescent Health, 36(6), 530.e21-530.e28. Roberts, C., Currie, C., Samdal, O., Currie, D., Smith, R. & Maes, L. (2007). Measuring the health and health behaviours of adolescents through cross-national survey research: recent developments in the Health Behaviour in School-aged Children (HBSC) study. Journal of Public Health, 15, 179-186. Sweeting, H. (1995) Reversals of fortune? Sex differences in health in childhood and adolescence. Social Science and Medicine, 40(1), 77-90. Sweeting, H. & West, P. (2003). Sex differences in health at ages 11, 13 and 15. Social Science and Medicine, 56, 31-39. Whitehead, M & Dahlgren, G. (2006). Levelling up (part 1): A discussion paper on concepts and principles for tackling social inequalities in health. Copenhagen: WHO Regional Office for Europe.
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II.2 Social contexts of health and health behaviour

II.2 Social contexts of health and health behaviour


II.2.1 Social Inequality
Holstein B, Currie C, Zambon A, Boyce W, Richter M, Damsgaard MT, Levin K, Balakireva O, Simetin IP, Andersen A, Zakaris I, Krlner R, Due P.

1. Scope and purpose


Social inequality - a challenge within public health It is one of the main priorities of public health research and practice to document, explain and design interventions to prevent and reduce social inequalities in health and health behaviours. The Commission on Social Determinants of Health which was set up by the World Health Organization in 2005 stated in their recent publication Closing the gap within a generation (2008) that: Inequities in how society is organized mean that the freedom to lead a flourishing life and to enjoy good health is unequally distributed between and within societies. Different groups will have different experiences of material conditions, psychosocial support, and behavioural options, which make them more or less vulnerable to poor health. Social stratification likewise determines differential access to and utilization of health care, with consequences for the inequitable promotion of health and well-being, disease prevention, and illness recovery and survival. Within the HBSC study we describe and analyse the socio-economic patterning of health and health behaviours. The socio-economic variations across the HBSC member countries are considerable: the Gross National Income per inhabitant per year varies from approximately 7,000 to 60,000 USD and income inequality, as measured by the gini coefficient, varies from less than 25% in countries with low income inequality, to more than 40 % which signals very high income inequality. Poverty is another aspect of socio-economic inequality, and across the industrialised world, socio-economic inequality is increasing and the number of people living in poverty is growing (Atkinson et al. 1995). In most countries, between 3% and 22% of children and young people live in poverty as defined by national standards (Closing the gap within a generation 2008). Socio-economic inequality has led also to changed living conditions for children and adolescents. In some countries, globalised and restructured economies have resulted in
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reduced material and social well-being among young people as more and more parents are unemployed, have low-paid jobs, or have contractual employment without social benefits. Some of the HBSC countries have experienced extraordinary changes in wealth, income distribution, political system, social welfare, migration, and other aspects of the general living conditions over the past 20 years; with very rapid change also happening from time to time (Closing the gap within a generation 2008).

Social inequality in health There is abundant documentation for social inequalities in health and health behaviours among young people. Most often, young people from families of lower socio-economic position have higher prevalence of poor health outcomes (Currie et al. 2008a, Spencer 1996, Starfield et al. 2002). Social inequalities in health do however vary across health outcomes. Poor self-rated health, poor life-satisfaction, multiple health complaints, overweight, infrequent intake of fruit and vegetables, infrequent tooth brushing, skipping breakfast, and low level of physical activity are more prevalent in lower than higher socio-economic groups (Currie et al. 2008a, De Bourdeaudhuij et al. 2008, Due et al. 2009a, Holstein et al. 2009, Rasmussen et al. 2006). There are inconsistent findings regarding injuries. A recent HBSC report shows higher prevalence of medically attended injuries in higher socio-economic groups (Currie et al. 2008), while other studies find higher prevalence of injuries in lower than in higher socio-economic groups (Dowswell / Tower 2002, Engstrm et al. 2003, Laflamme / Engstrm 2002). Some risk behaviours are more prevalent in higher than lower socio-economic groups, at least in some countries. This has been shown for alcohol use (Andersen et al. 2008, Currie et al. 2008a). Still, other risk behaviours such as smoking are more prevalent in lower than higher socio-economic groups but only in selected countries (Currie et al. 2008a). Another example of variations in social inequalities across countries is daily consumption of sugar-sweetened soft drinks which is more prevalent in higher than lower socioeconomic groups in some Central European countries while the pattern is opposite in Western European countries (Veerecken et al. 2005). Some studies suggest that childhood and youth is the life stage with the least social inequalities in health and propose the equalization in youth hypothesis. This hypothesis was introduced by West (1988, 1997) and confirmed by Rahkonen and Lahelma (1992) because they were unable to document any social inequalities in health and behaviours in their studies in Glasgow (Scotland) and Helsinki (Finland). This hypothesis has been influential and is often
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referred to; but a range of publications from the HBSC study does show substantial social inequalities in health and health behaviours, i.e. increasing health and behaviour problems with decreasing socio-economic position (Currie et al. 2008a). Because of these inconsistencies, we need to continue our research into social inequalities in health and health behaviours to provide a nuanced and updated picture. Despite considerable research efforts it is still difficult to explain the processes which result in social inequalities in health and behaviours. We may need specific explanations for each specific health outcome. For example, social inequality in smoking may be explained by higher exposure to parental smoking in lower than higher socio-economic groups (Griesbach et al. 2003). Another example is that social inequality in injuries may be explained by higher exposure to injury risks in the physical and residential environment (Engstrm et al. 2002, Laflamme et al. 2002). A third example is that social inequality in symptom load may be explained by a higher exposure to poor school-related social relations among children and adolescents from lower socio-economic groups and that poor school-related social relations increase the risk of high symptom load (Due et al. 2003). It is a challenge to find appropriate indicators of socio-economic position among children and adolescents (Currie et al. 1997, Currie et al. 2008b). Schoolchildren are usually outside the labour market and do not have a socio-economic position of their own. The socio-economic position of their families can be described in several ways, e.g. by their parents education and occupational social class, by family affluence, or by indicators of wealth or social deprivation in the residential area. These indicators are not mutually interchangeably. They express different aspects of the socio-economic circumstances and may tap different aspects of social inequality when used in research on social inequality in health. For these reasons, it is vital that we continue the study of social inequalities in health and health behaviours in youth. We need to describe the disparities and explain the processes behind them. Further, we need to continue our efforts to develop valid indicators of social background and social inequality.

Migration and ethnic background There are large variations in population composition within the HBSC countries. Some of the participating countries are very homogeneous from an ethnic point of view while others are truly multi-ethnical and multi-cultural countries. Furthermore, the population composition is not stable over time. Migration results in significant changes in population composition in some geographical regions. Some studies document health disparities across ethnic groups and between migrants and the native population (Consolation et al. 2004, Klineberg et al.
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2006, Whaley / Francis 2006). There is however, very little documentation of such differences and even less insight into the processes by which migration and ethnicity pattern health and health behaviours among young people. This is a challenge we have to meet within HBSC during the next decade.

2. Objectives
The objectives of HBSC in relation to social inequalities in health are: 1a. To describe socio-economic differences in young peoples basic living conditions (material wealth; family situation; access to well-functioning schools; exposure to health hazards and health promoting factors), how these differences vary within and across countries and regions, and how they change over time. 1b. To describe ethnic differences in young peoples basic living conditions, how these differences vary within and across countries and regions, and how they change over time. 2a. To analyse social inequalities in health and health behaviours between and within countries and how these inequalities develop over time. 2b. To analyse ethnic inequalities in health and health behaviours between and within countries and how these inequalities develop over time. 3. To analyse how different components of socio-economic position (parents occupational social class, family affluence, wealth and deprivation of the local community) are associated with different aspects of health and health behaviours. 4a. To develop appropriate and valid measures of socio-economic position. 4b. To develop appropriate and valid measures of ethnic background. 5a. To study the processes behind the socio-economic patterning of health and health behaviours 5b. To study the processes behind the ethnic patterning of health and health behaviours

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3. Theoretical framework
A socio-environmental perspective Within HBSC we have been working towards a socio-environmental conceptualisation of socioeconomic position as a resource that is accessible at multiple levels (individual, family, local area). Dahrendorfs Theory of Life Chances (1979) is an example of a theory which encompasses this HBSC perspective. The theory is based upon Dahrendorfs search for a concept which reflects the individuals opportunities to gain control over his or her life. He proposes the basic concept life chances which is defined as the sum of opportunities offered to individuals by their society and their specific position within this society. Life chances are not attributes of individuals; individuals have life chances based on their position in the larger social structure; their lives reflect these chances. Life chances result from two elements, options which provide life chances and ligatures which limit life chances. Options and ligatures are not individual attributes but products of the social structure. The study of social inequality in young peoples health and health behaviour is therefore based on the view that we live our lives within a social structure which patterns individuals life chances.

A macro perspective HBSC also applies an ecological or macro-sociological perspective in analysis of social inequalities in health. This ecological / macro perspective is in line with the Theory of Life Chances: Life chances are influenced by characteristics of the local community in which we live, e.g. its affluence and the distribution of affluence and social deprivation. We have access to register data about macro-indicators such as Gross National Income or gini coefficients for individual countries. In some cases we have access to register data about social deprivation in local areas. In other instances we have to rely on data collected from the participating students, e.g. self-reported socio-economic circumstances of the area in which the students live.

Research strategy We propose a strategy for the study of social inequality in health and health behaviours based on Diderichsens theoretical model (2001). This model suggests that the empirical study of social inequalities should be organised in four steps.

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1. The study of differential exposure: How much are children and adolescents from different socio-economic groups exposed to health hazards (e.g. poor schools, poor residential areas, bullying at school, marketing of goods that increase the likelihood of poor dietary habits, smoking, alcohol drinking) and health protective factors (e.g. supportive social relations, health promoting policies, health education). This step is in accordance with the Theory of Life Chances. Exposure to health protective factors is one way to express options and exposure to health hazards is one way to express poor life chances. The basic hypothesis is that students from higher socio-economic groups have more options and students from lower socio-economic groups have fewer options to live healthy lives. 2. The study of differential vulnerability: Exposure to health hazards does not always result in poor health or poor health behaviours. Some individuals are resilient to such exposures or they have sufficient resources and options to avoid being harmed, while other individuals are vulnerable and end up with poor health and health behaviours. The study of differential vulnerability is in accordance with the Theory of Life Chances because escape from the negative consequences of harmful exposures is a result of more options and more life chances. The basic hypothesis is that students from higher socio-economic groups are less vulnerable to harmful exposures. 3. The study of differential effect: Poor health and poor health behaviours may sometimes have deleterious effects and sometimes less serious effects. One example is that students who drink much alcohol or smoke much cannabis may suffer from severe problems such as poor academic performance, injuries, unprotected sex, conflicts with the police, and disabled social relations. Some students end up with all of these problems, others avoid them. The study of differential effect is once again in accordance with the Theory of Life Chances because some people have more options to escape from the negative effects of poor health and poor health behaviour. The basic hypothesis is that poor health and poor health behaviours have more deleterious effects among students from lower than higher socio-economic groups. 4. Finally, the study on how macro factors (macro economic circumstances, policies) influence the above three processes: Differential exposure to hazardous circumstances is an issue for regulation through policies and distribution of wealth. Differential vulnerability and differential effect is likewise an issue for regulation through policies and structural aspects of the society. This kind of research should combine individual data on health

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outcomes and macro data on economic circumstances and policies. The HBSC study is particularly appropriate for such studies if we develop databases with valid data about the above mentioned macro circumstances.

Indicators of socio-economic position Within HBSC, we use two coding procedures to determine socio-economic position: Occupational social class and family affluence.

Occupational social class We use two coding schemes: 1. The Registrar General Social Class (RGSC) coding scheme which reflects the hierarchical social structure of the society (Macintyre et al. 2003) or a national equivalent. RGSC is a coding of occupation by two criteria: how difficult it is to fill the occupation (required educational qualifications) and the control over people or capital (size of the company or number of subordinates). This coding scheme is a direct reflection of the Theory of Life Chances because the position within the social structure determines both options and ligatures, i.e. life chances. This coding is mandatory. 2. The International Standard Classification of Occupations (ISCO) is a multidimensional coding scheme which combines employment, business, and level of competence (Ganzeboom / Treiman 1996, International Labor Office 1990). This coding is optional.

Family affluence Many young people are unable or unwilling to provide sufficient information about parents occupation and it is a challenge to code information about occupation to occupational social class. For these reasons, we have developed a different proxy indicator for socio-economic position which also reflects life chances: The Family Affluence Scale FAS (Currie et al. 2008b) which is a measurement of access to material goods in the family. During the past two waves of data collection, we have included items on own bedroom, family cars, number of computers in the family and number of family vacations. These items may be less appropriate with increasing wealth and it is possible to develop the scale by inclusion of new items that tap new aspects of life chances. One of the challenges we face is to develop new items appropriate for the identification of very poor families.

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Ethnic background The study of students ethnic background is new within HBSC and we do not have a solid experience in analysing such data or interpreting differences across ethnic groups. There is a range of conceptual approaches to this area of interest. Within medicine and health science, papers often refer to race or race/ethnicity. This approach and terminology has been met with criticism because of lack of conceptualisation and an unjustified signal that we are studying something which is basically genetic or biological (Bhopal 2004, Ellison et al. 2007, Linn / Kelsey 2000). Today, there is no consensus regarding terminology and we apply the general term ethnic background, which covers a range of perspectives. There are three general observations from empirical studies on the association between ethnic background and health and health behaviours among children and adolescents. First, there are many studies which document ethnic differences in a wide range of health outcomes: mental health and wellbeing (Stansfeld et al. 2004, Klineberg et al. 2006, Consolation et al. 2008), selfreported (Saxena et al. 2002) and general health (Whaley / Francis 2006), overweight (Kumar et al. 2004, Sorof et al. 2005, Taylor et al. 2005, Will et al. 2005) and other cardiovascular risk factors (Winkelby et al. 1999) and health behaviour such as diet (Cullen et al. 2002) and physical exercise (Gordon-Larsen et al. 1999). Second, the most exposed groups are not similar from one country setting to another. Third, the similarities in health problems between ethnic groups are often more pronounced than the differences. These observations constitute an important challenge for the future studies of ethnic background and health outcomes. The HBSC study has not adopted any specific conceptual or theoretical approach. The data we collect provide three options which all have special appeal to HBSC: 1. The data about country of birth reflects a cultural approach: It is for instance possible to study the large minorities of immigrants in Europe from Somalia, Lebanon and Pakistan. The HBSC project offers an opportunity to study diversity in health and behaviour across ethnic minorities and to study similarities in health and behaviour within ethnic minorities who live in different countries. We hypothesize that young people from different cultures have very different lifestyles which may influence their health. 2. The data about fathers, mothers and students country of birth provide opportunities to study migration and health. It is possible to separate three categories: the native population, descendents of immigrants, and immigrants. These categories provide a crude measure of time since immigration. Descendents have on average lived more years in their new country than immigrants. We hypothesise that the migration process itself causes
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considerable changes in material living conditions and practical problems. These changes may result in severe stress, which again influences health and behaviours. 3. The item on language spoken at home reflects an acculturation or integration approach: Acculturation was originally a neutral term for meeting of cultures but increasingly means how much immigrant or minority populations integrate themselves with the native or majority population. There are two important dimensions of acculturation, the degree to which one feels attached to the culture of origin and the degree to which one feels attached to the culture of the new homeland. Integration is defined as the situation in which both these feelings are strong. Language spoken at home is an indicator of whether the immigrant family maintains their language (and culture) of origin or adopt the language of their new country. We hypothesise that the meeting of cultures may result in psychosocial problems (e.g. stress, lack of control) which again may influence health and behaviours. Regardless of the conceptual approach, all minority groups may suffer from discrimination which reflects prejudice in the host or majority population. Exposure to discrimination, or the perception that you are discriminated against, have considerable negative effects on health (Krieger 2000, Williams et al. 2003, Landring et al. 2006). The HBSC study does not include measures of perceived discrimination.

4. Summary of previous work


In 2007, a working group including Pernille Due, Saoirse Nic Gabhain, Candace Currie and Mette Rasmussen reviewed all HBSC papers published in English and this was held in the ICC office in Edinburgh. This section describes the previous work on socio-economic variations in health and health behaviours, in total approximately 25 papers. There is a wealth of information about socio-economic variations from HBSC but an even larger pool of issues we have not addressed yet.

Socio-economic variations in social relations A study from Italy (Zambon et al. 2006) showed that children from families with high socioeconomic position (SEP) were more likely to report ease of communication with father and best friend, but there are no SEP differences for mother and teacher. Another study from Italy showed a greater sense of community (school connectedness) in schools of higher school level

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SEP (Vieno et al. 2005). A study from the US also found higher levels of school connectedness in schools with more wealthy students (Thompson et al. 2006). A study from Denmark found that children from low SEP families were more likely not to have positive school-parent-child relations and were more likely to feel badly connected to their school, as compared to those from high SEP families (Due et al. 2003). In Denmark, children from lower SEP families as assessed by parents occupational social class, were less likely to report: liking school, parental school support, school satisfaction, autonomy at school and school identification. Not all these associations were significant, but all are in the same direction (Andersen et al. 2007). Furthermore, there are large social inequalities in exposure to bullying: across almost all participating countries students from low SEP families were bullied more often than students from high SEP families (Due et al. 2009b).

Socio-economic variations in health and well-being In general, we find increasing proportions reporting good self-rated health as family affluence increases. Furthermore, high family affluence is associated with reporting of fewer subjective health complaints. These patterns are found in most countries (Holstein et al. 2009) and some of these findings are reported in more detail from analyses of national data. For instance, Due et al. (2003) showed that in Denmark, school connectedness and parents-school support explained almost all of the social inequality in physical and psychological symptoms among children. Torsheim et al. (2004) found substantial social inequalities in self-rated health across HBSC countries at both the individual, school and country level - with an additive effect for individual and area level inequalities. The most deprived 11 year-olds had odds of > 8 for poor self-rated health compared to the least deprived child. Ranking countries by low FAS highly correlated with ranking on health. In 11 selected countries family wealth was consistently associated with symptom load (Currie et al. 2001). Also, Zambon et al. (2006) showed that in all countries (2002), FAS was negatively related to symptom load and poor life satisfaction; and that countries with stronger redistributive policies were more effective in reducing health inequalities. Molcho et al. (2007a) focused on the indicator of poverty (hunger / food poverty) and found that across all countries, food poverty was associated with low life satisfaction. In Ireland it was found that food poverty was similarly distributed across social classes and associated with higher symptom load (Molcho et al. 2007a). Furthermore, there are marked socioeconomic variations in the circumstances in which injuries occur (Williams et al. 1997).

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Country level economic inequality Living in countries with high levels of income inequality appear to increase the probability of poor self-rated health, since adolescents living in the group of countries with highest inequalities (high standard deviations of FAS) had more than 2:1 odds of reporting poor health, even when controlling for individual level FAS and family support (Torsheim et al. 2006). Furthermore, higher levels of income inequality are associated with higher levels of drinking and drunkenness (Elgar et al. 2005) and higher prevalence of multiple complaints (Holstein et al. 2009). Social inequality is not restricted to soft indicators such as self-rated health, complaints, and well-being but also applies to other health outcomes: A Canadian study showed that low SEP at the individual and at the area level was associated with higher prevalence of obesity (Janssen et al. 2006) and in most of the HBSC countries (but not all) overweight is most prevalent among children from families with low socio-economic position (Due et al. 2009a).

Socio-economic variations in risk behaviours Cross-nationally, there is no systematic socio-economic inequality in smoking and drinking (Richter et al. 2006, Currie et al. 2008a, Currie 2001, Holstein et al. 2004). National studies from Greenland (Del Carmen Granado / Pedersen 2001, Del Carmen Granado et al. 2002) and Belgium (Vereecken et al. 2004) found no association between socioeconomic position and risk behaviour (smoking and drinking) while a study from Denmark found increasing smoking prevalence by decreasing socio-economic position (Rasmussen et al. 2008). An international study showed that cannabis use was most prevalent among students from families with high SEP (Ter Bogt et al. 2006). In Lithuania, Zaborskis et al. (2006) found higher levels of alcohol consumption among students who reported that their family was well off and in Italy, Zambon et al. (2006) found that those with lower levels of family affluence were less likely to report frequent alcohol consumption. In Denmark, children from families with low SEP were less likely to report drunkenness than other children (Andersen et al. 2007). A study from Denmark showed that medicine use for common complaints (headache, stomach-ache, difficulties in getting to sleep, nervousness) was more prevalent among students whose parents had low occupational social class (Holstein et al. 2004).

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Socio-economic variations in health behaviours In most countries, students from families with high SEP brush their teeth more often (Maes et al. 2006, Honkala et al. 1997) and do more physical activity (Inchley et al. 2005, Holstein et al. 2004). A study from Canada (Janssen et al. 2006) showed that both individual level and area level SEP were independently associated with obesity, while only area-level SEP was associated with unhealthy eating and only individual level SES was associated with physical activity. A study from Belgium demonstrated that a lower educational level among adolescents is associated with a higher prevalence of indicators of unhealthy lifestyle. For parental SEP the results were less straightforward (Vereecken et al. 2004). A study from Denmark showed that the experience of health dialogue with a school health nurse has a more positive outcome for children from lower socio-economic groups (Borup / Holstein 2004).

Socio-economic position as effect modifier A study from Denmark (Andersen et al. 2007) showed that children from families with low socio-economic position had higher prevalence of poor school relations, and weak relations to school generally seemed to increase prevalence of drunkenness among children. However, when stratified by SEP there were large socially differential impacts of the association between social relations and drunkenness. For instance, poor school autonomy was strongly associated with drunkenness among high/middle SES children, but inversely associated with drunkenness among low SES children. In addition, poor identification with school decreased the risk of drunkenness among girls from all social groups, and boys from low SES groups, but increased risk of drunkenness among boys from high and middle SES groups.

Ethnic variations A study from the US showed that the prevalence of depression was higher among girls from all ethnic minority groups (Saluja et al. 2004). A study from Finland revealed an association between minority status and perceived health: School children from the Swedish-speaking minority reported a better self-rated health than children from the Finnish-speaking majority (Suominen et al. 2000). Children of ethnic minorities in Denmark had a higher prevalence of medicine use than ethnic Danish children, and for all ethnic groups, girls had more prevalent use than boys (Holstein et al. 2005).

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II.2 Social contexts of health and health behaviour

In summary We do have strong evidence about social inequalities in health and health behaviours in some areas, particularly documented from country level papers. What we need to do better is: 1) to use the international data file for more internationally comparative papers, 2) to increase our efforts to understand and explain social inequalities, 3) to include macro level information to understand and explain country differences, 4) to perform studies on how social inequalities in health and behaviours change over time, 5) to start analysing data within areas that have not attracted much attention, and 6) to increase our efforts to document and explain differences in health and behaviours between ethnic groups.

5. Research questions
Differential exposure 1. What is the association between socio-economic position and exposure to health hazards (e.g. low material wealth in the family, poverty, social deprivation in the community, high income inequality, low access to well-functioning schools, risk factors for unhealthy behaviours)? 2. Does the pattern of associations between socio-economic position and exposure to health hazards vary within and across countries and does it change over time? 3. To what degree is exposure to health hazards associated with ethnic background? 4. What is the association between area socio-economic status and exposure to other health hazards?

Socio-economic and ethnic disparities in health 5. What degree of socio-economic variations exists in each of the health outcomes we study in HBSC? Do socio-economic variations vary across gender and country and do they change over time?

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II.2 Social contexts of health and health behaviour

6. To what extent do different components of socio-economic position (occupation, social class, family affluence, area deprivation) show associations with health and health behaviours? Do these patterns vary across gender group and country? 7. Are there ethnic variations in each of the health outcomes we study in HBSC? Do ethnic variations vary across countries and change over time?

Measurements 8. What is the validity of the applied measurements of socio-economic position and ethnic background? Does the validity differ across countries and specific population groups? 9. Which indicators of affluence and poverty do we need to improve in the measurement of family affluence?

Explanations: differential vulnerability and differential effect 10. What are the processes which contribute to social inequality in each of the health measures and measures of health behaviours? Can these processes be explained in term of differential vulnerability and differential effect? 11. How much do these processes vary across gender group and countries and how much do they change over time?

Macro level explanations 12. What degree of cross-level interaction exists in social inequalities in health: are social inequalities sensitive to macro factors such as GNI, gini, health promotion efforts and policies, and characteristics of the local community?

6. Instruments
The measurement of socio-economic position is complicated because it is a multidimensional construct, involving individual variables such as occupational social class, education, income, and community based variables such as social deprivation of the residential area. These dimensions are not identical and cannot easily substitute each other because they represent different kinds of life chances (Macintyre et al. 2003). Occupational social class is often regarded as a structural variable, an indicator of the individuals position in a social structure which again influences his or her control life chances. Education reflects cultural capital in the
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II.2 Social contexts of health and health behaviour

family, income and affluence reflect economic opportunities, and residential indicators of social deprivation reflect external stressors. The classification of children and adolescents according to socio-economic position involves data about the parents, the family, or the residential area and many young people may not be able to report these data exactly in surveys based on self-reported data.

6.1 Mandatory items


HBSC includes four mandatory measures of socio-economic position, two measures relating to family and two measures of local area socio-economic position. Parents occupation: The classical indicator of social class is occupation, in this case parents occupation. HBSC includes four items about fathers and mothers employment, working place, and job function. See item box 1. These items have been included in HBSC since the very first survey in the beginning of the 1980s and represent a research tradition in studies within social sciences and public health, especially studies of adults. It is mandatory to code this information in order to characterise the parents occupational social class into five rank-ordered social classes (Currie et al. 1997), either by applying an appropriate national coding scheme or preferably, in accordance with the classical RGSC (Registrar General Social Class) coding scheme (RGSC) (Macintyre et al. 2003). Item box 2 explains the mandatory coding into five social classes and three other categories. There is an optional coding of these data according to the ISCO-standard (International Standard Classification of Occupations) to characterise parents occupation (Ganzeboom / Treiman 1996, International Labor Organization 1990). Several countries applied two coding formats of occupational social class in the 2005/2006 study; the RGSC format and the ISCO format. We need to explore how these two coding formats function in relation to the study of social inequality in health and health behaviours.

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II.2 Social contexts of health and health behaviour

Item box 1
MQ47 Father Does your father have a job?
1 2 3 4

Mother Does your mother have a job?


1 2 3 4

Yes No Dont know Dont know or dont see father

Yes No Dont know Dont know or dont see mother

If YES, please say in what place he works (for example: hospital, bank, restaurant) ____________________________________ Please write down exactly what job he does there (for example: teacher, bus driver) ____________________________________ If NO, why does your father not have a job? (Please tick the box that best describes the situation) . He is sick, or retired, or a student 1 He is looking for at job 2 He takes care of others, or is full-time at 3 home I dont know 4

If YES, please say in what place she works (for example: hospital, bank, restaurant) ____________________________________ Please write down exactly what job she does there (for example: teacher, bus driver) ____________________________________ If NO, why does your mother not have a job? (Please tick the box that best describes the situation) She is sick, or retired, or a student 1 She is looking for at job 2 She takes care of others, or is full-time at 3 home I dont know 4

Source: HBSC 1989/1990 & 1993/1994 & 1997/1998 & 2001/2002 & 2005/2006, although the provided examples in parentheses and the format of the items have changed over time. The present format was introduced in the 2001/2002-survey.

Code 1 Code 2 Code 3 Code 4 Code 5 Code 6 Code 7 Code 8

Highest socio-economic position

Professionals and top managers

Lowest socio-economic position Economically active but unclassifiable into codes 1-5 Economically inactive, e.g. sick, retired, student Unclassifiable, missing, dont know, response unclear

Unskilled occupation

Figure 1: Mandatory coding of parents occupation

The validity of childrens reports about parents education and occupation has often been described as acceptable. A study by Lien et al. (2001) used matched data from 12-year-old children and their parents about parents education and occupation. The correspondence between childrens and parents information about parents education was low, while the correspondence regarding occupation was high. Other similar studies confirm that childrens
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II.2 Social contexts of health and health behaviour

report of parents occupation is fairly valid (Veerecken / Vandegehuchte 2003, West et al. 2001). Krlner (2004) studied the correspondence between 11-year-old children and their parents reports about employment and occupational social class in a study with 1400 matched child-parent questionnaires. There was high correspondence regarding current employment (kappa-values around 0.90) and white collar vs. blue collar occupation (kappavalues around 0.90). The correspondence between children and their parents regarding a more detailed coding of occupational social class into five groups resulted in crude kappa-values around 0.60 and adjusted kappa-values around 0.70. It is important to carry out new validation studies of parents occupational social class. Family affluence: There were two reasons for developing an alternative to the above measure of occupational social class. One was the observation that application of several measures increased the possibilities of providing a thorough and detailed analysis of social inequalities in health (Currie et al. 1997). The other was the observation that many children had difficulties in giving complete account of their parents occupation, a problem which was most prevalent among the younger participants and which was very prevalent in some of the participating countries. Therefore, we needed a measure which was easy to answer for young children and applicable across countries, in this case a scale based on simple items on indicators of affluence in the respondents home, the Family Affluence Scale (FAS). The first version of FAS was used in the studies in 1993/94 and 1997/98. It included three items on car ownership, own bedroom and family holidays; items which have their origin in classical measures of material and social deprivation (Townsend et al. 1988, Carstairs / Morris 1991). To increase the scales discrimination in affluent countries where having ones own bedroom, family car and family holidays are commonplace, we added an item on computer ownership in the studies in 2002/02 and 2005/06, see item box 3. See Currie et al. (2008b) for a more detailed account of the development and validity of FAS. Item box 2
MQ48 Does your family own a car, van or truck? No Yes, one Yes, two or more

1 2 3

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II.2 Social contexts of health and health behaviour

MQ49

Do you have your own bedroom for yourself? No Yes During the past 12 months, how many times did you travel away on holiday [vacation] with your family? Not at all Once Twice More than twice How many computers does your family own? None One Two More than two

1 2

MQ50

1 2

3 4

MQ51

1 2

3 4

Source:Currie et al. 2008b. Items on family cars, own bedroom and family holidays were introduced in the HBSC 19971998 questionnaire and the item on family computers was added in the HBSC 2001/2002 questionnaire.

Currie et al. (2008b) propose calculation of FAS by summation of answers into a scale from 0 to 9 or categorisation into three broader groups (low 0-3, medium 4-6, and high 7-9). More experience and validation studies are needed before we may be able to recommend specific coding schemes. The validity of FAS has been addressed by several studies (see review in Currie et al. 2008b). The average FAS of the schoolchildren in a country correspond with objective measures of wealth in this country, e.g. GNI (Boyce et al. 2006, Torsheim et al. 2006). Andersen et al. (2008b) described high agreement between parents and 11-year-old students response on the FAS items in six countries. There was high agreement for three of the four items and for the total FAS-point but problems regarding the holiday-item. A study in Ireland showed that FAS revealed a moderate internal reliability and FAS scores were significantly associated with reported parental occupation (Molcho et al. 2007b). Although FAS seems to be an appropriate and easily applied indicator of socio-economic position, the comparability of FAS may not be ideal (Batista-Foguet et al. 2004). A recent paper by Schnohr et al. (2008) shows that the four items need to be weighted in a country specific manner in order to facilitate cross-national comparison of the scale. Over the next period we need to discuss whether FAS is a reflective or a formative index and in which situations it is more appropriate to decompose the scale and use the four items as separate indicators of socio-economic position. We also need to consider if and in which situations we should apply

25

II.2 Social contexts of health and health behaviour

weighting procedures of FAS items in order to strengthen international comparability (Schnohr et al. 2008). Further, some of the FAS items may become irrelevant, e.g. the computer item will become irrelevant when in the near future most households in the participating countries have several computers. We need therefore, to develop and validate new FAS-items, especially items that increase the scales discrimination in affluent countries and items which reflect poverty. Perceived family wealth: This item, first used in the 1993/94 study, was designed to measure young peoples perceptions of their own familys socio-economic circumstances. This was part of the strategy proposed by Currie et al. (1997) to include several indicators of socio-economic position in studies of social inequalities among adolescents. Over the past decade, several scholars have developed and used measures of perceived social status (Demakakos et al. 2008, Finkelstein et al. 2006, Goodman et al. 2001). A pilot study in six-countries in 2002 (Canada, Macedonia, Norway, Poland, Scotland, Wales) demonstrated that almost all students answered the item and that it reflected dimensions of socio-economic status. Furthermore, the item shows association with practically all health and behaviour outcome measures applied in the HBSC study. There are two limitations of the item; first that some young people felt uncomfortable answering it. Second, the item does not translate well in some countries where it was necessary to explain the term well off by the term rich which is not an exact interpretation. The item (see item box 4) is mandatory and we need to address its function and validity in our future work. Item box 3
MQ52
1 2 3 4 5

How well off do you think your family is? Very well off Quite well off Average Not so well off Not at all well off

Source: HBSC 1993/1994 & 1997/1998 & 2001/2002 & 2005/2006

Hungry to bed: In acknowledgement of the fact that HBSC lacks a measure of very low socioeconomic status, we added an item about hungry to bed in the 2001/02 study. It is now widely accepted that food insecurity and shortage of food in the family is significantly associated with a range of indicators of poor health, poor well-being, poor cognitive development, and poor health behaviours among children and adolescents, and even associated with a risk of overweight and obesity (Cook / Frank 2008, Cook et al. 2008, Casey et al. 2006). The item was chosen after considerable consultation and pilot work. The six country pilot study in 2000
26

II.2 Social contexts of health and health behaviour

(Canada, Macedonia, Norway, Poland, Scotland, Wales) demonstrated that the item was generally accepted. Molcho et al. (2007) analysed the issue in the Irish HBSC-study 2002 and concluded that food poverty in schoolchildren was not restricted to those from lower social class families and that food poverty was associated risk to physical and mental health and wellbeing. The item (see item box 5) is mandatory. Item box 4
MQ53 Some young people go to school or to bed hungry because there is not enough food at home. How often does this happen to you? Always Often Sometimes Never

1 2 3 4

Source: Molcho et al. 2007a and Molcho et al. 2007b, HBSC 2001/2002 & 2005/2006

6.2 Optional items


Local area socio-economic status: We recognise that the socio-economic circumstances of ones local area may have a contextual effect on health outcomes for individuals with varying socio-economic position. There is a growing interest in health and place (Macintyre et al. 2002) and within the past decade, it has been repeatedly documented that socio-economic circumstances in the area in which you live influence childrens and adolescents health (Reijneveld et al. 2005, Stansfeld et al. 2006), injury risk (Edwards et al. 2008) and health behaviours (Reijneveld et al. 2006, Romero 2007). We have therefore broadened the context in which socio-economic circumstances are assessed and developed two new items to measure socio-economic status of the local area in which young people live. The proposed item on How well off is the area in which you live? parallels the item on perceived family wealth. The proposed items on problems in the neighbourhood were adapted from a set of questions from the National Longitudinal Survey of Children in Canada about the neighbourhood, and a neighbourhood observation guide for interviewers. These items are designed to tap the core elements of perceived local area appearance or condition: gang activity, social disorganisation, and deprivation. The items (see item box 6) were pilot tested in six countries (Canada, Macedonia, Norway, Poland, Scotland and Wales) in 2000 and proved easy to understand and fairly non-sensitive.

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II.2 Social contexts of health and health behaviour

Item box 5
SI 1.1 How well off is the area in which you live?
1 2 3 4 5

Not at all well off Not so well off Average Quite well off Very well off

Source: HBSC 2001/2002 & 2005/2006

Item box 6
SI 1.2 In the area where you live, are there....? Lots Groups of young people who cause trouble? Litter, broken glass or rubbish lying around? Run-down houses or buildings? Some None

Source: HBSC 2001/2002 & 2005/2006

Ethnic background: See the items in item box 7. The Child-Parent Validation Study which took place in 2005 in six HBSC-countries, collected data about ethnic background and showed a very high agreement between students and parents regarding answers to these four items. The issue of ethnic background is however very complex. We therefore need further studies to explore ways to collect appropriate and valid data about ethnic background and ways to deal with these data in the analyses. It has become increasingly common to determine ethnic background on the basis of which population group people feel they belong to (Lin / Kelsey 2000, Bhopal 2002, Ellison et al. 2007). This is also an issue we have to deal with in the coming years. Item box 7
SI 2.1
1 2

Were you born in [INSERT HBSC MEMBER COUNTRY NAME] ? Yes No

Source: HBSC 2001/2002

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II.2 Social contexts of health and health behaviour

Item box 8
SI 2.2 In which country was your mother born?

Dont know Source: HBSC 2001/2002

Item box 9
SI 2.3 In which country was your father born?

Dont know Source: HBSC 2001/2002

Item box 10
SI 2.4 What language do you most often speak at home?

Source: HBSC 2001/2002

7. References
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De Bourdeaudhuij I, te Velde S, Brug J, Due P, Wind M, Sandvik C, Maes L, Wolf A, Perez Rodrigo C, Yngve A, Thorsdottir I, Rasmussen M, Elmadfa I, Franchini B, Klepp KI. Personal, social and environmental predictors of daily fruit and vegetable intake in 11-year-old children in nine European countries. European Journal of Clinical Nutrition 2008; 62: 834-41. Boyce W, Torsheim T, Currie C and Zambon A. The Family Affluence Scale as a Measure of National Wealth: Validation of an Adolescent Self-reported Measure. Social Indicators Research 2006; 78: 473-87. Casey PH, Simpson PM, Gossett JM, Bogle ML, Champagne CM, Connell C, Harsha D, McCabe-Sellers B, Robbins JM, Stuff JE, Weber J. The association of child and household food insecurity with childhood overweight status. Pediatrics 2006; 118: e1406-13. Carstairs V, Morris R. Deprivation and health in Scotland. Aberdeen: Aberdeen University Press 1991. Closing the Gap in a Generation: Health Equity through Action on the Social Determinants of Health. Geneva: World Health Organization 2008. Consolacion TB, Russell ST, Sue S. Sex, race/ethnicity, and romantic attractions: multiple minority status adolescents and mental health. Cultur Divers Ethnic Minor Psychol 2004; 10: 200-14. Cullen KW, Baranowski T, Owens E, Moor C, Rittenberry L, Olvera N, Resnicow K. Ethnic differences in social correlates of diet. Health Education Research 2002; 17: 7-18. Currie CE, Elton RA, Todd J, Platt S. Indicators of socio-economic status for adolescents: the WHO Health Behaviour in School-Aged Children Survey. Health Education Research 1997; 12: 385-97 Currie C. Socioeconomic circumstances among school-aged children in Europe and North-America. In Vleminckz K, Smeeding TM, eds. Child well-being, child poverty and child policy in modern nations. London: The Policy Press 2001. Currie C, Nic Gabhain S, Godeau E, Roberts C, Smith R, Currie D, Picket W, Richter M, Morgan A, Barnekow V, eds. Inequalities in young peoples health. HBSC international report from the 2005/2006 survey. Copenhagen: World Health Organization, 2008 (Currie et al. 2008a). Currie C, Molcho M, Boyce W, Holstein BE, Torsheim T, Richter M. Researching health inequalities in adolescents: the development of the Health Behaviour in School-aged Children (HBSC) Family Affluence Scale. Social Science & Medicine 2008; 66: 1429-36 (Currie et al. 2008b). Dahrendorf R. Life chances. Approaches to social and political theory. Chicago: University of Chicago Press 1979. Demakakos P, Nazroo J, Breeze E, Marmot M. Socioeconomic status and health: the role of subjective social status. Social Science & Medicine 2008; 67: 330-40. Diderichsen F. Income maintenance policies: Determining their potential impact on socioeconomic inequalities in health. Pp. 53-67 in Mackenbach J, Bakker M, eds. Reducing inequalities in health. A European perspective. Copenhagen: WHO Regional Office for Europe, 2000. Diderichsen F, Evans T, Whidtehead M. The social basis of disparities in health. In Evans T, ed. Challenges in inequalities in health. From ethics to action. Oxford: Oxford University Press 2001. Dowswell T, Towner E. Social deprivation and the prevention of unintentional injury in childhood: a systematic review. Health Education Research 2002; 17: 221-37. Due P, Lynch J, Holstein BE, Modvig J. Socioeconomic health inequalities among a nationally representative sample of Danish adolescents: the role of different types of social relations. Journal of Epidemiology and Community Health 2003; 57: 692-98. Due P, Damsgaard MT, Rasmussen M, Holstein BE, Srensen TIA, Wardle J, Merlo J, Currie C, Ahluwalia N, Lynch J. Socioeconomic position, macro-economic environment, and overweight among adolescents in 35 countries. Submitted (Due et al. 2009a). Due P, Merlo J, Harel Y, Damsgaard MT, Holstein BE, Hetland J, Currie C, Nic Gabhainn S, Matos MG, Lynch J. Social inequality in exposure to bullying in adolescence: international comparative crosssectional multilevel study in 35 countries. American Journal of Public Health, in press (Due et al. 2009b). Edwards P, Green J, Lachowycz K, Grundy C, Roberts I. Serious injuries in children: variation by area deprivation and settlement type. Archives of Disabled Children 2008; 93: 485-9.

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Elgar FJ, Roberts C, Parry-Langdon N and Boyce W. Income inequality and alcohol use: a multilevel analysis of drinking and drunkenness in adolescents in 34 countries. The European Journal of Public Health 2005; 15: 245-50. Ellison GT, Smart A, Tutton R, Outram SM, Ashcroft R, Martin P. Racial categories in medicine: a failure of evidence-based practice? PLoS Medicine 2007; 4: e287. Engstrm K, Diderichsen F, Laflamme L. Socioeconomic differences in injury risks in childhood and adolescence: a nation-wide study of intentional and unintentional injuries in Sweden. Injury Prevention 2002; 8: 137-42. Finkelstein DM, Kubzansky LD, Goodman E. Social status, stress, and adolescent smoking. Journal of Adolescent Health 2006; 39; 678-85. Ganzeboom HBG, Treiman, DJ. Internationally Comparable Measures of Occupational Status for the 1988 International Standard Classification of Occupations. Social Science Research, 1996; 25: 20139. Gordon-Larsen P, McMurray RG, Popkin BM. Adolescent physical activity and inactivity vary by ethnicity: The National Longitudinal Study of Adolescent Health. Journal of Pediatrics 1999; 135: 301-6. Goodman E, Adler NE, Kawachi I, Frazier AL, Huang B, Colditz GA. Adolescents perception of social status: development and evaluation of a new indicator. Pediatrics 2001; 108: E31. Goodman E, Huang B, Schafer-Kalkhoff T, Adler NE. Perceived socioeconomic status: a new type of identity that influences adolescents self-rated health. Journal of Adolescent Health 2007; 41: 479-87. Griesbach D, Amos A, Currie C. Adolescent smoking and famiuly structure in Europe. Social Science & Medicine 2003; 56: 41-52. Holstein BE, Hansen EH. Self-reported medicine use among adolescents from ethnic minority groups. European Journal of Clinical Pharmacotherapy 2005; 61: 69-70. Holstein BE, Hansen EH, Due P. Social class variation in medicine use among adolescents. European Journal of Public Health 2004; 14: 49-52. Holstein BE, Parry-Langdon N, Zambon A, Currie C, Roberts C. Socioeconomic inequality and health. Pp 165-172 in: Currie C, Roberts C, Morgan A, Smith R, Settertobulte W, Samdal O, Rasmussen VB, eds. Young peoples health in context. Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen: World Health Organization, 2004. Holstein BE, Currie C, Boyce W, Damsgaard MT, Gobina I, Kknyei G, Hetland J, de Looze M, Richter M, Due P. International Journal of Public Health, in press (Holstein et al. 2009). Honkala E, Kuusela S, Rimpel A, Rimpel M, Jokela J. Dental services utilization between 1977 and 1995 by Finnish adolescents of different socioeconomic levels. Community Dentistry and Oral Epidemiology 1997; 25: 385-390. Inchley JC, Currie DB, Todd JM, Akhtar PC, Currie CE. Persistent socio-demographic differences in physical activity among Scottish schoolchildren 1990-2002. European Journal of Public Health 2005; 15: 386-8; International Labor Office (ILO). International Standard Classification of Occupations: ISCO88. Geneva: International Labor Office 1990. Janssen I, Boyce W, Simpson K, Pickett W. Influence of individual- and area-level measures of socioeconomic status on obesity, unhealthy eating, and physical inactivity in Canadian adolescents. American Journal of Clinical Nutrition 2006; 83: 139-45. Klineberg E, Clark C, Bhui KS, Haines MM, Viner RM, Head J, Woodley-Jones D, Stansfeld SA. Social support, ethnicity and mental health in adolescents. Social Psychiatry and Psychiatric Epidemiology 2006; 41: 755-60. Krieger N. Discrimination and health. In Berkman LF, Kawachi I (eds.). Social Epidemiology. New York: Oxford University Press, 2000. Krlner R. Measurement of parents occupational social class in school surveys - a validation study (In Danish: Mling af forldres socialgruppe i skolebrnsundersgelser et valideringsstudie). MScthesis, Institute of Public Health, University of Copenhagen, Copenhagen 2004.7: 999-1008.

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Kumar BN, Holmboe-Ottesen G, Lien N, Wandel M. Ethnic differences in body mass index and associated factors of adolescents from minorities in Oslo, Norway: a cross-sectional study. Pubic Health Nutrition 2004; Laflamme L, Engstrm K. Socioeconomic differences in Swedish children and adolescents injured in road traffic incidents: cross sectional study. British Medical Journal 2002; 324: 396-7. Landring H, Klonoff EA, Corral I, Fernandez S, Roesch S. Conceptualizing and measuring ethnic discrimination in health research. Journal of Behavioral Medicine 2006; 29: 79-94. Lien N, Friestad C, Klepp K-I. Adolescents proxy reports of parents socio-economic status: How valid are they? Journal of Epidemiology and Community Health 2001; 55: 731-7. Linn SS, Kelsey JL. Use of race and ethnicity in epidemiological research: concepts, methodological issues, and suggestions for research. Epidemiological Reviews 2000; 22: 187-202. Lynch J, Kaplan G. Socioeconomic position. Pp 13-35 in Berkman LF, Kawachi I, eds. Social Epidemiology. New York: Oxford University Press, 2000. Macintyre S, McKay L, Der G, Hiscock R. Socio-economic position and health: what you observe depends on how you measure it. Journal of Public Health Medicine 2003; 25: 288-94. Macintyre S, Ellaway A, Cummins S. Place effects on health: how can we conceptualise, operationalise and measure them? Social Science & Medicine 2002; 55: 125-39. Maes L, Vereecken C, Vanobbergen J, Honkala S. Tooth brushing and social characteristics of families in 32 countries. International Dental Journal 2006; 56: 159-67. Molcho M, Gabhainn SN, Kelly C, Friel S, Kelleher C. Food poverty and health among schoolchildren in Ireland: findings from the Health Behaviour in School-aged Children (HBSC) study. Public Health Nutrition 2007; 10: 364-70 (2007a). Molcho M, Gabhainn SN, Kelleher CC. Assessing the use of the Family Affluence Scale (FAS) among Irish schoolchildren. Irish Medical Journal 2007; 100 (suppl): 37-9 (2007b). Mota J, Almeida M, Santos P, Riberio JC. Perceived Neighborhood Environments and physical activity in adolescents. Preventive Medicine 2005; 41: 834-6. Palermo TM, Riley CA, Mitchell BA. Daily functioning and quality of life in children with sickle cell disease pain: relationship with family and neighborhood socioeconomic distress. Journal of Pain 2008; 9: 833-40. Rahkonen O, Lahelman E. Gender, social class and illness among young people. Social Science & Medicine 1992; 34: 649-56. Rasmussen M, Krlner R, Klepp KI, Lytle L, Brug J, Bere E, Due P. Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part I: Quantitative studies. International Journal of Behavioral Nutrition and Physical Activity 2006; 3: 22. Rasmussen M, Due P, Damsgaard MT, Holstein BE. Social inequality in adolescent daily smoking: Has it changed over time? Scandinavian Journal of Public Health 2009, in press. Reijneveld SA, Brugman E, Verhulst FC, Verloove-Vanhorick SP. Area deprivation and child psychosocial problems - a national cross-sectional study among school-aged children. Social Psychiatry and Psychiatric Epidemiology 2005; 40: 18-23. Richter M, Leppin A, Nic Gabhainn S. The relationship between parental socio-economic status and episodes of drunkenness among adolescents: findings from a cross-national survey. BMC Public Health 2006; 6: 289. Richter M and Leppin A. Trends in socio-economic differences in tobacco smoking among German schoolchildren, 19942002. European Journal of Public Health 2007; 17: 565-71. Romero AJ. Low-income neighborhood barriers and resources for adolescents' physical activity. Journal of Adolescent Health. 2005; 36: 253-9. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN. Prevalence of and Risk Factors for Depressive Symptoms Among Young Adolescents. Archives of Pediatric and Adolescent Medicine 2004; 158: 760-5. Saxena S, Eliahoo J, Majeed A. Socioeconomic and ethnic group differences in self reported health status and use of health services by children and young people in England: cross sectional study. British Medical Journal 2002; 325: 520-3. 32

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Schnohr C, Kreiner S, Due P, Currie C, Boyce W, Diderichsen F. Differential item functioning of a family affluence scale: Validation study on data from HBSC 2001/02. Social Indicators Research 2008; 89: 79-95. Singh GK, Kogan MD, Siahpush M, van Dyck PC. Independent and joint effects of socioeconomic, behavioral, and neighborhood characteristics on physical inactivity and activity levels among US children and adolescents. Journal of Community Health 2008; 33: 206-16. Sorof JM, Lai D, Turner J, Poffenbarger T, Portman RJ. Overweight, ethnicity, and the prevalence of hypertension in school-aged children. Pediatrics 2004; 113: 475-82. Spencer N. Poverty and child health. Oxford: Radcliffe Medical Press 1996. Stansfeld SA, Haines MM, Head JA, Bhui K, Viner R, Taylor SJ, Hilier S, Klineberg E, Booy R. Ethnicity, social deprivation and psychological distress in adolescents: school-based epidemiological study in east London. British Journal of Psychiatry 2004; 185: 233-8. Starfield B, Riley AW, Witt WP, Robertson J. Social class gradients in health during adolescence. Journal of Epidemiology and Community Health 2002; 56: 354-61. Suominen SB, Vlimaa RS, Tynjl JA, Kannas LK. Minority status and perceived health: a comparative study of Finnish- and Swedish-speaking schoolchildren in Finland. Scandinavian Journal of Public Health 2000; 28: 179-87. Sweeting H, West P, Young R. Obesity among Scottish 15 year olds 1987-2006: prevalence and associations with socio-economic status, well-being and worries about weight. BMC Public Health. 2008; 8: 404. Taylor SJC, Viner R, Booy R, Head J, Tate H, Brentnall SL, Haines M, Bhui K, Hillier S, Stansfeld S. Ethnicity, socio-economic status, overweight and underweight in East London adolescents. Ethnicity and Health 2005; 10: 113-28. Ter Bogt T, Schmid H, Nic Gabhainn S, Fotiou A, Vollebergh W. Economic and cultural correlates of cannabis use among mid-adolescents in 31 countries. Addiction 2006; 101: 241-51. Thompson DR, Iachan R, Overpeck M, Ross JG, Gross LA. School connectedness in the health behaviours in school-aged children study: the role of student, school, and school neighbourhood characteristics. Journal of School Health 2006; 76: 379-86. Torsheim T, Currie C, Boyce W, Samdal O. Country material distribution and adolescents' perceived health: multilevel study of adolescents in 27 countries. Journal of Epidemiology and Community Health 2006; 60: 156-61. Torsheim T, Currie C, Boyce W, Kalnins I, Overpeck M, Haugland S. Material deprivation and self-rated health: a multilevel study of adolescents from 22 European and North American countries. Social Science & Medicine 2004; 59: 1-12. Townsend P, Phillimore P, Beattie, A. Health and deprivation: inequality and the North. London: Croom Helm 1988. Vereecken CA, Maes L, De Bacquer D. The influence of parental occupation and the pupils educational level on lifestyle behaviours among adolescents in Belgium. Journal of Adolescent Health 2004; 34: 330-338. Vereecken CA, Inchley J, Subramanian SV, Hublet A, Maes L. The relative influence of individual and contextual socio-economic status on consumtion of fruit and soft drinks among adolescents in Europe. European Journal of Public Health 2005; 15: 224-32 Vereecken C, Vandegehuchte A. Measurement of parental occupation: Agreement between parents and their children. Archives of Public Health 2003; 61: 141-9. Vieno A, Perkins DD, Smith TM, Santinello M. Democratic school climate and sense of community in school: a multilevel analysis. American Journal of Community Psychology 2005; 36: 327-341. West P. Inequalities? Social class differentials in health in British youth. Social Science & Medicine 1988; 27: 291-6. West P. Health inequalities in the early years: is there equalisation in youth? Social Science & Medicine 1997; 44: 833-58.

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West P, Sweeting H, Speed E. We really know what you do: a comparison of reports from 11 year olds and their parents in respect of parental economic activity and occupation. Sociology 2001; 35: 539-59. Whaley AL, Francis K. Behavioral health in multiracial adolescents: the role of Hispanic/Latino ethnicity. Public Health Reports 2006; 121: 169-74. Will B, Zeeb H, Baune BT. Overweight and obesity at school entry among migrant and German children: a cross-sectional study. BMC Public Health 2005; 5: 45. Williams J, Currie C, Wright P, Elton R, Beattie T. Socioeconomic status and adolescent injuries. Social Science & Medicine 1997; 44: 1881-91. Williams DR, Neighbors HW, Jackson JS. Racial/ethnic discrimination and health: findings from community studies. American journal of Public Health 2003; 93: 200-8. Winkelby MA, Robinson TN, Sundquist J, Kraemer HC. Ethnic variation in cardiovascular disease risk factors among children and young adults. Journal of the American Medical Association 1999; 281: 1006-13. Zaborskis A, Lenciauskiene. Health behaviour among Lithuanias adolescents in context of European Union. Croatian Medical Journal 2006; 47: 335-43. Zambon A, Lemma P, Borraccino A, Dalmasso P, Cavallo F. Socio-economic position and adolescents health in Italy: the role of the quality of social relations. European Journal of Public Health 2006; 16: 627-32.

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II.2.2 Family Culture


Moreno, C, Granado-Alcn, MC., Borup, I, Marklund, U, Dallago, L, Zaborskis, A, Smith, B, Tabak, I, Camacho, I, Vasileva, L, Elgar, F, Kuzman, M, Massa, M, rknyi, A, Arnarsson, A, Atanasov, D, Kallay, E

1. Scope and purpose


The family is a developing and socializing context where children learn and internalize values and norms, and develop behaviours orientated towards being adjusted to the society in which they live. Interacting with the family, plus other primary settings such as peer groups or school also promote the socialization process, although it has been well documented scientifically that the family setting has the major influence on this process (Parker / Buriel 2006), and has to be analyzed to fully understand how it shapes the life style of young people. Within the HBSC project we use an ecological - systemic perspective in order to describe the family structure in which adolescents live and to analyze the family dynamics (including communication with and attachment to parents, monitoring, disciplinary parenting styles) and family life (including family activities and satisfaction with the global family atmosphere). The most recent and relevant revisions of family and adolescence (see for example Collins / Steinberg 2006, Collins / Laursen 2004, Granic et al. 2003, Grotevant 1998, Rodrigo / Palacios 1998, Steinberg 2001), showed these topics as the most significant issues by which to explain family influence in patterning health and healthy behaviour in the adolescent population, and as a good base to develop appropriate prevention and intervention strategies and programmes. According to the stated arguments, the next section shows the objectives of HBSC in relation to the family setting within and between countries.

2. Objectives
1. Description of the family configuration (family structure: bi-parental, single parents, stepparents, and others; extended family grandparents; and number of sisters and brothers) in order to analyze how changes within the family structure may introduce variations in childrens living conditions (i.e. social capital, family affluence, interaction with the parents, well-being, vulnerability to the adoption of risk behaviours).

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2. Analyses of the family dynamics, paying special attention to the consequences on health and healthy behaviours in normal and vulnerable contexts. 3. Description of the activities that adolescents carry out with their family as potential agents for development. 4. Study the variables which, together with the ones under study, moderate the development of adolescents in order to give a global picture of the family, and which contribute to enrich the findings about the family and to develop prevention and intervention strategies.

3. Theoretical framework
Socialization is a process in which an individuals standards, skills, motives, attitudes, and behaviours change to conform to those regarded as desirable and appropriate for his or her present and future role in any particular society. Many agents and agencies play a role in the socialization process, including family, peers, school, and the media. But it is recognized that family, as first development context, has the greatest influence on socialization (Parke / Buriel 2006). From the beginning of the 20th century, the family has been a topic generating great interest between researchers. The first theoretical approaches Psychoanalysis and Behaviourism theories opened the way to new theories more interested in explaining the multi-influential relationships that occur within families. Today, this idea is completed with the assumption that individuals cannot be studied outside of the different contexts in which they live and develop, and leads us to accept the ecological-systemic theory as the best approach to the study of family setting. From this perspective, the HBSC study broaches two of the dimensions under study within the family: family dynamics and family life. From the human development ecological perspective these dimensions belong to the first level of analysis micro-system or the immediate space where the child interacts, in which three subsystems can be defined; conjugal, parental, and fraternal. Due to the effect that it can cause on the rest of subsystems and on the adjustment and well-being of the child, the most important subsystem is the one named conjugal. Conflicts between parents, divorce or separation, modify the family structure and alter the family dynamics, resulting in less implication in the rearing of the child, inconsistent parenting style, less time spent together, less availability and responsiveness, etc. (Brown 2004, Hoffman 2006). It has been shown that family dynamics, which are demanding while at the same time responsive, and offer open communication, are associated with health and healthy behaviours. As a contrast, when changes or problems
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II.2 Social contexts of health and health behaviour

within the family take place, not only are these associated with bad psychological (poor well being, depression, anxiety) (Ge et al. 2006, Granado et al. 2008) and adjustment behavioural problems, (drugs consumption, early sexual activity, antisocial behaviour, more vulnerability to being involved in the antisocial behaviour of peers, school absenteeism, bullying at school) (Granado / Pedersen 2002, Granado et al. 2003, Hetherington 2003) but also extends to other contexts such as at school, with poor school performance (McLanahan / Sandefur 1994, Jeynes 1998). Family and school are contexts in which children play an active roll, but there are also other contexts in which they do not take part directly, but are affected by what is going on in their immediate context. This area, known as the exo-system, is made up of the family and school contexts and contemplates both formal social structures (the work context of the parents, services from the local community, social support, familiar mediation service, etc.) and informal social structures (social support network, such as family, friends, neighbourhood, etc.) that indirectly affect the life of the child, contributing to a better adjustment in their proximal contexts. A good example of how the exo-system is associated with the well-being of the child and their opportunities in life, could be the changes that a divorce cause in the family, such as the decreasing of family income; the change of residence, neighbourhood, or school; lack of employment or underpaid job, etc. (Weinraub et al. 2002). These changes also lead us to consider the association between family context and social inequalities in health, in order to promote intervention and prevention policies and strategies that improve the adjustment of the child. Further, in the HBSC Survey, we cannot end our theoretical approach without pointing out the influence of the cultural contexts in family issues. Cross-cultural studies showed that although most cultures show general patterns of functioning, each of them have their own specificity (patterns of behaviours, beliefs, cultural values, attitudes, socio-historic events, etc.) (Santrock 2003), which can introduce differences in the well-being and adjustment of the child (Granado et al. 2008). As a final conclusion, we would like to point out that in the HBSC, even if we considered and treated family structure as one of the relevant variables in the development of the child, it is well known that health and healthy behaviour outcomes go beyond the structure of the family, the specific dynamic processes within each family structure being the most important (Kaufmann et al. 2000, Granado et al. 2002, Weinraub et al. 2002). The scientific community recommend researching this aspect in depth, analyzing functioning dynamics within each

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family structure and broaching, from an ecological-systemic perspective, how processes pattern the health and healthy behaviour of the child.

3.1 Family Structure


In recent decades, the family (especially in Western countries) has undergone major changes. One of these most significant changes in the European Union relates to the family structure in which the child develops (Deven 1996), showing how the traditional family - composed of biological parents and their children - is no longer so common (Eurostat 1995, 1996, 2006), and is making way for new family configurations in which children live either with one of the biological parents and his/her partner, with just one of the biological parents, or with other people (Currie et al. 2008, Pedersen et al. 2004a). These changes constitute a good argument to reflect on how and under what conditions these situations affect the development of the child. Previous research concluded that living in a bi-parental family is a protective factor for the development of children and adolescents, while living in other family configurations, especially those in which multiple family transitions are experienced, is associated with a higher risk of psychological (i.e. depression, anxiety, poor wellbeing, and social withdrawal) (Amato 2001, Ge et al. 2006, Granado et al. 2008, Hetherington 2003), behavioural (i.e. early sexual activity, and substance and alcohol consumption (Amato 2001, Hetherington 2003, Barret / Turner 2006, Hetherington 2003, Granado / Pedersen 2001, Granado / Pedersen 2002, Tood et al. 2007), social and academic problems (absenteeism and absence from school, antisocial behaviour and absence from home (Amato 2001, Hetherington 2003), and higher vulnerability to peer pressure (Hetherington 2003).

3.2 Family dynamics


These are based on the interpersonal relationships between the family members, which are characterized by both the quality of the interactions and disciplinary strategies practised by the parents. Most of the studies revealed better adjustment in children and adolescents who reported having an open communication with their parents (Stattin / Kerr 2000) and who perceived them as physically and emotionally accessible (Bowlby 1987 cit. in Ainswoth 1990). This evidence directs our approach to analyze the specific variables that shape the interpersonal relationships built within the family setting: communication and attachment to parents, monitoring, and disciplinary parenting styles. Communication is a mandatory measure and the rest of the variables belong to optional packages (attachment and monitoring:
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II.2 Social contexts of health and health behaviour

optional package number 1; disciplinary parenting style, family activities, family structure and satisfaction with the global family atmosphere: optional package 2).

3.2.1 Communication with parents Parent-child communication is revealed as one of the basic elements of analysis within the family. Due to this importance it has been shown as a development protection factor (see Collins / Laursen 2004, Steinberg 2001, Steinberg / Silk 2002). Research demonstrated that during adolescence, children would speak less to their parents spontaneously; therefore communication would become more difficult during these years. Differences in easiness or difficulty in communicating showed that those families with a good quality of communication have more resources to overcome this developmental stage successfully compared with those families that, reporting a history of previous problems in communication, found more interaction difficulties during adolescence (Laursen / Collins 2004, Loeber et al. 2000). Age and gender differences showed that difficulties in communication increased with age; girls have more difficulties than boys in talking to parents; and both girls and boys find it easier to talk to their mother than to their father.

3.2.2 Parental Bonding Despite significant changes in communication during the adolescent years reported before, most families experience a reassuring continuity in their emotional bonds. Parental bonding is one of the elements to be considered when approaching the study of family dynamics. It refers to a bond of affection, characterized both by continuity over time and reciprocal relationships between parents and children (Cummings / Cummings 2002). This relationship varies and decreases from infancy to adolescence in relation to demonstrations of explicit affection, although the sense and meaning of the parent - child bond remains the same as in early childhood. What changes in adolescence is a decreasing need for physical proximity and affectionate demonstrations and an increasing need to perceive the attachment figure as available, open to communication, physically accessible and responsive if called on for help (Bolwby 1987 cit. in Ainsworth 1990). These changes in the period of adolescence are explained by experts not as negative behaviour, but as a normal evolutionary process orientated to strengthen the childs own autonomy and independence, which shows a similar tendency for both parents, although mothers were found to demonstrate more intimacy and show more affection to their children than fathers (Eberly / Montemayor 1999).
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The importance that parental bonding has for the development of the child has been documented by various researchers, showing that a warm and loving relationship with parents correlates to better psychological welfare and self-esteem (Oliva et al. 2002, Steinberg / Silverberg 1986), better behavioural and academic competence (Maccoby / Martin 1983, Steinberg et al. 1992, Steinberg et al. 1994), and less behavioural problems (Ge et al. 1996).

3.2.3 Parental Monitoring Monitoring is a parental control sign related to the parents knowledge of their childs activities, whereabouts, relationships or friends (Jacobson / Crockett 2000). During adolescence, girls and boys spend much of their time outside the home, and opportunities for autonomy and independence increase considerably when compared to previous years. Therefore, it is critical for parents to monitor their children. Concerns may include troublesome friends or risk-taking. At the same time, it is believed that adolescents who grow up knowing that there is an external monitoring being exercised on them will later interiorise this monitoring structure (these adolescents will end up making these behavioural expectations and rules their own). In fact, results seem to support this idea, since correlations have been found between monitoring and better school adjustment (Crouter / Head, 2002), less antisocial and delinquent activities (Barber 1996, Jacobson / Crockett 2000) and less cases of early sexual initiation (Ensminger 1990). Recent work by Kerr and Stattin (Kerr / Stattin 2000, Stattin / Kerr 2000, Kerr et al. 2003, Fletcher et al. 2004) suggests that not all types of monitoring are good for the childs development. Using an intrusive or authoritarian parenting practice was associated with a lack of self-disclosure by adolescents about their activities, friends, etc. (Darling et al. 2006, Stattin / Kerr 2000), while a warm relationship and open communication related to the monitoring lead to the childs own contributions to the monitoring process, especially at the preadolescent period, when parents and children start negotiating issues of autonomy and independence. Self-disclosure is the contribution of the child to the monitoring process and it is associated with the adjustment of the child (the more self-disclosure, the less anti-social behaviour, the better school adjustment, the less depression, and the higher self-esteem; (Crouter / Head 2000, Stattin / Kerr 2000, Kerr / Stattin 2000).

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3.2.4 Disciplinary Parenting Style This refers to the strategies that parents used for the socialization of their child. The pioneer research of this topic was carried out by Baumrind (1971, 1973) who found three styles of parental control that were named authoritative, authoritarian, and permissive. Later, Maccoby and Martin (1983) redefined these parenting rearing styles into two dimensions; these were named demandingness vs undemandingness and responsiveness vs unresponsiveness. The former distinguishes between those parents who establish high expectations for their child and demand them to be carried out, and those parents who rarely demand anything nor try to influence their child's behaviour. The latter distinguishes between those parents who accept the opinions of their child, and verbally negotiate the position of both themselves and their child, versus those parents who reject their child and do not show any interest or responsiveness when the child demands support. The combination of these dimensions resulted in four parenting rearing styles: authoritative, permissive, authoritarian, and neglectful.
PARENTING STYLES Demandingness Undemandingness Responsiveness Authoritative- Reciprocal Permissive-Indulgent Unresponsiveness Authoritarian- repressive Permissive-Neglectful

Research has firmly shown that adolescents reared within authoritative families have better scores in several measures, such as self-esteem, sympathetic feelings, moral development, interest in school, academic accomplishment and motivation. They also have fewer behavioural problems, conform less to peer group pressure and have more cognitive resources with which to better avoid risk behaviours (such as drug abuse, early sexual initiation, etc.) (see Aunola et al. 2000, Darling / Steinberg 1993, Glasgow et al. 1997, Steinberg et al. 1992). The opposite is true for adolescents reared in negligent or indifferent families, who have higher developmental risks and problems since they are more impulsive and more willing to engage in early risk behaviours (Fuligni / Eccles 1993, Kurdek / Fine 1994).

3.2.5 Family Life Family life refers to the activities that children and parents do together. These measures belong to the optional package number 2.

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Adolescence is a period in which adolescents want and need to reach greater autonomy and independence. This is why a significant part of their free time is spent with peers and out of the family context. Research has shown, however, that in spite of this, it is important during these years that parents should succeed in spending family time together and also engage in certain activities together (see, for example Larson et al. 1996).

3.2.6 Satisfaction with the global family atmosphere This item was used for the first time in the HBSC 2006 survey. In Spain the analysis of this item showed that most adolescents reported being satisfied with their family (very good 30.2%; good 55.3; neither good nor bad 9.5%; bad 1.3%%; very bad 0.4%; mean: 8.40; standard deviation: 1.67). Differences between boys and girls showed that boys seem to be less satisfied than girls with their families. However, analyzing the global scales for both, boys and girls, the mean for each of them is almost equal (boys: mean 8.49, standard deviation 1.61; girls: mean 8.32, standard Deviation 1.7). Also the coefficient applied to the Chi-Square Test reported that there is not an association between gender and family satisfaction (p>0.001; Eta < 0.001; Moreno et al. 2008). A deeper reliability and validity analysis are needed for this item.

4. Summary of previous work


Bonding: The first works written with data obtained from the 2001/02 HBSC survey (the first time this topic was included in the HBSC survey; see, for example Dallago et al, in press; Granado et al. 2004) support continuing work with this construct. It has been found, for example, that adolescents feel very close emotional attachment to their parents (especially to their mothers), even if emotional attachment perception decreases with age. The father is perceived differently by boys than by girls, the former perceive him to be closer than girls do, but this is not true for how mothers are perceived. This emotional attachment to parents (especially when it is to both parents) becomes a significant protection factor (particularly for mental health issues) for this age group. Monitoring: results found in the 2001/02 survey offered sufficient insights to make us consider the need to keep it in the next survey. Some of the results are (see Granado et al. 2003, Pedersen et al. 2004a, Pedersen et al. 2004b, Moreno et al, in press):
-

Adolescents (girls more than boys) feel that their mothers monitor them more than their fathers.
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II.2 Social contexts of health and health behaviour

Both monitoring carried out by the mother and by the father decreases as the age of the child increases. This helps adolescents to progressively learn to become increasingly autonomous.

There is a close connection between the developmental status of the adolescent, and parental monitoring, especially so when monitoring is performed within a family context marked by affection and good communication.

Disciplinary Parenting Style: As was also true for parental bonding and monitoring, research on styles of discipline was added to the HBSC in the 2001/02 survey. Work done so far (see, for example, Granado et al. 2003, Moreno et al. 2004, Moreno et al. 2005) confirms the benefits of keeping this topic in the 2005/06 survey. Some of the results obtained are:
-

Styles at both poles (the most neglectful and the most authoritarian) were represented by few adolescent families, whereas the prevailing styles are the more democratic and more permissive ones.

As adolescents grow, democratic style leaves more and more space for a more permissive one. This could be interpreted in developmental terms as a strategy to give the adolescent increasing autonomy and thus facilitate his/her transition to adult life.

Family life: Analysis carried out so far with data obtained from the 2001/02 survey confirms that this topic should continue to be included in the 2005/06 survey (Moreno et al. 2005, Zaborskis et al. 2007). Some of these results showed, for example, that:
-

Family time spent together in shared activities varies in different countries, although the size of this variability was small relative to the overall effect.

For the majority of family time variability was due to age category (family activities tend to decrease as the age of the adolescent increases)

Considering country, gender and age impact on this variability, it was found that the distribution of joint activities of children and parents also tends to be dispersed by family structure and family wealth.

Satisfaction with Family Global Atmosphere: This item was introduced for the first time in the HBSC 2006 survey (see Moreno et al., in press).

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5. Research questions
The following research questions have been addressed individually for each variable to explore the family setting:

Family Structure 1. What are the structural features of families from the HBSC study? 2. How does family structure evolve over time in the countries of the HBSC study? 3. How does each type of family work (in terms of communication, attachment, monitoring, etc)? 4. How is the structure of each family associated with the development of adolescents? 5. What are the variables to be used so as to better understand or clarify this association?

Communication with parents 1. How does communication with the father and the mother change for each sex throughout adolescence? 2. What are the connections between parental communication patterns and adolescent development? 3. What trends can be found in this data when compared with that of previous surveys? 4. What are the connections between the structure of this support network and adolescent development for each age and sex?

Parental Bonding 1. How does attachment to parents change for each sex throughout adolescence? 2. What trends can be found in this data when compared to that of previous surveys? 3. What are the connections between the different types of attachment to parents and adolescent development? 4. What is the significance of parental support and autonomy stimulation throughout adolescence?

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II.2 Social contexts of health and health behaviour

Parental Monitoring 1. What is the real significance of monitoring? 2. How does it relate to age and sex in the various countries of the study? 3. How is it connected to adolescent development results? 4. What trends can be found in this data when compared to that of previous surveys?

Satisfaction with the Global Family Atmosphere 1. How does satisfaction with the global family atmosphere change for each sex and country throughout adolescence? 2. How is satisfaction with the global family atmosphere connected to other family culture measurements? 3. How is satisfaction with the global family atmosphere connected to the development results of adolescents of each sex and age?

Disciplinary Parenting Style 1. How do boys and girls perceive the disciplinary style of their family to change throughout adolescence? 2. What are the connections, at each stage of adolescence, between disciplinary styles and the developmental status of the adolescents? 3. What trends can be found in this data when compared to that of previous surveys?

Family life & Enjoyment of family activities 1. What family activities change during adolescence for each sex and in each country? 2. What is the developmental profile of the liking by the adolescent for these activities for each sex and country? 3. What is the connection between performing these family activities, liking them and certain health related issues? 4. What trends are found in results for family activities when compared to previous surveys?

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6. Instruments
6.1 Mandatory Items
6.1.1 Family structure Because of the many problems posed by the 2001/02 question, in 2005/06 we have tried different alternatives and have finally decided to replace the two-column (two houses) format with two independent questions, having the second one a skip format (MQ33. All families are different (for example, not everyone lives with both their parents, sometimes people live with just one parent, or they have two homes or live with two families) and we would like to know yours. Please answer this first question where do you live all or most of the time and tick the people who live there. MQ34. Do you have another home or another family, such as the case when your parents are separated or divorced?). It tries to be somewhat sensitive to the fact that not everybody lives with both their parents, and emphasises that the second home should be considered only if parents do not live together. The questionnaire also explores the number of sisters and brothers following this same logic (the main house and the second house) and using a simple format. Item box 1
MQ33 All families are different (for example, not everyone lives with both their parents, sometimes people live with just one parent, or they have two homes or live with two families) and we would like to know about yours. Please answer this first question for the home where you live all or most of the time and tick the people who live there Adults
1 2 3 4 5 6 7

Mother Father Stepmother (or fathers girlfriend) Stepfather (or mothers boyfriend) Grandmother Grandfather I live in a foster home or childrens home

Children Please say how many brothers and sisters live here (including half, step or foster brothers and sisters). Please write in the number or write 0 (zero) if there are none. Please do not count yourself. How many brothers? _____ How many sisters? _____

Someone or somewhere else: please write it down

Source: HBSC survey 2001/02 & 2005/06 (revised)

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Item box 2
MQ34 Do you have another home or another family, such as the case when your parents are separated or divorced? No GO TO QUESTION XX Yes How often do you stay there?
1 2 4 5

1 2

Half the time Regularly but less than half the time Sometimes Hardly ever

Please tick the people who live there: Adults


1 2 3 4 5 6 7

Children
Mother Father My fathers partner My mothers partner Grandmother Grandfather I live in a foster home or childrens home Please say how many brothers and sisters live here (including half, step or foster brothers and sisters). Please do not include those you already listed in the question above or yourself. Write in the number or write 0 (zero) if there are none. How many brothers? _____ How many sisters? _____

Someone or somewhere else: please write it down

Source: HBSC survey 2001/02 & 2005/06 (revised)

The FC-FG suggests keeping the same translation guidelines present in the 2001/02 protocol: Response option I live in a foster home or childrens home: The intention here is to identify those children who do not live with family members and who are cared for by the state. The terms used for state care of children/young people may need to be adapted to country circumstances where necessary. In the UK, foster care is a family home that takes in children whose own parents are unable to look after them (either temporarily or for a long period of time); a childrens home is an institution where children live (either temporarily or for a long period of time) when their parents are dead or otherwise unable to look after them. Response option Someone or somewhere else: this option is included for sensitivity reasons, i.e. so that children who have some other living arrangement or live with people other than those listed are able to complete the question. It is not intended that the written answers are coded if the option is checked, it will simply be coded as 1=yes (see mandatory questionnaire codebook).

47

II.2 Social contexts of health and health behaviour

6.1.2 Communication between parents and adolescents The FC Focus Group debated on the suitability of including a communication measure in the 2009/10 questionnaire in order to inquire on topic-based communication quality (friendship, free time, sexuality, drugs, school issues, political issues, etc.). This would be advisable in as much as it allows for the drawing of a communication scale (which is not possible right now) and because it would allow for a more thorough exploration of how communication affects adolescent behaviour: It is known for example that good family communication on sexual issues corresponds to less high-risk sexual behaviours in adolescents (Hutchinson Cooney 1998). This possibility was finally rejected taking into account that the HBSC measure used up to this moment (MQ35) has been useful and that it has been reported as such by different focus groups and teams and also because it would imply including a quite more extensive instrument than the one being used now. Item box 3
MQ35 How easy is it for you to talk to the following persons about things that really bother you? Please tick one box for each line Very easy Easy Difficult Very difficult Dont have or see this person
5 5 5 5 5 5 5 5 5

Father My fathers partner Mother My mothers partner Elder brother(s) Elder sister(s) Best friend Friends of the same sex Friends of the opposite sex

1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4

Source: HBSC surveys1985/86, 1989/90, 1993/94, 1997/98, 2001/02 & 2005/06.

6.2 Optional items


6.2.1 Parental Monitoring The measure of Parental Control is based on the instrument built by Brown et al. (1993). The items try to get information about the childs perception of the knowledge that parents have of the activities they do outside of the home.

48

II.2 Social contexts of health and health behaviour

HBSC includes five items in the optional package 1 to measure this topic. Items are repeated for the mother and the father. Each item contains four answer options repeated for each of them: 1 = Knows a lot; 2 = Knows a little; 3 = Doesnt know anything; 4 = Dont have or see this person (see item box 4). Item box 4
FC1.1. How much does your mother really know about? She knows a lot She knows a little She doesnt know anything
3

Dont have or dont see mother


4

Who your friends are How you spend your money

Where you are after school Where you go at night What you do with your free time FC1.2
1 2 3 4

How much does your father really know about? He knows a lot He knows a little He doesnt know anything
3

Dont have or dont see father


4

Who your friends are How you spend your money Where you are after school Where you go at night What you do with your free time

Source: Brown et al. (1993). Parenting practices and peer group affiliation in adolescence. Child Development, 64 (2), 467-482. Used for HBSC 2002 and 2006 (optional package 1). No changes have been introduced for the 2010 survey.

6.2.2 Parental Bonding This measure is based on the already classic instrument built by Parker et al. (1979), used to assess the quality of the attachment links between adults and adolescents. It measures two independent dimensions: emotional support and promotion of autonomy. HBSC includes eight items in the optional package 1 to measure this topic. Items are repeated for the mother and the father. Each item contains four and four answer options repeated for each of them: 1 = almost always; 2 = Sometimes; 3 = Never; 4 = Dont have or see this person. The dimension related to emotional support is measured by the items 1, 3, 4 and 8; the

49

II.2 Social contexts of health and health behaviour

dimension of promotion of autonomy is measured by the items 2, 5, 6 and 7. Items 1-5 and 8 are positive aspects of parental bonding, items 6-7 are negative (see item box 5). Item box 5
FC1.3 My mother. He knows a lot He knows a little He doesnt know anything
3

Dont have or dont see father

helps me as much as I need lets me do the things I like doing is loving understands my problems and worries likes me to make my own decisions tries to control everything I do treats me like a baby makes me feel better when I am upset FC1.4 My father.

1 1 1 1 1 1 1

2 2 2 2 2 2 2

3 3 3 3 3 3 3

4 4 4 4 4 4 4

He knows a lot

He knows a little

He doesnt know anything


3 3 3 3 3 3 3 3

Dont have or dont see father


4 4 4 4 4 4 4 4

helps me as much as I need lets me do the things I like doing is loving understands my problems and worries likes me to make my own decisions tries to control everything I do treats me like a baby makes me feel better when I am upset

1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2

Source: Parker et al. (1979) used in HBSC 2002 and 2006 (optional package 1). No changes have been introduced for the 2010 survey.

6.2.3 Disciplinary Parenting Style The measure of Disciplinary Parenting Style is an adaptation of Hoffman (1970) based on the dimensions identified by Maccoby and Martin (1983): responsiveness vs. unresponsiveness and demandingness vs. undemandingness.
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II.2 Social contexts of health and health behaviour

HBSC includes four items in the optional package 2 to measure this topic. The items are repeated for the mother and the father. Each item contains six answer options repeated for each of them: 1 = Very often; 2 = Often; 3 = Sometimes; 4 = Seldom; 5 = Never; and 6 = dont have or see this person. A scale measuring the four parental disciplinary styles from authoritarian to neglectful: Statement 1 = permissive-neglectful; statement 2 = authoritative-reciprocal; statement 3 = permissive-indulgent; statement 4 = authoritarian-repressive (see item box 6). Item box 6
FC2.1 What does your mother do, when you do something that she thinks is wrong? Please tick on box for each line. Very often Often Sometimes Seldom Never Dont have or dont see mother

My mother doesnt punish 1 2 3 4 5 6 me, she takes no notice My mother explains to me what I have done wrong and 1 2 3 4 5 6 why I am being punished My mother tells me that I behaved badly but doesnt 1 2 3 4 5 6 punish me My mother punishes me immediately without telling 1 2 3 4 5 6 me why FC2.2 What does your father do, when you do something that he thinks is wrong? Please tick on box for each line. very often Often Sometimes Seldom Never Dont have or dont see father
6

My father doesnt punish me, he takes no notice My father explains to me what I have done wrong and why I am being punished My father tells me that I behaved badly but doesnt punish me My father punishes me immediately without telling me why

Source: (adapted from) Hoffman, 1970. Used for HBSC 2002, 2006, and 2010)

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II.2 Social contexts of health and health behaviour

Other optional packages/items listed below can be found in the item bank on the HBSC website. Familiy Activities Family Structures (New Version) Satisfaction with the global family atmosphere

7. References
Ainsworth, M.D.S. (1990). Epilogue: some considerations regarding theory and assessment relevant to attachments beyond infancy. In M.T. Greenberg, D. Cicchetti & E.M. Cummings (Eds.), Attachment in the preschool years (pp. 463 488). Chicago: University of Chicago Press Amato, P.R. (2001). Children of divorce for adults and children. Journal of Marriage and the family, 62, pp. 1269 1287 Aunola, K., Stattin, H. & Nurmi, J. (2000). Parenting styles and adolescents' achievement strategies. Journal of adolescence, 23(2), 205-222. Barber, B.K. (1996). Parental psychological control: revisiting a neglected construct. Child Development, 67, 3296-3319. Barret & Turner, J. (2006). Family structure and substance use problems in adolescence and early adulthood: examining explanations for the relationships. Addiction, 101, 109-120 Baumrind (1971). Current Patterns of Parental Authority. Developmental Psychology Monograph, vol. 4, n 1, part. 2, pp. 1 - 103 Baumrind (1973). The developmental of instrumental competence through socialization. En A.D. Pick (ed), Minnesota Symposia on Child Psychology, (vol. 7, pp. 3 46). Minneapolis: University Minnesota Press. Brown, S. (2004). Family structure and child well-being: the significance of parental cohabitation. Journal of Marriage and Family, 66, 2; pp. 356 367. Brown, B. B., Mounts, N., Lamborn, S. D. & Steinberg, L. (1993).Parenting practices and peer group affiliation in adolescence. Child Development, 64 (2), 467-482. Collins, W. A., & Laursen, B. (2004). Parent-adolescent relationships and influences. In R. Lerner & L. Steinberg (Eds.), Handbook of adolescent psychology (pp. 331-361). New York: Wiley. Collins, W. A., & Laursen, B. (2004). Parent-adolescent relationships and influences. In R. Lerner & L. Steinberg (Eds.), Handbook of adolescent psychology (pp. 331-361). New York: Wiley. Collins, W.A. & Steinberg, L. (2006), Adolescent development in interpersonal context. Chapter to appear in: Damon, W. (Series Ed.), & Eisenberg, N. (Vol. Ed.). Handbook of Child Psychology (5th ed.) (pp. 1005-1052). New York: Wiley. Crouter, A. C. & Head, M.R. (2002). Parental monitoring and knowledge of children. In M. Bornstein (Ed.), Handbook of parenting (2nd ed., pp. 461-484). Mahwah, NJ: Lawrence Erlbaum. Cumming, E.M. & Cummings J.S. (2002). Parenting and Attachment. In M.H. Bornstein (Ed.), Handbook of Parenting. Vol. 5. Practical Issues in Parenting. London: LEA Currie C, Nic Gabhain S, Godeau E, Roberts C, Smith R, Currie D, Picket W, Richter M, Morgan A & Barnekow V, eds. Inequalities in young peoples health. HBSC international report from the 2005/2006 survey. Copenhagen: World Health Organization, 2008 (2008a). Dallago, L., Granado, M.C. et al (in progress). Adolescent boys and girls attachment to parents throughout adolescence and across countries 52

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Darling, N., & Steinberg, L. (1993). Parenting Style as Context: An integrative Model. Psychological Bulletin, 113(3), 487-496. Darling, N.; Cumsille, P.; Caldwell, L.L. & Dowdy, B. (2006). Predictors of Adolescents Disclosure to Parents and Perceived Parental Knowledge: Between and Within Person Differences. Journal of Youth and Adolescence, Vol. 35, N4, pp. 667 678. Deven, F. (1996). Relatiepatronen en gezinsdynamiek. (Relational Patterns and Family Dynamics). En R.L. Cliquet (ed.), Gezinnen in de verandering. Veranderende gezinnen. CBGS Monografie 1996/2. Brussel: Centrum voor Bevolkings-en Gezinsstudie, pp. 59-82 Eberly, M.B. & Montemayor, R. (1999). Adolescent affection and helpfulness toward parents: a 2 years follow-up. Journal of Early Adolescence, 19, 226-249. Ensminger, M.E. (1990). Sexual activity and problem behaviours among black, urban adolescents. Child Development, 61, 2032-2046. Eurostat (1995). Women and men in the European Union: a statistical portrait. Office for official publications of the European Commission, Luxembourg Eurostat (1996). The demographic situation in the European Union 1995.Office for official publications of the European Commission, Luxembourg Eurostat (2006). The family in the EU25 seen through figures. N 59/2006. Luxembourg, Eurostat. Fletcher, A.C., Steinberg, L. & Williams-Wheeler, M. (2004). Parental influences on adolescent problem behaviour: a response to Stattin y Kerr. Child Development, 75, 781-796. Fuligni. A. & Eccles, J. (1993). Perceived parent-child relationships and early adolescents orientation towards peers. Developmental Psychology, 29, 622-632. Ge, X., Best, K.M., Conger, R.D. & Simons, R.L. (1996). Parenting behaviour and the occurrence and cooccurrence of adolescent depressive symptoms and conduct problems. Developmental Psychology, 32 (4), 717-731. Ge, X.; Natsuaki, M.N. & Conger, R.D. (2006). Trajectories of depressive symptoms and stressful life events among male and female adolescents in divorced and non-divorced families. Development and Psychopathology, 18, pp. 253 -273 Glasgow, K. L., Dornbush, S. M., Troyer, L. Steinberg, L., & Ritter, P. L. (1997). Parenting styles, adolescents' attributions, and educational outcomes in nine heterogeneous high schools. Child Development, 63(3), 507-529. Granado, C., Moreno, C., Pedersen, M., Borup, I., Muoz-Tinoco, M.V., Prez, P. & Snchez, I. (2004). Family influences shaping a concept of health status in adolescents: a cross-national survey. th Poster presented in 18 Biennial Meetings of International Society for the Study of Behavioural Development. Ghent, Belgium, July, 11-15th. Granado, M.C. & Pedersen, J.M. (2001), Family as a child development context and smoking behaviour among schoolchildren in Greenland. International Journal of Circumpolar Health, 60, 52-63. Granado, M.C., Moreno, M.C., Pedersen, M., Borup, I., Kuntsche, E., Massa, M. & Smith, B. (2003). Family as protective context for avoiding risk behaviours across countries. Paper presented in HBSC International Scientific Full Meeting & Conference, Bergen (Noruega), 5-8, June. Granado, M.C.; Moreno, C.; Jimnez, A.; Ramos, P. & Ribera, F. (2008). Monoparentalidad y satisfaccin vital: una perspectiva internacional. Congreso Internacional sobre Divorcio y Monoparentalidad. Retos de nuestra sociedad ante el divorcio. Celebrado en la Universidad de Deusto (Bilbao) del 19 20 de Junio de 2008 (Single-parenthood and life satisfaction: an international perspective. Oral st presentation at the 1 International Congress about Divorce and Single-parenthood, Organized by University of Deusto (Bilbao Spain) 19 20th of June, 2008) Granado, M.C.; Pedersen, J.M. & Carrasco, A.M. (2003). Factores relacionados con la agresividad entre iguales en el entorno escolar: contexto familiar, educativo, grupo de iguales y conductas de riesgo para la salud. Encuentros en Psicologa Social, 1(4), pp. 308 314 (Factors related to aggressiveness between equals in the school environment: in the contexts of family, education, peer group and conducts at risk to health. Meetings in Social Psychology)

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Granic, I., Dishion, T.J. & Hollenstein, T. (2003). The family ecology of adolescence: A dynamic systems perspective on normative development. In G.R. Adams & M.D. Berzonsky (Eds.), Blackwell handbook of adolescence (pp. 60-91). Malden, MA: Blackwell Publishers. Grotevant, H.D. (1998). Adolescent development in family contexts. In W. Damon (Series Ed.) and N. Eisenberg (Vol. Ed.), Handbook of child psychology: Vol. 3. Social, emotional, and personality development (5th edition, pp. 1097-1149). New York: Wiley. Hetherington, E.M. (2003). Should we stay together for the sake of children? En M.E. Coping with divorce, single parenting, and remarriage. A risk and resiliency perspective. Pp. 93 116. Mahwah, NJ: Lawrence Erlbaum Hoffmann, J.P. (2006). Family structure, community, and adolescent problem behaviours. Journal of Youth Adolescence, 35, 867-880 (Demo, 1992; Jacobson, K. C., & Crockett, L. J. (2000). Parental monitoring and adolescent adjustment: An ecological perspective. Journal of Research on Adolescence, 10(1), 65-97. Jeynes, W. (1998). Does divorce or remarriage have the greater impact on the academic achievement of children? Journal of divorce and remarried, 29, 79 101 Kaufmann, D.; Gesten, E.; Santa Luca, R. Sakedo, O.; Rendina, G. & Gadd, R. (2000). The relation between parenting style and childrens adjustment: the parents perspective. Journal of Children and Family Studies, N 9, 231-245. Kerr, M. & Stattin, H. (2000). What parents know, how they know it, and several forms of adolescent adjustment: further support for a reinterpretation of monitoring. Developmental Psychology, 36 (3), 366-380. Kerr, M., Stattin, H., Biesecker, G., & Ferrer-Wreder, L. (2003). Relationships with parents and peers in adolescence. In R. Lerner, Easterbrooks, M. A., & Mistry, J. (Ed.), Handbook of Psychology (Vol. 6. Developmental Psychology, pp. 395-419). New York: Willey. Kuntsche, E. N. & Silvereisen, R.K. (2004). Parental closeness and adolescent substance use in single and two-parent families in Switzerland. Swiss Journal of Psychology, 63 (2), 85-92. Kurdek, L. A., & Fine, M. A. (1994). Family warmth and family supervision as predictors of adjustment problems in young adolescents: Linear, curvilinear, or interactive effects? Child Development, 65, 1137-1146. Larson, R.W., Richards, M.H., Moneta, G., Holmbeck, G. & Duckett, E. (1996). Changes in adolescents' daily interactions with their families from ages 10 to 18: Disengagement and transformation. Developmental Psychology, 32, 744-754. Laursen, B., & Collins, W. A. (2004). Parent-child communication during adolescence. In A.L. Vangelisti (Ed.). Handbook of Family Communication (pp. 333-349). Mahwah, NJ: Erlbaum. Linver, M S., & Silverberg, S. B.(1997). Maternal predictors of early adolescent achievement-related outcomes: Adolescent gender as moderator. Journal of Early Adolescence, 17, 294-318. Loeber, R., Drinkwater, M., Yin, Y., Anderson, S. J., Schmidt, L. C., & Crawford, A. (2000). Stability of family interaction from ages 6 to 18. Journal of Abnormal Child Psychology, 28, 353-369. Maccoby, E.E. & Martin, J.A. (1983). Socialization in the context of the family: parent-child interaction. En E.M. Hetherington (Ed.), P.H. Mussen (Series Ed.). Handbook of child psychology, (4 ed. Vol. 4, pp. 1 102. Nueva York: Wiley McLanahan, S. & Sandefur, D. (1994). Growing up with a single parent: What hurts, what helps. Cambridge, MA: Harvard University Press Moreno, C., Muoz-Tinoco, M.V., Prez, P. & Snchez, I. (2004). Attachment, monitoring and disciplinary th styles in adolescents and their families in Spain. Poster presented in 18 Biennial Meetings of International Society for the Study of Behavioural Development. Ghent, Belgium, July, 11-15th. Moreno, C., Muoz-Tinoco, M.V., Prez, P. & Snchez, I. (2005). Los adolescentes espaoles y su salud. Resumen del studio. Health Behaviour in School-Aged Children. Summary of the study (HBSC2002). Madrid: Ministerio de Sanidad y Consumo (Ministry of health and consumption). Moreno, C., Ramos, P., Rivera, F., Muoz-Tinoco, V., Snhez-Queija, I., Granado, M.C. & Jimnez-Iglesias, A. (2008). Desarrollo adolescente y salud en Espaa. Resumen del studio. Health Behaviour in

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School-aged Children. Summary of the study. (HBSC 2006). Madrid: Ministerio de Sanidad y Consumo (Ministry of health and consumption). (http://www.msc.es/profesionales/saludPublica/prevPromocion/promocion/saludJovenes/adoles Salud_2006.htm). Moreno, C., Ramos, P., Rivera, F., Muoz-Tinoco, V., Snchez-Queija, I., Granado, M.C. & JimnezIglesias, A. (in press). Resumen del studio (Summary of the study) Health Behaviour in Schoolaged Children (HBSC 2006). Oliva, A., Parra, A. & Snchez, I. (2002). Relaciones con padres e iguales como predoctoras del ajuste emocional y conductual durante la adolescencia. Apuntes de Psicologa, 20, 3-16. (Relations with parents and equals as predictors of emotional and behavioural adjustment during adolescence) Parke, R.D. & Buriel, B. (2006). Socialization in the family: Ethnic and Ecological Perspective. En William Damon (Editor), Richard M. Lerner (Editor), Nancy Eisenberg (Eds.), Handbook of Child Psychology, Volume 3, Social, Emotional, and Personality Development, (5th edition, pp. 10971149). New York: Wiley. Parker, G., Tupling, H. & Brown, L. (1979) A parental bonding instrument. British Journal of Medical Psychology, 52, 1-10 Pedersen, J.M.; Granado, M.C.; Moreno, M.C. & Smith, B. (2004b). Family and Health. In Currie et al. Young peoples Health in Context; Health Behaviour in School-Aged Children: WHO Cross National Study (HBSC), International Report from the 2001/2002 survey. WHO, Copenhagen. Pedersen, J.M; Granado, M.C.; Moreno, M.C. & Smith; R (2004a). Life circumstances of young people: Family. En C. Currie; Ch.. Robert; A. Morgan; R. Smith; W. Settertobulte; O. Samdal; V. Rasmussen (eds.), Young peoples health in context. Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. World Health Organization. Regional Office for Europe (Denmark) Rodrigo, M.J. & Palacios, J. (Eds.) (1998). Familia y desarrollo humano (Family and human development). Madrid: Alianza Editorial. Santrock, J.W. (2003). Infancia. Psicologa del Desarrollo (Infancy. Developmental Psychology). Madrid: MCGraw-Hill Stattin, H & Kerr, M. (2000). Parental monitoring: a reinterpretation. Child Development, 71 (4), 10721085. Steinberg, L. & Silverberg, S. (1986). The vicissitudes of autonomy in early adolescence. Child Development, 57, 841-851. Steinberg, L. (2001). We know some things: Adolescent-parent relationships in retrospect and prospect. Journal of Research on Adolescence, 11, 1-19. Steinberg, L., & Silk, J. S. (2002). Parenting adolescents. In M. H. Bornstein (Ed.), Handbook of parenting. Mahwah, NJ: Lawrence Erlbaum. Steinberg, L., Lamborn, S.D., Darling, N., Mounts, N. & Dornbusch, S.M. (1994). Over-time changes in adjustment and competence among adolescents from authoritative, authoritarian, indulgent and neglectful families. Child Development, 65, 754-770. Steinberg, L., Lamborn, S.D., Dornbusch, S.M. & Darling, N. (1992). Impact of parenting practices on adolescent achievement: authoritative parenting, school involvement and encouragement to succeed. Child Development, 63, 1266-1281. Tood, J.; Smith, R.; Levin, K.; Inchley, J.; Currie, D. & Currie, C. (2007). Family structure and relationships and health among schoolchildren. HBSC Briefing Paper 12. University of Edinburgh, Vol. 15, pp. 69 81 Weinraub, M.; Horvath, D. & Gringla, M. (2002). Single parenthood. In M.H. Bornstein (Ed.), Handbook of parenting. Vol. 3 Being and becoming a parent. London: LEA Zaborskis, A., Zemaitiene, N., Borup, I., Kuntsche, E. & Moreno, C. (2007). Family joint activities in a cross-national perspective. BMC Public Health, 7:94 (30 May 2007).

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II.2.3 School setting


Griebler, R, Dr, W, Samdal, O, Freeman, J, Danielsen, AG, Currie, D, Mager, U, Rasmussen, M

1. Scope and purpose


Childhood and adolescence are crucial periods of the life course with fundamental influences on all developmental aspects of life including health and health behaviours. During these important periods, thousands of hours are spent at school. A supportive school environment may be considered a resource for the development of health-enhancing behaviours, health and life satisfaction, while a non-supportive school environment may constitute a risk. This perspective is supported by numerous empirical findings, which are concentrated around a number of focus areas: satisfaction with school and school connectedness, academic achievement, and school-related stress; although these areas have been studied to varying extents. Within the empirical literature, operationalisations of school satisfaction and school connectedness are often overlapping, indicating that distinct conceptualisations are still unclear. However, the association with health and health behaviours is evident. Several studies find that low school satisfaction or the feeling of not being connected to school is associated with compromising health behaviours related to cigarette smoking, alcohol consumption and marijuana use (e.g., Simons-Morton et al. 1999, Bonny et al. 2000, Samdal et al. 2000, Rasmussen et al. 2005, Bond et al. 2007), with lower self-rated health (e.g., Bonny et al. 2000) and with increased load of somatic and psychological symptoms (e.g., Torsheim et al. 2001, Due et al. 2003, Shochet et al. 2006, Bond et al. 2007, Shochet et al. 2008). An association between low school satisfaction and reduced likelihood of following the advice received from the school health nurse has also been observed (Borup / Holstein 2006). The influence of academic achievement on health and health behaviour is studied less extensively. Longitudinal analyses suggest that high levels of academic achievement predict higher self-rated health (Mechanic et al. 1987). Other studies although cross-sectional support this finding with the possibility that the effect of academic achievement may be mediated through other factors, such as self-esteem and tobacco use (Vingillis et al. 1998). Based on the international HBSC dataset from 2001, high academic achievement was moderately associated with the absence of multiple subjective health complaints, good or
56

II.2 Social contexts of health and health behaviour

excellent self-related health, high life satisfaction and not being a smoker (Ravens-Sieberer et al. 2004, Danielsen et al. 2009). By the use of an alienation measure (including a measure of academic achievement), Nutbeam et al. (1993) found an association between being alienated and being a smoker, drinking alcohol, having experienced drunkenness, and eating unhealthy food. Additionally, an immediate effect on self-esteem and general well-being has been documented (Covington / Beery 1976, Byrne 1984, Hoge et al. 1990, Schunk / Zimmerman 1994, Mortimore 1998, Danielsen et al. 2009). The body of literature on the association between health/health behaviours and schoolrelated stress often operationalised by measures of perceived pressure by school - tends to have consistent findings. In general, it is found that students who experience higher levels of pressure at school are characterized by more compromising health behaviours, by more frequent health complaints (i.e., headache, abdominal pain, backache, dizziness), and by psychological complaints, such as feeling sad, tense and nervous (Samdal et al. 2000, Torsheim / Wold 2001a, Torsheim / Wold 2001b, Torsheim et al. 2001, Gdin et al. 2003, Hjern et al. 2008). High levels of school pressure are also shown to be associated with lower self-reported health, lower life satisfaction and lower levels of well-being (Ravens-Sieberer et al. 2004). Finally, multilevel analyses have shown that school class level of perceived school pressure has an independent effect on higher levels of health complaints beyond that predicted by individual-level perceived school pressure (Torsheim / Wold 2001b). Thus the importance of the school setting for students development of health and health behaviours is evident. Due to the nature of school systems, many health promotion initiatives are implemented within the school setting where most children can be reached. However, most health promotion programmes focus on behaviour-specific interventions aiming at affecting personal factors, such as knowledge, attitudes and self-efficacy, or structural factors, such as availability of services and policies. Rarely have students experiences in terms of school satisfaction, academic achievement and school-related stress been integrated into health promotion programmes. However, the relevance of students school experiences for health and health behaviour is evident, and an integration of these elements with personal and structural factors into future health promotion initiatives may be beneficial. Here, the HBSC has a huge potential to contribute with new and important knowledge. Beyond describing the prevalence of students perceptions and experiences at school, the HBSC provides an outstanding opportunity to study the relationship between students school life and health and health behaviours. Additionally, due to the cross-national design of the study, the HBSC gives the opportunity to study the influence of cross-cultural factors.

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II.2 Social contexts of health and health behaviour

2. Objectives
The objectives of the school package in the HBSC-study are: to describe the prevalence of school factors relevant for health and health behaviours; these are:
-

classroom interactions between students (support, climate, estimation) classroom interactions in the context of teaching between teachers and students (support, autonomy)

individual factors resulting from classroom interactions such as academic achievement, perceived pressure, demands, liking school, and self attributed scholastic competence

to investigate cross-cultural differences in prevalence of school factors to investigate the relations/associations between school factors and students health behaviours, health and well-being. to inform and instruct policy makers in the health and education sector.

3. Theoretical framework
The scientific thinking about the complex interplay between students health and school factors such as school satisfaction, school-life, teaching and learning styles and many more has led to a variety of theories and concepts that have not coalesced into a coherent scientific theory of the subject. In particular, the differences between psychological, sociological and educational perspectives and theorizations rather imply heterogeneous and sometimes competing perspectives than a holistic picture that could guide research and instruct subtle and effective policies. To locate and integrate the different theoretical approaches within an overarching framework the school focus group of the HBSC study has decided to use basic elements of modern Systems Theory, as suggested by the German sociologist Niklas Luhmann (1995, 2006). This framework provides a theoretical underpinning for the drawing together of such diverse concepts as social systems, organisations, interactions, and individual behaviours, perceptions, attitudes, and health and wellbeing. Luhmann differentiates among three types of systems; living, psychic and social, all of which are based on and differentiated by a very special, distinct operational mode: life,

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consciousness and communication. These operational modes are self-referential, meaning that they connect only to themselves: only life produces life, only thoughts produce thoughts, only communication communicates (Luhmann 1995, Maturana / Varela 1989). Thus, systems are closed in an operational sense: no system can operate within the borders of any other system; organisations cannot operate in individual minds and vice versa. However, despite the operational closure of systems, they are open to their environment through observation based on which they construct adaptations and reactions. This openness can only happen in strict accordance with the systems own mode of operation (see Luhmann 1995; Nassehi 2005). This restriction limits and redefines the idea of causality between systems that are no more than irritations for each other and cannot translate a certain intention one-to-one onto another systems reaction. This theoretical premise has wide-reaching consequences, which are of much importance, especially in the field of education (see Dr 2008). The most important consequence is that social systems do not consist of individuals as, for example, bread consists of flour, water, salt and caraway, but is constructed only of communications. Therefore, in full accordance with the modern constructivist learning theory (Foerster 2002), learning as a behavioural or psychological process is under full control of the learning individual and not under the control of the school: it may be irritated, positively influenced or disturbed by the teacher and by the learning environment, but in a very strict sense it is the student who learns - or doesnt.

3.1 Theory of schools as organisations


Trying to understand schools, their function and their impact, forces us to focus on their social reality as organisations. Thinking of schools in this respect may start with two questions: What do they organise? How do they organise? The answer to the first question is: education. Education names the basic function of schools, as reflected in curricula, didactics, teaching and learning styles, schedules, school attendance, and so on. The answer to the second question is: organisations organise by making decisions, meaning that all communications that establish the social system of school, are based on, prepare or execute decisions made by the organisation itself. It should be borne in mind that it is an organisational characteristic of schools that they cannot control all of these conditions completely. This lack of control restricts the autonomy of schools to a larger or smaller degree, depending on each countrys basic educational system. Curricula for example, are usually decided in higher institutions like ministries. More

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importantly the employment of teachers as well as many facets of the school setting, like its infrastructures, ecological conditions, and even the provision of food, are usually not under the financial control of the schools head teacher country specific differences in school systems must, however, be acknowledged. We can state that organised education is the schools primary function. However, the actual realization of organised education takes place in another type of social system, namely interactions, which are defined as communications between present persons teachers and students. These communications are based on the participants mutual perception of their presence (Luhmann 1995). Therefore, didactics and learning theories are not only about contents and communication arrangements and materials, but also have to take into account, and to design, the presence of minds and bodies, meaning that educational interactions have to bring attention to the teacher and the bodies to the seats. In contrast to the audience of operas or at theatres who attend by ones own initiative, the control of students minds and bodies is not unconditionally granted. As a consequence, the reality of schools is not completely defined by educational processes, but much more by relations between persons; in terms of Systems Theory: by socialization, which is not subject to decisions, as socialisation is defined as the inevitable unconscious adaptation of individuals to a social situation (Dr 2008). Again, it is a specific characteristic of schools as compared to companies, that the interactions between individuals play a more important part than the decision-making process on the organisational level. As a result, the academic achievement of students depends to a high degree on their interactions with their teachers, in both dimensions: education and socialisation. The teachers effect on the learning process of students is as much determined by their social competences as by their academic and educational competences. In a similar way, the relations among students themselves, be they supportive or destructive, have a strong impact on a single students learning behaviour and results and on his or her school satisfaction and motivation. Recognising the importance of the socializing effect of interactions, organisations try to influence what is called their organisational culture. This notion comprises both explicit and informal rules and norms, and the bundle of soft factors such as modes of communication, valuation, respect, expression of feelings, and so on. In all organisations, aspects of organisational culture play an important role for the understanding of the quality of processes and outcomes, but in schools this effect is probably even stronger. It is, therefore, more

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relevant for schools to intervene on their own culture by decision and organisational development. Organisational development is one of the basic and most effective strategies of quality management in organisations and comprises interventions into structures and processes, both seen as the only enablers that can improve organisational results (Donabedian 1966, 1980). In the school sector, the most important research in quality so far has been done under the topic of school effectiveness research, giving evidence for the importance of quality dimensions including transformational leadership, democracy, participation, and integration and others (McBeath / Mortimore 2001, Mortimore 1998, Teddlie / Reynolds 2004). Since the HBSC study focuses on students, these dimensions cannot be investigated in a meaningful way. A questionnaire to be administered to head teachers has been developed during previous surveys and will be further developed for the up-coming survey to attempt to measure these higher level dimensions. Just as organisational and interactional factors are important for the academic outcomes of schools, they are even more relevant when we try to understand the schools impact on health and health behaviours of students. In terms of a basic approach, this impact can be conceptualized as the sum of influences of organisational decisions (concerning processes and structures, the latter as far as possible), teaching and learning interactions, and the organisational culture. What is needed, therefore, are theories and concepts that can conceptualize the interplay between social systems organisations and interactions and individuals health and wellbeing, understood as a result of somato-psychological processes in organic and psychic systems (Pelikan 2007). Such concepts as used in HBSC are: the theory of effort-rewardimbalance, the theory of self-determination, the theory of empowerment (as opposed to trivialisation), the theory of organised participation and the theory of quality and effectiveness of teaching (see Figure 1).

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School
structures processes

Classroom interactions
processes

Student
perceptions, attitudes, beliefs academic and psychological outcomes health well-being

achievement goal theory

motivational climate
theory of quality and effectiveness of teaching theory of organized participation

perceived belongingness perceived autonomy perceived competences


theory of self-determination

school engagement academic achievement school pressure


theory of effort-reward imbalance

subjective health mental & physical health complaints lifesatisfaction

classroom management student-centered teaching styles teacher support classmate support


theory of empowerment

student participation

systems theory

Figure 1: Concepts and approaches for investigating the schools impact on students health and wellbeing

3.2 Theory of effort-reward-imbalance


Studies focusing on students academic achievement and their health display significant links between students low academic performances at school and low self-rated health and wellbeing (Danielsen et al. 2009, Huebner et al. 1999, Ravens-Sieberer et al. 2004, Suldo et al. 2006, Vingilis et al. 1998). In addition, some evidence is provided by longitudinal studies that students academic achievement functions as a health predictor (Cole et al. 2001, Kistner et al. 2007, Mechanic / Hansell 1987). From the perspective of the effort-reward imbalance theory, this association is not at all surprising. The effort-reward imbalance theory proposed by Siegrist (1996) is considered to be one of the leading work stress theories in occupational health research (Hintsa et al. 2007). It is based on the sociological hypothesis that formalized social exchange, as mediated through core social roles, is rooted in contracts of reciprocity of cost and gain (van Vegchel 2005). In the case of the workplace, reciprocity depends on a balance between perceived effort spent in terms of psychological and physical job demands and obligations - and rewards received in return - in terms of money, esteem, job security, and/or career development (Siegrist 1996). The theory further postulates that, insofar as effort expended by employees exceeds the rewards they achieve, they will be subjected to higher levels of job strain, with negative consequences to their emotional and physical health. In addition, a striking body of evidence

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proves that an imbalance in terms of high effort and low reward leads to a state of active distress by stimulating neurobiological, psychological, and behavioural pathways (Henry / Stephens 1977) that, in the long term, increases the risk of stress-related mental and physical illness as well as the risk of restricted health assessed by different self-rated health measures (Marmot et al. 2002, Schnall et al. 2000, Siegrist 2002, van Vegchel 2005; Figure 2). As preliminary results demonstrate, this relationship holds true for students health (Dr et al. submitted).

effort
balanced +/- imbalanced

distress

(ill-)health

reward

Figure 2: The effort-reward imbalance model

For the operationalization use optional package 3 and optional package 4 as well as MQ43 and MQ46.

3.3 Theory of self-determination and motivational climate


Self-Determination Theory is a general theory of understanding how intrinsic motivation, growth and well-being develop through conditions that nurture three basic human needs; needs for i) competence (peoples strivings to control outcomes and to experience effectance); ii) relatedness (peoples strivings to relate to and care for others, to feel that those others are relating authentically to ones self, and to feel a satisfying and coherent involvement with the social world more generally); and iii) autonomy (or self-determination, peoples strivings to be agentic, to feel like the origin of their actions, and to have a voice or input in determining their own behaviour (Ryan / Deci 2000). The need for competence is fulfilled by the experience of effectively bringing about desired effects and outcomes. This leads people to seek challenges that are optimal for their capacities. In a school setting it is important that expectations from teachers and parents match the students capability. Then he/she will experience the satisfaction of having the

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resources to meet the challenges of school. The need for relatedness pertains to the feeling that one is close and connected to significant others. To feel belongingness with other individuals as well as with ones community is important as it has strong effects on emotional patterns as well as cognitive processes (Baumeister / Leary 1995) and is found to have an indirect effect on life satisfaction through intrinsic motivation. School plays a central role in addressing the basic need to experience relatedness or belonging. School supportive relations with parents, teachers and peers may increase students school satisfaction and development of initiative and engagement for school work. Student autonomy is related to the extent to which students are allowed to have influence on and take decisions related to the regulations and daily activities in school. Students who perceive that they have high autonomy are more likely to feel that they are important contributors to the daily life in school. This may increase their interest in and adaptation to school (Mortimore 1998), which again may promote their life satisfaction because school satisfaction is an important part of global life satisfaction as school has a direct influence on important issues in students own life (Huebner et al. 1999). Achievement goal theory addressing the relevance of a mastery climate for high performance and learning is also highly in line with the postulated effect of meeting the need for competence for development of life satisfaction (Ames 1992, Dweck 1986, Nicholls 1989) (see Figure 3). This theory aims at understanding the motivational differences in a mastery motivational climate addressing internal motivation through task involvement, and a performance motivational climate stimulating ego involvement (Duda 2001). In a mastery motivational climate the teacher and significant others attribute success to effort, and a students individual improvement is perceived by the student as the most important learning goal. In line with the self-determination theory, a mastery climate is likely to stimulate the students development of internal motivation for schoolwork when a student is self-initiating and persistent because the school-tasks are perceived as interesting or personally important (cf. Reeve et al. 2008).

Experienced Belongingness Mastery Climate Experienced Competence Experienced Autonomy

School satisfaction Health / Life satisfaction

Academic achievement

Figure 3: Mastery climate stimulating basic needs for development of inner motivation and promoting school satisfaction, academic achievement and life satisfaction

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For the operationalization use the optional packages 5 to 7 .

3.4 Theory of empowerment


Empowerment is one of the guiding ideas of the Ottawa-Charter, and is more of a political strategy than a scientifically elaborated concept. Wallerstein (2006) argues that realizations of the concept in diverse settings and targeting to different populations have an independent impact on health. A basic definition of empowerment is given by Rappaport (1987), characterising empowerment as the connecting idea in all interventions into people, organisations or structures that try to increase peoples control over their lives. Rissel (1994) points out that empowerment therefore, refers to three quite different levels: the individual, the organisation, and the financial, legal and political environment of settings, and thus is rather complex or, as one might say, fuzzy. To shape the scientific concept of empowerment, it might be reasonable to focus on the organizational level, as proposed by Dr (2008) building on the theory of non-trivial machines by Heinz von Foerster (2002). Von Foerster criticizes the common educational systems and teaching processes for treating students like trivial machines, comparable to copiers or tape recorders, and describes the non-triviality of human beings as a basic precondition of their learning. As a consequence, teaching styles and methods need to be changed from an instructive teacher-centred to a constructive student-centred manner, as defined in many modern didactics with activating and self-controlled methods (e.g., problembased learning). In this approach empowerment is understood as a quality of organizational processes in schools, especially but not only with regard to teaching and learning, that open up areas for students to experience their self and self-control, and to develop their cognitive, emotional, and social competencies. In order to make effective use of such areas, students will need guidance and support, both from teachers and from classmates, depending on the students prevailing developmental stage. In this sense, social support is an environmental prerequisite for the systemic selfexperience and development. This theoretical shape of the concept of social support is more or less compatible with known and common conceptualisations, but refers to self-control more specifically than these (e.g. Baumeister / Leary 1995). As a facet of empowerment, teacher and classmate support, therefore, are defined as characteristics of the school as an organisation. Other facets are the forms of self-control and autonomy in teaching and learning processes, as

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indicated above, as well as the forms of participation in decision-making processes (see below). For the operationalization use the optional packages 6, 9 and 10 as well as MQ45.

3.5 Theory of organised participation


One of the key features of health-promoting schools is an appropriate arena for students to participate in relevant aspects of decision-making concerning the students life. Participation could be viewed as both a means to and an end of a health-promoting intervention as well as the main constituent of the teaching and learning strategies within democratic health education. The perspective of Rifkin et al. (Rifkin et al. 1988) points to three key characteristics of any activity that qualifies as participation: participation must be active, participation involves choice, and choice must be potentially effective. On the basis of Harts ladder of participation, which sets up procedural democratic criteria for distinguishing participation from nonparticipation (Hart 1992), Simovska differentiates between two qualities of student participation in the school context, namely token (focused solely on information) and genuine participation (inclusion in decision-making) (Simovska 2007). The concept of meaningful participation has its roots in the writing of Habermas (1990) who endorses emancipatory processes of communicative action in which all stakeholders have a voice. Students can exercise participation in a variety of contexts within schools, most notably by influencing both the content and the process of their learning and through involvement in formal school governance processes. For the operationalization use the optional package 9.

3.6 Theory of quality and effectiveness of teaching


According to recent educational theories and in accordance with basic theories on quality (Donabedian 1966, 1980), the overall quality of teaching is seen as a result of at least three different processes (Baumert et al. 2004, Brophy 1999a, Klusmann et al. 2006): a) an effective classroom management, which comprises all actions taken by teachers to ensure order and effective time use during lessons (Brophy 1999b, Doyle 1986),

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b) student-centered and autonomy-promoting teaching styles that challenge students and give them control over their learning processes (Baumert et al., 2004, Dr 2008, p.97), c) a sufficient amount of teacher support - in an emotional and motivational sense - to meet these challenges in a successful way (Baumert et al. 2004), d) and a trustful and respectful relationship.

The components b) and c) are the same as described in the section on empowerment (see above) and can also be seen in connection with the Self-Determination Theory (see chapter 3.3). Additional to these is the concept of effective classroom management (cf. Brophy 1999b, Kunter et al. 2007). It can be characterized by (a) clear rules, regulations and stable routines, (b) enforcement of rules by vigilantly observing classroom happenings and (c) prompt interventions in case of rule violations or other distractions (cf. Emmer / Stough 2001). Furthermore, (component d) trustful and respectful relationships constitute the base of successful teaching and learning processes and are therefore of major importance. Our research model assumes that classroom management, like teaching styles and teacher support, affects students school engagement (cf. Kunter et al. 2007) in a positive way and consequently promotes students academic achievement (Emmer / Stough 2001, Freiberg et al. 1995, Wang et al. 1993) and well-being (Reeve 2005, Danielsen et al. 2009).
classroom management student-centered teaching styles health school engagement academic achievement

teacher support

trustful and respectful relationships

Figure 4: A model on teaching, school engagement, academic achievement and health

For the operationalization use optional packages 6, 7, 8 and 9.

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4. Summary of previous work


Much of the work using HBSC school items to understand health and health behaviours has originated in the Scandinavian countries, particularly Norway and Denmark, with a focus on country-specific data from the 1997/98 survey. Norwegian analyses by Torsheim, Aaroe and Wold (2001) demonstrated that sense of coherence and school-related stress interacts in relation to subjective health complaints during early adolescence. Another study by Torsheim and Wold (2001a) showed that shared psychosocial school class environment (aggregated measures at the class level of student-reported school perceptions) may have main effects on adolescent health complaints. In Denmark, Due et al. (2003) found that poorer relations with teacher and school are associated with worse health. In addition, patterns of parent-child relations with the school are the greatest contributors to socioeconomic differences in physical and psychological symptoms. Further, Rasmussen et al. (2005) documented that high school connectedness is associated with being a non-smoker. Further analyses showed that the association between school connectedness and smoking is moderated by parental smoking norms. Finally, the same data indicate that Danish adolescents were more likely to follow health advice given by school nurses and to discuss that advice with their parents if their school satisfaction was higher (Borup / Holstein 2006). All three studies used 1997/98 data. In contrast, using 2001/02 data, Andersen et al. (2007) showed that among girls exposure to school-related risk factors were more prevalent in lower socioeconomic groups. Poor school satisfaction was associated with drunkenness among girls from high SEP. Among boys from high SEP autonomy was associated with drunkenness, whereas poor school satisfaction was associated with drunkenness among boys from intermediate SEP. Weak parental support and disliking school were associated with drunkenness among boys from low SEP. Work by Samdal (1998) with data from Norway, Finland, Latvia, and Slovakia showed that the predictors of students school satisfaction with school differed from those for academic achievement. With respect to health risk behaviours, low-level student autonomy, high-level student support, low satisfaction with school and unreasonable expectations predicted students smoking and alcohol use. High-level social support from fellow students was the strongest predictor of subjective well-being. These findings have been replicated by Danielsen et al. (2009) using structural equation modelling, with both parental support and classmate support having direct effects on students life satisfaction, and teacher support a substantial indirect effect through school satisfaction (2001/02 Norwegian data; 13 and 15 year olds).

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While the work in Scandinavia has been the most extensive, other country-specific work has been conducted. This work uses the HBSC data to examine the school experience. In the United States, Thompson et al. (2006) found that school connectedness could be explained by student, school, and school neighbourhood characteristics (2001/02 data). In Canada, Volk et al.s (2006) analyses of the 1997/98 Canadian data revealed that greater parental support and better mental health both predicted more positive feelings toward school, over and above that accounted for by age, sex, and socioeconomic status. Vieno et al. (2005) used 2001/02 data from the Veneto region of Italy to examine differences in perceptions of school community at the individual, class, and school levels, with the greatest variation at the individual level. Here the strongest predictor was students perceptions of a democratic school climate. Aggregate class-level and school-level perceptions of a democratic school climate and aggregate school SES were significant additional predictors. Research spanning the entire HBSC network has been limited to date. One of the very first publications was by Nutbeam et al. (1993) who showed that school alienation was associated with smoking and alcohol use for 15 year olds in 13 countries [1989/90 data]. Ravens-Sieberer, Kkyei and Thomas (2004) showed that both perceived academic achievement and liking school are associated with fewer subjective health complaints, good self-rated general health, greater overall life satisfaction and a lower risk of smoking (2001/02 data). Young people who do not feel greatly pressured by schoolwork are much more satisfied with their lives and have fewer subjective health complaints. Social support from peers also seems to influence subjective health. Most recently, Dr et al. (in press) predicted students subjective health in all countries (2005/06 data). Generally, the imbalance between effort and reward tended to increase with age, with older adolescents more likely to report poor returns on their scholastic investment. Furthermore, the students who had higher rewards in combination with lower effort had better mental well-being than other groups, while those students with higher effort and lower rewards had poorer mental well-being.

5. Research questions
1. What are students perceptions of autonomy, belongingness, and competences in school? 2. How do students experience motivational climate, the quality of classroom management, teacher and student support and teaching styles?

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3. How does motivational climate affect students perceived autonomy, belongingness and competences and subsequently their health, health behaviours and life satisfaction? 4. What is the impact of effort-reward imbalance conditions at school on students life satisfaction and risk behaviour? 5. Does empowerment (teacher support, classmate support, empowering teaching styles) influence students school engagement, academic achievement, life satisfaction health and health behaviours? 6. Does participation in school-life have an impact on students well-being, health and health behaviour? 7. How do organizational factors affect the motivational climate, the quality of classroom management, the extent of teacher support and the way students get taught? All research questions have international relevance.

6. Instruments
The 2009/10 HBSC survey contains 6 mandatory items and several optional packages. The mandatory items are described fully below while all optional items are described in the 2009/10 item bank on the HBSC website. The item descriptions below provide a brief re-iteration of the place of each item within the broader theoretical framework detailed above, details of use in previous surveys, any changes to questions over time, the original source of each item and any information on validation and reliability studies carried out. A separate protocol chapter describes the 2009/10 HBSC school-level survey designed to measure data on organisational level of schools (see section II.2.4).

6.1 Mandatory items


6.1.1 School Engagement The extent to which pupils engage with school can be influenced by aspects of the organisation of the school as well as the quality of relationships between students and their teachers and peers. Effective classroom management and teaching styles that are challenging and promote

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autonomy, as well as emotional and motivational support from teachers, are all seen to promote engagement with the school or class. Within the context of self-determination theory being optimally challenged by teachers, having supportive interactions with teachers and peers and feeling that they can influence daily activities will permit students to have their basic needs of autonomy, relatedness and competence satisfied and will consequently result in greater engagement with school. Also students opportunities to participate in school- or classrelated decision making processes as well as effort-reward imbalance conditions influence students school engagement and can therefore lead to adverse or positive health. School engagement is proposed to be measured by a single mandatory item and two optional packages, which can be found in the item bank on the HBSC website. The mandatory item measures students emotional and psychological connectedness to school in terms of liking school. It has been included in the HBSC survey since 1985/86 and has over the years been found to be a powerful correlate of health behaviours and health perceptions (Samdal et al. 1998b, Wold et al. 1994). It has been retained for the 2009/10 survey. Item box 1
MQ44
1 2 3 4

How do you feel about school at present? I like it a lot I like it a bit I dont like it very much I dont like it at all

Source: HBSC 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, 2005/06, 2009/10

Reliability and validity of items Validation work is planned for this item as part of a school-item pilot and validation study carried out in several HBSC regions in spring 2009.

6.1.2 Effort/Demands Within the school setting the job demands placed on students are mostly concerned with their academic performance. Teachers play a vital role in making clear what the demands are, as well as how the student is expected to fulfil these demands. An important element of these demands is the extent to which they match students' capabilities and allow experiences of mastery rather than failure. The perceived level of demand from schoolwork can be seen as measuring effort within the effort-reward imbalance theory. Imbalance, where demands are higher (or lower) than perceived reward, is associated with health-compromising behaviours
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and poorer mental health. Demands on students are measured by a mandatory item which intends to measure the global feeling of being pressured by the demands of schoolwork, which includes work at school and homework and by an optional package presented in the item bank on the HBSC website. Item box 2
MQ46
1 2 3 4

How pressured do you feel by the schoolwork you have to do? Not at all A little Some A lot

Source: HBSC 1993/94, 1997/98, 2001/02, 2005/06, 2009/10

Reliability and validity of items Validation work is planned for this item as part of a school-item pilot and validation study carried out in several HBSC regions in spring 2009.

6.1.3 Academic achievement Academic achievement is a fundamental desired outcome of the school system. Within HBSC, it is students perceptions of their academic achievement that have been the focus, for example within the context of Self-Determination Theory. Perceived academic competence may promote positive feelings about school and a feeling of mastery. Perceived academic achievement has been associated with level of enjoyment in school, self-esteem and wellbeing. In the context of the Effort-Reward Imbalance theory, academic achievement can be seen as measuring reward, with negative consequences when not balanced by the perceived effort students apply to their work. It also reflects students social position within a class which may affect students health and well-being per se. Students academic achievement is measured by one mandatory item: a measure of the students perception of how the teacher evaluates his or her academic performance compared to their class-mates.

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Item box 3
MQ43 In your opinion, what does your class teacher(s) think about your school performance compared to your classmates? Very good Good Average Below average

1 2 3 4

Source: HBSC 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, 2005/06, 2009/10

Reliability and validity of items Validation of the item academic achievement against PISA data will be carried out in 20092010. This group-level validation will include 15 year olds only. In some countries, validation at an individual level may be possible by use of additional data on exact grades of individual pupils.

6.1.4 Student support Interactions between teacher and pupils and between pupils themselves form part of the core process of schools, that of education. For the students, these interactions can provide an opportunity to experience a sense of relatedness or belonging, one of the basic human needs stressed within Self-Determination Theory. Supportive relations with teachers and peers are associated with developing initiative, engagement with school work and decreased stress reactions to effort-reward imbalance. Experience of such supportive environments may contribute to improved academic achievement, increased satisfaction with school and ultimately positive health outcomes such as improved life satisfaction. Within HBSC student support is measured by three mandatory items and additional items that can be found in the item bank on the HBSC website. The three mandatory items on student support have been included in each survey since 1993/94. In the 2001/02 survey the introductory text was revised to specify students and response categories were changed to strongly agree strongly disagree from always never).

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Item box 4
MQ45 Here are some statements about the students in your class(es). Please show how much you agree or disagree with each one. Please tick one box for each line Strongly agree The students in my class(es) enjoy being together. Most of the students in my class(es) are kind and helpful. Other students accept me as I am. Agree Neither agree nor disagree
3

Disagree

Strongly disagree

Source: HBSC 1993/94, 1997/98, 2001/02*, 2005/6*, 2009/10*

*revised text

Reliability and validity of items The classmate support scales were included in validation analyses along with a three-item parental support scale. In the 1993/94 and 1997/98 HBSC surveys (Samdal et al. 1998b, Wold et al. 1994), the three-item scales for each of the three support dimensions were included in the mandatory international questionnaire. In an optional part of the survey, one or two additional items for each of the scales were suggested. Confirmatory factor analyses of the teacher, classmate and parent support showed that a correlated 3-factor model fit the data well, indicating that the division into a teacher, a classmate and a parent support subscale was a valid measurement model (Osen et al. 2000, Torsheim et al. 2000).

Coding Guidelines The items are intended to form a composite scale to measure social support from classmates. A sum-score should be generated from the responses to the three items.

6.2 Optional items


All optional packages listes below can be found in the item bank on the HBSC website. OP1: Academic self efficacy OP2: School engagement OP3: Effort OP4: Reward OP5: Achievement Goal Theory OP6: Competence/autonomy (SDT)

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OP7: Relatedness (SDT) OP8: Classroom management OP9: Participation OP10: Student relations

7. References
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Doyle W. (1986). Classroom organization and management. In M.C. Wittrock (Eds.), Handbook of research on teaching (pp. 392431). New York: Macmillan. Duda JL. (2001). Achievement Goal Research in Sport: Pushing the Boundaries and Clarifying Some Misunderstandings. In: Roberts GC. (Eds.), Advances in Motivation in Sport and Exercise; chapter 5 (129-182). Due P, Lynch J, Holstein B, Modvig J. Socioeconomic health inequalities among a nationally representative sample of Danish adolescents: the role of different types of social relations. J Epidemiol Community Health 2003;57(9):692-698 Dr W (2008): Gesundheitsfrderung in der Schule. Empowerment als systemtheoretisches Konzept und seine empirische Umsetzung, Hans Huber Verlag, Basel. Dr W, Griebler R, Freeman J, Currie D, Rasmussen M, Samdal O, Hansen F (submitted): When students get nothing in return! Effort-reward conditions at school and their linkage to health. Results from the international HBSC-study. Dweck CS. (1986). Motivational processes affecting learning. American Psychologist 1986;41: 1040-1048. Emmer ET, Stough LM. Classroom management: a critical part of educational psychology, with implications for teacher education. Educational Psychologist 2001;36(2):103-112. Foerster H von (2002): Understanding Understanding: Essays on Cybernetics and Cognition. Springer: Berlin. Fraser BJ. Twenty years of classroom climate work: progress and prospect. Journal of Curriculum Studies 1989;21(4):307-27. Freiberg JH, Stein TA, Huang S-y. Effects of a classroom managemant intervention on student achievement in inner-city elementary schools. Educational Research and Evaluation 1995;1(1): 36-66. Gdin KG, Hammarstrm A. Do changes in the psychosocial school environment influence pupils health development? Results from a three-year follow-up study. Scand J Public Health 2003;31(3):169177. Habermas, Jrgen (1990). Moral consciousness and communicative action. Cambridge: Polity Press. Hart, Roger A. (1992). Children's Participation: From tokenism to citizenship. UNICEF ICDC, Florence. (Innocenti Essay) Henry JP, Stephens PM. Stress, health, and the social environment. Berlin, Germany: Springer, 1977. Hintsa T, Kivimki M, Elovainio M, Hintsanen M, Pulkki-Rback L, Keltikangas-Jrvinen L. Preemployment family factors as predictors of effort/reward imbalance in adulthood: A prosoective 18-year follow-up in the Cardiovascular Risk in Young Finns study. Journal of Occupational Environmental Medicine 2007;49:659-666. Hjern A, Alfven G, Ostberg V. School stressors, psychological complaints and psychosomatic pain. Acta Paediatr 2008;97(1):112-117. Hoge, D.R., Smit, E.K., & Hanson, S.L. School experiences predicting changes in self-esteem of sixth- and seventh-grade students. Journal of Educational Psychology 1990;82(1):117-127. Huebner ES, Gilman R, Laughlin JE. A multimethod investigation of the multidimensionality of childrens well-being reports: discriminant validity of life satisfaction and self-esteem. Social Indicators Research 1999;46:122. Judge TA, Watanabe S. Another look at the job satisfaction-life satisfaction relationship. Journal of Applied Psychology 1993;78(6):939-948. Keith KD, Schalock RL. The measurement of quality of life in adolescence: The Quality of Student Life Questionnaire. American Journal of Family Therapy 1994;22(1):83-87. Kistner JA, David-Ferdon CF, Lopez CM, Dunkel SB. Ethnic and Sex Differences in Cildrens Depressive Symptoms. Journal of Clinical Child and Adolescent Psychology 2007;36(2):171-181. Klusmann U, Kunter M, Trautwein U, Baumert J. Lehrerbelastung und Unterrichtsqualitt aus der Perspektive von Lehrenden und Lernenden. Zeitschrift fr Pdagogische Psychologie 2006;20 (3):161173. Kunter M, Baumert J, Kller O. Effective classroom management and the development of subject-related interest. Learning and Instruction 2007;17:494-509.

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Lance CE, Lautenschlager GJ, Sloan CE, Varca PE. A comparison between bottom-up, top-down, and bidirectional models of relationships between global and life facet satisfaction. Journal of Personality 1989;57(3):601-624. Luhmann N (1995). Social Systems. Stanford, CA: Stanford University Press. Luhmann N (2006). System as Difference. Organization, Volume 13(1): 37-57. Marmot MG, Theorell T, Siegrist J. Work and coronary heart disease. In: Stansfeld SA, Marmot, eds. Stress and the heart. London, England: BMJ Books, 2002:50-71. Maturana H, Varela F (1980). Autopoiesis and Cognition: The Realization of the Living. Springer:Berlin. McBeath J, Mortimore B. (Hg.) (2001). Improving school effectiveness, Buckingham and Philadelphia: Open University Press. Mechanic D, Hansell S. Adolescent competence, psychological well-being, and self-assessed physical health. Journal of Health and Social Behavior 1987;28:364-374. Mortimore P. (1998). The Road to Improvement: Reflections on school effectiveness, Lisse: Swets & Zeitlinger Publishers. Nassehi A. Organizations as decision machines: Niklas Luhmanns theory of organized social systems. Sociological Review 2005;53:178-191. Nicholls JG. (1989). The competitive ethos and democratic education. Cambridge, MA: Harvard University Press Nutbeam D, Smith C, Moore L, Bauman A. Warning! Schools can damage your health : Alienation from school and its impact on health behaviour. Journal of Paediatrics and Child Health 1993;29(Suppl. 1):25-30. Osen EM, Torsheim T, Wold B. Skolerelatert sttte som moderator av kjnnsforskjeller i subjektive helseplager hos norsk skoleungdom (Norwegian). (School-related support moderating gender differences in subjective health complaints in Norwegian students). Tidsskrift for Norsk Psykologforening (Journal of Norwegian Federation of Psychologists 2000), 37, 900-907. Pelikan, Jrgen M. (2007) Understanding Differentiation of Health in Late Modernity - by use of sociological system theory. In: McQueen, David V., Kickbusch, Ilona S. [Eds.]: Health and Modernity: The Role of Theory in Health Promotion, pp. 74-102. New York: Springer. Rappaport J. Terms of Empowerment/Exemplars of Prevention: Toward a Theory for Community Psychology. In: American Journal of Community Psychology 1987;15(2):121-148. Rasmussen M, Damsgaard MT, Holstein BE, Poulsen LH, Due P. School connectedness and daily smoking among boys and girls: the influence of parental smoking norms. European Journal of Public Health 2005,15:607-612. Ravens-Sieberer U, Kokonyei G, Thomas C. School and health. In: Currie C, Roberts C, Morgan A, et al., eds. Young peoples health in context: international report from the HBSC 2001/02 survey. WHO policy series: health policy for children and adolescents. Issue 4. Copenhagen: WHO Regional Office for Europe, 2004. Reeve J. (2002). Self-determination theory applied to educational settings. In E. L. Deci & R. M. Ryan (Eds.), Handbook of self-determination research (pp. 183-203). Rochester, N.Y.: University of Rochester Press. Reeve, J. (2005). Understanding motivation and emotion. Hoboken: Wiley. Reeve J, Ryan R, Deci EL, Jang H. (2008). Understanding and Promoting Autonomous Self-Regulation: A Self-Determination Theory Perspective. In: D. H. Schunk & B. J. Zimmerman (Eds.), Motivation and Self-Regulated Learning. Lawrence Erlbaum Associates, New York. Rifkin, SB, Muller F, Bichmann W. Primary health care: on measuring participation. In: Social Science & Medicine 1988;26(9):931-940. Rissel C. Empowerment: the holy grail of health promotion? In: Health Promotion International, 1994;9(1):39-47. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development and life satisfaction. American Psychologist 2000;55(1):68-78.

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Samdal O. (1998): The school environment as a resource or risk for students health-related behaviours and subjective well-being. Thesis submitted in partial fulfilment for the requirements for the degree of Doctor of Philosophy. Samdal O, Nutbeam D, Wold B, Kannas L. Achieving health and educational goals through schools: A study of the importance of school climate and students' satisfaction with school. Health Education Research 1998a;13(3):383-397. Samdal O, Wold B, Torsheim T. (1998b). Rationale for school items: The relationship between students perception of school and their reported health and quality of life. In: Currie,C: Health Behaviour in School-aged Children. Research protocol for the 1997-98 Survey, pp. 51-59 + 73-79. Samdal O, Wold B, Bronis M. The relationship between students perceptions of the school environment, their satisfaction with school and perceived academic achievement: an international study. School Effectiveness and School Improvement 1999;10(3):296-320. Samdal O, Wold B, Klepp KI, Kannas L. Students' perception of school and their smoking and alcohol use : A cross-national study. Addiction Research 2000;8(2):141-67. Schnall P, Belkic K, Landsbergis P, et al. The workplace and cardiovascular disease. Occupational Medicine State of the Art Reviews. Philadelphia, Pennsylvania: Hanley and Belfus, 2000. Schunk DH, Zimmerman BJ. (1994). Self-regulation of learning and performance : Issues and educational applications. Hillsdale: Lawrence Erlbaum Associates. Shochet IM, Dadds MR, Ham D, Montague R. School connectedness is an underemphasised parameter in adolescent mental health: results of a community prediction study. J Clin Child Adolesc Psychol 2006;35(2):170-9. Shochet IM, Homel R, Cockshaw WD, Montgomery DT. How do school connectedness and attachment to parents interrelate in predicting adolescent depressive symptoms? J Clin Child Adolsc Psychol 2008;37(3):676-81. Siegrist J. Effortreward imbalance at work and health. In: Perrowe PL, Ganster DC, eds. Historical and current perspectives on stress and health. Amsterdam, Holland: JAI Elsevier, 2002:261-291. Siegrist, J. Adverse health effects of high-effort/low-reward conditions. Journal of Occupational Health Psychology 1996;1:27-41. Simons-Morton BG, Crump AD, Haynie DL, Saylor KE. Student-school bonding and adolescent problem behaviour. Health Educ Res 1999;14(1):99-107. Simovska, V. The changing meanings of participation in school-based health education and health promotion: the participants' voices. Health Education Research 2007;22(6):864-878. Spector PE. (1997). Job satisfaction : Application, assessment, causes, and consequences. Thousand Oaks: SAGE Publications. Suldo SM, Riley KN, Shaffer EJ. Academic correlates of children and adolescents life satisfaction. School Psychology International 2006;27(5):567582. Teddlie C, Reynolds D. (2004). The International Handbook of School Effectiveness Ressearch, London, New York: Falmer Press. Thompson DR, Iachan R, Overpeck M, Ross JG, Gross LA. School Connectedness in the Health Behavior in School-Aged Children Study: The Role of Student, School, and School Neighborhood Characteristics. Journal of School Health 2006;76(7):379-386 Torsheim T, Aaroe LE, Wold B. School-related stress, social support, and distress: Prospective analysis of reciprocal and multi-level relationships. Scandinavian Journal of Psychology 2003;44(2):153-159. Torsheim T, Wold B. School-related stress, support, and subjective health complaints among early adolescents: a multilevel approach. Journal of Adolescence 2001a;24(6):701-713. Torsheim T, Wold B. School-related stress, school support, and somatic complaints: A general population study. Journal of Adolescent Research 2001b;16(3):293-303. Torsheim T, Aaroe LE, Wold B. Sense of coherence and school-related stress as predictors of subjective health complaints in early adolescence: interactive, indirect or direct relationships? Social Science & Medicine 2001; 53:603-614.

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Torsheim,T., Wold,B., Samdal,O. (2000): The teacher and classmate support scale: Factor structure, test-retest reliability and validity in samples of 13 and 15 year-old adolescents. School Psychology International, 21(2), 195-212. van Vegchel N. Two models at work. A study of interactions and specificity in relation to the DemandControl Model and the Effort-Reward Imbalance Model. PhD Thesis. Utrecht: Utrecht University, 2005. Vieno A, Perkins DD, Smith TM& Santinello M. Democratic School Climate and Sense of Community in School: A Multilevel Analysis. American Journal of Community Psychology 2005;36:327-341. Vieno A, Santinello M, Galbiati E, Mirandola M. School Climate and Well Being in Early Adolescence: A Comprehensive Model. European Journal of School Psychology 2004;2:219-237. Vingilis E, Wade TJ, Adlaf E. What factors predicts student self-rated health? Journal of Adolescence 1998;21:88-97. Volk A, Craig W, Boyce W, King M. Perceptions of parents, mental health and school among Canadian adolescents from the provinces and the northern territories. Canadian Journal of School Psychology 2006;21:33-47. Walberg HJ, Paik SJ. (2000). Effective educational practices, Vol. 3. Geneva, Switzerland: International Academy of Education/International Bureau of Education. Wallerstein N. (2006): What is the evidence on effectiveness of empowerment to improve health? WHO Regional Office for Europe (Health Evidence Network) report, Copenhagen. Wang MC, Haertel GD, Walberg HJ. Toward a knowledge base for school learning. Review of Educational Research 1993;63(3):249-294. Wold B, Aar LE, Smith C. (1994). Health Behaviour in School-Aged Children. A WHO Cross-National Survey. (HBSC): Research protocol for the 1993/94 study. Bergen: University of Bergen, Research Center for Health Promotion.

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II.2.4 School-level questionnaire


Mager, U, Griebler, R, Dr, W, Samdal, O, Maes, L, Haug, E and the HBSC school focus group

1. Scope and purpose


The importance of supportive environments or settings for peoples health is strongly emphasized by health sciences, at least since the Ottawa Charter for health promotion, which states that: Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love (WHO 1986). School is one of these crucial settings, with school having an influence on students health and health behaviour (described in detail in section II.2.3) and, at the same time, being one of the most promising settings for health promotion interventions (Booth et al. 2001). The notion of settings in the Ottawa Charter remains quite unspecified and is in need of elaboration in scientific research. Theoretical elements to the setting concept, especially the difference between health promotion in settings vs. health promoting settings were first introduced by Leo Baric (Baric 1993) and are of enduring importance. This difference distinguishes between measures that implement health promotion into settings as an addition vs. health promotion measures that touch upon the basic organisational processes and structures. For this differentiation the terms add-on health promotion and add-in health promotion have been adopted by the scientific community. Since the add-in health promotion is less understood to date, a focus on this type of health promotion may be more important from a research perspective. As described in the chapter on school as a setting (see section II.2.3) one needs to distinguish among organisational factors, interactional or interpersonal factors (classroom level) and individual factors to investigate the impact of the school setting and school health promotion on students health and health behaviour. Whereas data on classroom and individual factors are collected by the student survey, complementary information at an organisational level can be collected by a school-level questionnaire. These data will help to distinguish schools in terms of organisational factors (e.g. nature of the physical environment, existence of quality management systems, opportunities for student participation, existence of specific health promotion structures) and in terms of health promotion measures, thus explaining differences in students health and health behaviour.

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Through its data collection procedures (sampling whole classes within schools) the HBSC study offers a rich potential for studying how the school setting affects students health and health behaviour by applying multilevel techniques. Until now organisational factors and school health promotion measures have received little attention within the HBSC study. Although a school-level questionnaire was introduced in the 2005/06 survey, few countries used it and it was rather limited in the topics covered. Thus a comprehensively revised school-level questionnaire has been developed.

2. Objectives
The objectives of the HBSC school-level questionnaire are: to describe schools specific health promotion structures and measures, to describe schools according to their general organisational factors relevant for health and health promotion, and to analyze how organisational factors and specific health promoting structures and measures are associated with students health behaviours, health and life satisfaction.

3. Theoretical framework
Within public health there is an increasing awareness that organisational factors are important determinants of population health. Although many of the main determinants of health can be viewed as individual factors (e.g. behaviours and lifestyles), societal conditions may act to reinforce the maintenance and expression of such factors and consequently may indirectly influence students health (for further details see section II.5); societal conditions can also have a direct influence on health and health behaviours by themselves. Thus, it is a key priority in public health research to examine the links between organisational and individual factors when aiming to understand health and health behaviours (Subramanian et al. 2003). This line of reasoning builds on an ecological approach that has become a prominent theoretical framework to better understand factors influencing health behaviours during the past decades. Such ecological models simultaneously investigate individual or intrapersonal, interactional or interpersonal, organisational, and societal factors as well as their cross-level interaction effects (Sallis / Owen 2001). The relationship between individual and

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environmental factors is assumed to be transactional in nature and characterised by recurring cycles of reciprocal influence between an individual and his or her surroundings (King et al. 2002). A more complex but very similar approach to conceptualise the interaction between an individual and his or her environment stems from modern systems theory, described in detail in section II.2.3. Building upon the ecological approach, modern systems theory (a) distinguishes between living and psychic systems on the individual level and differentiates between social and physical environments, (b) redefines the idea of causality between systems stating that the connections between systems are no more than irritations for each other, and (c) differentiates between structures and processes at the system level (for further details see section II.5). For the scientific observation of schools as organisations it is of utmost importance to develop a better understanding of structures and processes in schools. According to organisational theories (e.g. Drucker 1990, Mintzberg 1979, 1996, Senge 1994, 1999) we differentiate between structures (e.g. school policies) and processes of leadership and management and structures and processes of the organisational performance. This differentiation discriminates between decision-making processes on the one side and their realisation in core and support processes on the other. In schools, core processes are defined as teaching and learning processes, while support processes and structures comprise all other areas of school life (e.g. hygiene, breaks, food, physical environment, behaviour on school grounds, etc.).

4. Summary of previous work


Previous research within the HBSC study indicates that organisational factors can have an influence on students health and health behaviour. For example, young peoples diet can be affected in that school food policies and the actual availability of food items at school can make a difference in the consumption of less healthy foods (Vereecken et al. 2005). The HBSC study has further identified that both the physical environmental characteristics of schools (e.g. facilities for physical activity) and their written policy in the area can contribute to students daily physical activity at school (Haug et al. 2008; Haug et al. in press). Moreover, health promotion measures or activities that affect organisational factors can have an influence on students health and health behaviour. The HBSC satellite study, Control Adolescent Smoking (CAS), for example, showed that school policies and practices had a unique contribution to explaining differences in students smoking (Wold et al. 2004). Another

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study has shown that school smoking bans are associated with a lower risk of student smoking behaviour when rules are formulated clearly and are well communicated to the students (Maes / Lievens 2003).

5. Research questions
Based on the core part and the optional packages of the HBSC school-level questionnaire (see chapter 6) the following research questions address the influence of school organisational factors on students health/risk behaviours, their health and life satisfaction. 1. CORE part How do students health behaviours, health and life satisfaction differ by school characteristics? 2. OP1 Physical and social environment: What is the impact of schools physical and social environments on students health behaviours, health and life satisfaction? 3. OP2 Participation: What is the impact of student participation in school decision-making processes on students health behaviours, health and life satisfaction? 4. OP3 Quality management: To what extent does the existence of quality management activities help to explain differences in students perceptions of school and hence their health behaviours, health and life satisfaction? 5. OP4 Health promotion: What is the impact of school health promotion policies and practices (e.g. existence of a health promotion team) on students health behaviours, health and life satisfaction? 6. OP5 Nutrition: What is the impact of school nutrition policies, health promotion measures, school facilities and availability of foods and drinks on students eating behaviour? 7. OP6 Physical activity: What is the impact of school physical activity policies, health promotion measures, school facilities and possibilities for physical activity on students physical activity behaviour? 8. OP7 Violence/bullying: What is the impact of school policies and rules, rule enforcement and health promotion measures on students fighting and bullying behaviour? 9. OP8 Smoking and alcohol: What is the impact of smoking and alcohol rules, the enforcement of these rules and health promotion measures on students smoking and alcohol habits?
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6. Instrument
The HBSC school-level questionnaire has been developed under the lead of the HBSC school focus group. In the process of developing the questionnaire, areas of interest of HBSC focus groups and principal investigators were collected. On this basis a comprehensive draft was developed and possibility for feedback was provided. The school-level questionnaires of the previous HBSC cycle were considered and an extensive search for other survey instruments was carried out. Some items were adapted from PISA, former HBSC school-level questionnaires, and other instruments, while some questions were derived from WHO documents, NICE (National Institute for Health and Clinical Excellence (UK)) guidelines and reviews on different topics (see Table 1). At that point feedback of principal investigators and focus groups related to the topics covered by the questionnaire was incorporated. Additionally, qualitative testing for comprehensibility and applicability was carried out with a sample of head teachers from different school types in Austria.

Table 1: References used for development of the school-level questionnaire. Abbreviation AHSEP Student survey 2006 Dobbins et al. 2009 Reference Adolescent Health and Social Environments Program, Student survey, Australia, 2006 Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6-18 (Review). The Cochrane Library 2009, Issue 1 Early Childhood Longitudinal Study, Administrator questionnaire, USA, 2004 Education Longitudinal Study, Administrator questionnaire, USA, 2002 Evaluation der Schulservicestellen der Gebietskrankenkassen, Fragebogen fr Schulleiterinnen und Schulleiter, Ludwig Boltzmann Institute Health Promotion Research, Austria, 2007 HBSC School-level questionnaire 2005/06 HBSC School-level questionnaire ,Canada, 2005/06 HBSC School-level questionnaire, Scotland, 2005/06 HBSC School-level questionnaire, USA, 2009/10 Brgger G and Posse (2007). Instrumente fr die Qualittsentwicklung und Evaluation in Schulen (IQES): Wie Schulen durch eine integrierte Gesundheits- und Qualittsfrderung besser werden knnen. Band 2: Vierzig Qualittsbereiche mit Umsetzungsideen. Netzwerk Bildung und

ECLS Administrator Questionnaire 2004 ELS Administrator questionnaire 2002 Evaluation SSS LBIHPR 2007 HBSC SLQ 2005/06 HBSC SLQ Canada 2005/06 HBSC SLQ Scotland 2005/06 HBSC SLQ USA 2009/10 IQES 2007

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Gesundheit, Switzerland. Monshouwer et al. 2007 Monshouwer K, van Dorsselaer S, Van Os J, Drukker M, de Graaf R, Ter Bogt T, Verdurmen J, and Vollebergh W (2007). Ethnic composition of schools affects episodic heavy drinking only in ethnic-minority students. Addiction 102(5), 722-729. National Educational Longitudinal Study, USA, 1988

NELS 1988

NICE PH guidance 17 2009 National Institute for Health and Clinical Excellence Public Health guidance 17: Promoting physical activity, active play and sport for pre-school and school-age children and young people in family, pre-school, school and community settings, UK, 2009 NICE PH guidance 7 PISA Austria School questionnaire 2006 National Institute for Health and Clinical Excellence Public Health guidance 7 on school-based alcohol interventions, UK, 2007 Programme for International Student Assessment, School questionnaire, Austria, 2006

PISA School questionnaire Programme for International Student Assessment, School questionnaire, 2003 2003 QS Gesunde Schule LBIHPR 2008 SHPPS 2008 SNHPS 2002 SSOCS Principal questionnaire 2008 Story et al. 2008 Qualittsstandards Gesunde Schule, Ludwig Boltzmann Institute Health Promotion Research, Austria, 2008 School Health Policies and Programs Study, School Policy and Environment School Questionnaire, Austria, 2008 Swiss Network of Health Promoting Schools, Radialprofil, Switzerland, 2002 School survey on crime and safety, Principal questionnaire, USA, 2008 Story M, Kaphingst KM, Robinson-O'Brien R, and Glanz K (2008). Creating healthy food and eating environments: Policy and environmental approaches. Annual Review of Public Health 29, 253-272. Totten, Quigley & Morgan. Administrator Anti-Bullying/Harassment Program Survey, Canadian Public Health Association and the National Crime Prevention Strategy, 2004 WHO school policy framework, Implementation of the WHO Global Strategy on diet, physical activity and health, 2008 Wiener Netzwerk Gesundheitsfrdernde Schulen, Ludwig Boltzmann Institute Health Promotion Research, Austria, 2008

Totten et al. 2004

WHO school policy framework 2008 WieNGS LBIHPR 2008

Following the structure of the HBSC student questionnaire, the HBSC school-level questionnaire is divided into two parts: a short core part, which is compulsory for all countries that choose to use the school-level questionnaire, and a set of optional packages from which each country can choose according to its specific interest areas (see Figure 1). Both for the core part and the optional packages, it is highly recommended that countries use a complete package and not just single items; alternatively single items can be used for national questionnaires.

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In connection with the Schools for Health in Europe (SHE) network and its project on Healthy Eating and Physical activity for Schools in Europe (HEPS) the newly developed school-level questionnaire offers a range of indicators to investigate cross-national differences in school health promotion structures and measures as well as the influence of these on students health and health behaviour. The complete questionnaire is attached in the appendix.

Core part Basic school characteristics 9 items

OP1 E OP2 P Physical and Participation social environment 10 items 5 items

OP3 Q Quality management 5 items

OP4 H Health promotion 15 items

OP5 N Nutrition

OP6 PA Physical activity 14 items

OP7 V Violence/ Bullying 10 items

OP8 SA Smoking and alcohol 14 items

16 items

Figure 1: Overview of the school-level questionnaire

Content of HBSC school-level questionnaire In the following chapter the content of the HBSC school-level questionnaire is outlined. In the core part the HBSC school-level questionnaire addresses basic characteristics of schools. The questions in the core part provide background data on: school type, school location, number of students and teachers (to calculate a student-teacher-ratio), gender composition for both students and teachers, number of classes (to calculate the mean number of students per class) and ethnic minority or migration background (to study the social intermix, which may be associated with conflicts and tension between social groups). This compositional information can be relevant when studying how within- and between-country differences of the school impact on students health and health behaviour. Additionally, there are 8 optional packages on the following topics: OP1 Physical and social environment: This optional package includes questions on the condition of schools physical environment, problem areas and estimation of the school climate.

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OP2 Participation: This optional package includes items on student and parent participation, areas of participation, formal structures for participation and actual participation practices. OP3 Quality management: This optional package includes items that try to assess if schools are routinely engaged in quality management and development activities following the wellknown PDCA quality management cycle. OP4 Health promotion: This optional package comprises questions on school policy, aims for health promotion, further education of school personnel, existence and composition of a health promotion team and resources for health promotion. In the following optional packages, OP5 to OP8, items on policies or rules and enforcement of these policies or rules are included because putting explicit policies in place is vital to implementing effective school health programmes and ensuring their long-term sustainability (CDC 1997, Schmid 1995). Reinforcement of policies can be effective in influencing students behaviour. The optional packages OP5 to OP8 also include questions on further education of school personnel, integration of the specific topics into the curriculum, specific health promotion measures and procedures for informing students, parents and teachers about policies and rules. OP5 Nutrition: This optional package additionally includes questions on facilities and availability of food products and drinks, since availability can be influential on the choices the students take, and thus will be of importance when trying to promote healthy food habits. OP6 Physical activity: This optional package additionally includes questions on facilities for physical activity that are available for students and opportunities for students to engage in curricular and extracurricular physical activities, since it has been shown that both types of activities can have an effect on the physical activity habits of students. OP7 Violence/bullying: This optional package additionally includes questions on peermediation and problem handling. OP8 Smoking and alcohol: This optional package additionally includes a question on problem handling.

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7. References
Baric L (1993). The settings approach - implications for policy and strategy. Journal of the Institute of Health Education, 31 17-24. Booth SL, Sallis JF, Ritenbaugh C, Hill JO, Birch LL, Frank LD, et al. (2001). Environmental and societal factors affect food choice and physical activity: rationale, influences, and leverage points. Nutr Rev, 59(3 Pt 2), S21-39; discussion S57-65. Centers for Disease Control and Prevention (CDC) (1997). Guidelines for school health programmes to promote lifelong eating. Journal of School Health, 67, 9-26. Drucker PF (1990). Managing the nonprofit organization. Principles and Practices. New York: Harper Collins Publishers. Haug E, Torsheim T, and Samdal O (2008): Physical environmental characteristics and individual interests as correlates of physical activity in Norwegian secondary schools: The health behaviour in school-aged children study. International Journal of Behavioral Nutrition and Physical Activity, 5(47). Haug E, Torsheim T, and Samdal O (in press). Local school policies and practices associated with physical activity in secondary school. Health Promotion International. King AC, Stokols D, Talen E, Brassington GS, and Killingsworth R. (2002). Theoretical approaches to the promotion of physical activity: forging a transdisciplinary paradigm. American Journal of Preventive Medicine, 23(2 Suppl): 15-25. Maes L, Lievens J (2003). Can the school make a difference? A multilevel analysis of adolescent risk and health behaviour. Social Science & Medicine, 56(3): 517-529. Mintzberg H (1979). The Structuring of Organizations. New Jersey: Prentice-Hall. Mintzberg H (1996). The Five Basic Parts of the Organization. In Shafritz J, and Ott S. (Eds.), Classics of Organization Theory (pp.232-244). New York: Harcourt Brace College Publishers. Sallis JF, and Owen N. (2001). Ecological models of Health Behaviour. In Glanz K, Lewis FM, and Rimer BK (Eds.), Health behaviour and health education: theory, research and practice. San Francisco: Jossey-Bass. pp. 403-424. Schmid TL, Pratt M, and Howze E (1995). Policy as intervention: environmental and policy approaches to the prevention of cardiovascular disease. American Journal of Public Health 85(9): 1207-11. Senge PM, Ross R, Smith B (1994). The fifth discipline. Fieldbook. Strategies and tools for building a learning organization. New York/London/Toronto/Sydney/Auckland. Senge PM, Kleiner A, Roberts C, Ross R, Roth G, Smith B. (1999). The Dance of Change: The Challenges of Sustaining Momentum in Learning Organizations. A Fifth Discipline Resource. London: Nicholas Brealey Publishing. Subramanian SV, Jones K, and Duncan C (2003): Multilevel methods for public health research. In: Kawachi, I and Berkman, LF (eds): Neighborhoods and Health. New York: Oxford University Press. Vereecken CA, Bobelijn K, and Maes L (2005). School food policy at primary and secondary schools in Belgium-Flanders: does it influence young people's food habits? European Journal of Clinical Nutrition, 59(2): 271-277. Wold B, Torsheim T, Currie C, and Roberts C (2004). National and school policies on restrictions of teacher smoking: a multilevel analysis of student exposure to teacher smoking in seven European countries. Health Education Research, 19(3), 217-226. World Health Organisation (WHO) (1986). Ottawa Charter for Health Promotion. Geneva.

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II.2.5 Peer culture


Matos, M G, Van der Sluijs, W, Queija, I S, Tinoco, V M, Tom, G, Ferreira, M, Gaspar, T, Simes, C ,Ter Bogt, T, Lenzi, M, Leversen, I,Hansen, F, Kuntsche, E & the Peer Culture Focus Group

1. Scope and purpose


Adolescence is a time when peer relations become more intense and extensive. With altering family relationships, the adolescent begins to discover many new demands and expectations in social situations. For example, he/she may begin dating, spending time with different groups of friends without adult supervision, etcetera. What is more, peers become crucial in helping each other to define their identities and develop personal and social competences (Prez et al.2007). Furthermore, the dichotomy good peers and bad peers needs to be overcome. After all, a more in-depth insight is necessary in order to understand under what conditions peers can have a healthy or unhealthy influence (Sussman et al. 2007). On the other hand, the effect of having no friends at all needs to be explored (Lande 2007). For instance, Tom et al. (2008) associated having no friends with an increase in substance abuse in adolescents. It is critically important to capture and analyze the changing perceptions and experiences of young people as well as the complexity of the transitions they go through. Further research is needed in order to understand these mechanisms and processes of the peer role and how peers promote change in adolescents attitudes and behaviour, and whether this means risk-taking or health protection. An in-depth understanding would be of major importance regarding the definition of health promotion strategies as well as strategies to prevent health compromising behaviours in adolescents. Furthermore, it is extremely important to investigate the importance of peer and family relationships simultaneously, examining the degree to which they are concurrent or competitive in youths development (Corsano et al. 2006). To fully understand peer influence it is not enough to only examine the number of friends a person has and the contact frequency with their friends, but the role of sharing activities with friends must also be taken into consideration. Carrying out different types of activities, in fact, can not only influence the personal well-being of the people involved in these activities, but also shape social norms that are accepted inside the group, creating a culture shared by the members. Taking part in structured activities (for instance, practicing sport, participating in

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cultural activities or volunteering) with ones friends, for example, fosters the learning of important pro-social competences derived by the collaboration of reaching the same objective, such as helping and supporting disadvantaged people, appreciating different cultural backgrounds and developing the belief of being important in the community (Hansen et al. 2003). Sharing these kinds of activity with friends contributes to developing a set of shared norms and values that determines what is considered good inside a specific group of friends and what is better to avoid as part of this group. These processes are crucial in adolescence, when boys and girls are shaping their identity, starting from the system of beliefs and values created and shared inside the group. Also unstructured activities, such as listening to different kinds of music together, going for a walk or hanging out with friends, could be a vehicle of norms and values shared inside the group, determining which are the behaviours appreciated or discouraged. Values and norms created during the interactions with ones friends could be very different, depending on the specific activities carried out, but they may continue to be important for adolescents definitions of identity (Graziani et al. 2007). Moreover, besides taking part in activities with friends, including activities and behaviours carried out by each member of a group can strongly impact norms and values shared in the group. The most common behaviours in a specific group, in fact, shape values and norms that characterize the peer culture in it. Another crucial aspect of peer relationships concerns communication: the emerging challenges of the new technologies of communication and leisure have become extraordinarily important in adolescents social life. The impact of these technologies on adolescent health has to be clarified, because their influences are not always the same. Some seem to favour youths communication while others favour loneliness and social withdrawal. Some of these new technologies appear to provide a new format to previously identified problems (e.g. cyber-bullying). Finally, it is crucial to state how adolescents social life and perceptions of belonging can be related to health as well as to the perception of well-being and quality of life (Lande 2007). In a literature review, Matos (2005) presented several studies linking social competence with the ability to initiate and maintain social relationships with peers, and to well-being during adolescence. Some of the features related to social competence identified in the studies included in this review are: social understanding, problem-solving skills, empathy, identification and management of emotions and self-assertion. The author identifies three interactive styles: passive/withdrawal, aggressive/anti-social and assertive/pro-social which take shape during social development, first within, the family and then with peers

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(assertiveness being defined as the way to regulate social encounters, being able to express and defend oneself, and allowing the same rights to others). A great deal of previously reviewed work (Hartup 1992, Bender / Loser 1997) claimed that social isolation during childhood and adolescence has a devastating effect on well-being and tends to be a social status which is hard to change. The reason pointed out for this is that isolated children go on missing peers lives altogether: i.e. activities, challenges, support, rule management, decisions; the initial social isolation tends to increase and social skills have no opportunity to be developed. In a study with a broad contextual scope such as HBSC, questions on peer relationships can be used by other conceptual groups if not as an outcome, then as a predictor, meaning that having good peer relationships can be considered a health/well-being indicator (Kerr et al. 2003). Recent research highlights the importance of young people's participation in the identification of key issues in their social life and culture; therefore we included contributions from adolescent focus groups.

2. Objectives
The aim of this chapter is the improvement of the attention paid to peer culture and the development of sensible instruments with which to better understand the social lives of adolescents. The way young people perceive themselves within their own culture, their ways of being and functioning, and the study of their dynamic and trends are crucial.

3. Theoretical framework
From a Social Learning Theory point of view, peer relations provide an advantageous context in which skills can be learned relating to empathic capacity, the adoption of others perspective, communication, cooperation, and the management and resolution of conflicts (Hartup 1992). Children with no friends have fewer opportunities to learn social skills and their difficulties in relating to others can often perpetuate their isolation; friendship provides a supportive context for self-exploration and emotional growth (Bender / Loser 1997). The Social Information-Processing Model highlights possible problems in social learning and social behaviour due to bias in social perception (input), bias in information processing

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(processing) and bias in social behaviour (output). These biases can make social interaction more difficult in children and adolescents. From an Attachment Theory point of view, the characteristics and quality of early bonding with caregivers can facilitate secure relationships in the future (Soares 2007). Allen et al. (1998). This showed that adolescents with secure attachments are more socially competent when dealing with their peers. Friendship helps with adjustment to new situations and in facing stressful life experiences; it also predicts success in future relationships and is associated with happiness. There are a lot of empirical data on the importance and effect of peer relationships and friendship in relation to health, well-being, the perception of quality of life, school adjustment and happiness (Rubin et al. 2008). Hartup (1992) has long argued that the best child predictor for adult adjustment is not the intelligence, the schooling, or the behaviour in class, but the ability to relate to others.

3.1 Peer group and family ties


In some studies, peers are presented as a family substitute in cases where the family lacks consistency, adequate role modelling, monitoring, caring, etc. (Gauze et al. 1996). In other studies, family and peers complement each other (Meeus et al. 1996). An optimal social development during adolescence is facilitated by a continuing healthy attachment to ones parents, as well as by increasing healthy attachments to specific peers (Oliva et al. 2002). While the parent-child relationship offers the adolescent essential guidance and a secure base to explore his/her identity and the complexities of the adult world, peer relationships provide the developing adolescent with the opportunity to explore his/her potential as an autonomous, independently thinking and acting individual. Peers are likely to provide the adolescent with more opportunities for autonomous control than parent-child relationships. However, in early adolescence both types of relationship are needed as they offer different kinds of social relations critical for the childs healthy development (Dorius et al. 2004). The stage-environment perspective suggests that there is likely to be a curvilinear relationship between the amount of parental control and peer orientation. Both a lack of opportunities for autonomy and an excessive amount of autonomy without emotional support and guidance can result in a greater attachment to peers than to parents (Field 2002).

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3.2 Peer group


Although peer groups are important at all ages, friendship during adolescence plays a pivotal role (Brown 2004). Trust, self-disclosure and loyalty are aspects that characterize adolescent friendship which is already aimed at intimacy as a result of the emotional and cognitive changes that guide adolescents to autonomy and to understanding anothers point of view. Peer relationships during adolescence are critical because they are a good training ground for adult relationships with work colleagues, a partner or friends. From this perspective, peer groups are a source of support and a basic guide in this social learning process (Claudino et al. 2006). There is some evidence that certain undesirable, antisocial or delinquent behaviours are performed by almost all members within all groups of adolescents (Berndt 2002). However, results are rather contradictory, calling for an in-depth understanding of processes behind peer group support and peer group pressure. They call for the need to co-evaluate in parallel peer support and pressure and family support, as well as the need to check the distance between family culture and life choices and peer culture and choices, and the quality of communication among those systems (Brown 2004). Gender and quality of friendship are also to be considered (Hartup 2005). The literature shows that during adolescence most groups of friends develop around certain activities and a significant part of the essence of the group is therefore related to these activities. Knowing what activities they do together and where they do them is therefore relevant to understanding the dynamics of the group. The effect of peer relationships on psychological adjustment and on other developmental outcomes depends on factors such as the type of leisure activities they engage in with their peers. For example, engaging in substance abuse is more common among adolescents who spend their time in unorganised activities, especially in discos or pubs. However, when they share certain physical activities or sports, then friends can often have a protective role against such risk behaviour (Ciairano et al. 2002). The behavioural characterization of the group of friends offers an indirect measurement of the adolescents own behaviour. Research studies consistently report on the similarities found between friends behaviours. However, this method of indirect measurement of adolescents behaviour through the report of friends behaviour has been challenged. There are reasons to believe that such methods result in an overestimation of similarities. Adolescents sharing common behaviours have greater probabilities of becoming friends and this friendship will, in turn, make them more alike. This influence has been frequently assessed

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and interpreted from an exclusively negative point of view, particularly in relation to aggression and delinquent behaviour (Bender / Loser 1997). However, we know that the influence might be qualitatively different depending on whether the group of friends engage in sports or in substance abuse. Data from the HBSC 2001-2002 survey show the relationship between individual behaviour and how the subject perceives behaviours in the group of friends. For example, being the aggressor in bullying situations is related to the perception of antisocial behaviours, such as carrying guns, in the group of friends, whereas those who perceive pro-social behaviours in their groups of friends are less prone to engage in bullying (Moreno et al. 2004).

3.3 Friendship
About 90% of adolescents can name at least one peer whom they consider to be a close friend and when they are asked to name more than one, most of them name someone who in turn also names him or her as a close friend (Brown 2004). Friendship is a strong predictor of the perception of happiness, well-being, social support, sharing interests, self assurance, and social and emotional learning (Due et al. 2003), whereas conflict is associated with poor health (Laftman / stberg 2006). Having a satisfactory intimate experience with at least one peer is one of the factors that best predicts positive health (Bukowski 2003, Hartup 1992). Various studies have shown gender differences in types of friendship. Friendship among girls focuses more on self-disclosure and sharing emotional states, sharing secrets, etc., whereas among boys it is more related to doing activities together (Shulman et al. 1997). Adolescents can clearly discriminate between close friendship and other types of friendship, giving reasons related to good communication, support, trust or feeling good when being with his/her friend, with the quality of this friendship being the key issue (Bukowski 2003). Having at least one good close friend is seen as a resiliency factor.

3.4 Social Competence


Social competence is frequently related to social adjustment and to the ability to develop rewarding interpersonal relationships. During childhood and adolescence, acceptance by the group is closely linked to social skills which are supposed to be learnt by a social learning process within the family context (Hartup 1992, Matos 2005).
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McFall (1982) presents a tri-fold social competence model as a situational concept in which perceptive, cognitive and behavioural issues are highlighted. In this model, deficits in social competence could be due to bias in social perception, bias in information processing and decision-making or behavioural deficits. Making this still more complex, Felner et al. (1990) stated that motivation, attention and emotional management can interfere with the other processes. Social competence is a balanced mix of all these and, in addition, needs specific and changeable social contexts to be fully understood. It relates to the identification and expression of emotions: getting and giving social support, participating and contributing to group daily life, giving and being able to accept affection, expressing feelings, needs and opinions, defending ones rights, feeling free to discuss ones values and favourite activities, deciding and leading a group procedure, accepting that he/she was wrong and being able to defend himself/herself from social injustice and/or exclusion, and positive criticism (Matos 2005).

3.5 Leisure time: Musical preferences


As mentioned previously, some unstructured activities, such as listening to different kinds of music together, are a vehicle of norms and values shared inside the group, determining normative behaviours. A considerable number of researchers considers music an important medium (interface) for adolescents (North et al. 2000, Ferreira et al. 2008) namely: (1) adolescents listen to music for hours every day, (2) listening to music fulfils important (developmental) functions and that (3) pop music preferences are related to adolescent mental health and problem behaviour, including excessive substance use. Music fulfils important functions for adolescents. First, music has an emotional impact; it is experienced as a mood enhancer and a means for fending off boredom. Second, music is relevant for the worldview that adolescents develop, i.e. some music fans study and highly value the lyrics of their favourite artists. They identify with the lyrics because they feel that the lyrics reflect their own position and they may shape their worldview by adopting the opinions that their favourite artists articulate, because they want to resemble them. Third, music has a badge function: their music preferences may be part of their identity and through their taste in music young people may project an image to others. Fourth, music is important socially: it is a factor in the formation of adolescent groups. Musical taste is a binding element in adolescent cliques or crowds (e.g. North et al. 2000).

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Music preference has been shown to be associated with various forms of adolescent distress. For example, metal and rap fans may be more likely to report unsupportive family relationships and more often dislike or oppose basic social institutions such as school, church, or society in general (Miranda / Claes 2004). Deviant music fans social positioning may at least partially explain the link between their music preferences and their problems. For example, Lacourse et al. (2001) found that the correlation between a preference for heavy metal and suicidal risk disappears when controlling for other risk factors. However, in other studies, even when a set of confounding factors is controlled for, the relationship between music preference and problem behaviour remains significant, implying that fandom of some types of music is a unique contributing factor to the explanation of adolescent distress (Miranda / Claes 2004). Music preference is associated with adolescent mental health, problem behaviour and substance use. Although the mechanisms through which music taste is related to problem behaviour are not fully understood (Ter Bogt 2004), music can be seen as a significant marker for adolescent distress and may be studied accordingly, which is the basis for the inclusion of a few optional items on this topic in the 2009/10 HBSC survey.

3.6 The use of new technologies for learning, communicating and leisure EMC (Electronic Media Communication)
Adolescents access to and use of new media technology is on the rise. This explosion of technology brings with it potential benefits and risks. Attention is growing concerning the risk to adolescents of becoming victims of aggressive acts perpetrated by peers with the new technology (David-Ferdon / Hertz 2007). The increasing availability of Internet and cell phones has provided new structures with which adolescents can bully. Electronic bullying is a new form of bullying that may threaten adolescent social and emotional development. Raskauskas and Stoltz (2007) studied the relation between electronic and traditional bullying; showing that students' roles in traditional bullying predicted the same role in electronic bullying. A further discussion on the perceptions of the effects of and motivations for electronic bullying is given by Raskauskas and Stoltz (2007). Within HBSC, a specific group is studying bullying (including cyber-bullying) and its consequences for health and well being. This topic was discussed here in order to shine some light on new forms of friendships and peer group and new threats to peer relationships related to EMC.

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Willoughby (2008) suggests that being male is a significant predictor of both computer gaming and Internet use, and that a higher friendship quality and less positive parental relationships predict higher frequency of Internet use. More importantly, moderate use of the Internet is associated with a more positive academic orientation than non-use or high levels of use. Recent research shows that the phenomenon of online friendships is not familiar to teachers (Chou / Peng 2007). Regarding the use of Internet for interpersonal communication and, more specifically, the relationship between loneliness and massive use of the Internet, Prezza et al. (2004) confirm that Internet users report being lonelier, but also having more on-line friends. Further research is needed in order to understand whether this means that the Internet increases friendship, whether personal similarities between those adolescents promote the use of the Internet, or whether another association will show up? Punamaki et al. (2006) carried out a study with Finnish youths and concluded that boys are more frequent users of either Internet or online games and that girls use mobile telephones more often. According to these authors, the massive use of EMC (mobile phone, emails, surfing, and online games) was associated with a poorer perception of health and poorer sleeping habits. Frequent reasons referred to by adolescents for using a cell phone were: feels more safe, helps to manage time more efficiently, gives a good image, to keep contact with friends and family and cant do without it (Aoki / Downes 2003). Recent evidence suggested that greater use of electronic media is associated with greater face-to-face contact with friends (Kuntsche et al., in press). Taking into account the large increase of electronic media communication (EMC) in most countries, the frequency of EMC increased with increasing number of afternoons and evenings spent with friends (Kuntsche et al., in press). These findings are consistent with the idea that EMC facilitates rather than supersedes face-to-face contacts (Zhao 2006). For example, electronic media might be used to fix appointments and to coordinate and manage face-to-face contacts among peer group members in the afternoons and evenings (Kim et al. 2007). It has been suggested that EMC might facilitate the maintenance of existing relations and also help to establish new contacts with peers with whom to spend time and go out in the evening (Madell 2006). It is imperative that more research is carried out regarding this issue, with the intent to explore the relation of Internet and other EMC with well-being and health behaviour across different cultures, time, gender and ages.

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EMC can be seen as a significant and distinctive marker for adolescent social life and interpersonal communication. It should be studied accordingly, hence the inclusion of the optional items on this topic in the 2009/10 HBSC survey.

3.7 Adolescents opinions about peers, friendship and about Electronic Media Communication
Recent research highlights the importance of young people's participation in the identification of key issues in their social life and culture (Matos et al. 2008); therefore adolescent contributions were sought and nine focus groups held for the specific purpose of this rationale. Recruitment took place in schools where adolescents could volunteer to take part in a study aiming at optimizing a questionnaire about friendship, peer group and electronic communication and leisure. Adolescents were aged 10 to 16, of both genders, and participated in nine groups of 8-10 participants. During the focus groups, the researcher introduced themes related to friendship, peer groups and communication, and electronic media communication. The importance of friendship was highlighted and associated with sharing, trust, support, understanding and respect (even when in disagreement). Friendship was also referred to as sharing activities: i.e. play, talk, walk. Love also comes to light in the older groups. A minority referred to not having friends or believing in friendship. This situation is often associated with a deprived minority status (poverty, migrant status, chronic disease). Regarding electronic media used during leisure time, adolescents referred to playing on the computer, the PlayStation or to watching TV. They refer to the Internet as a tool for searching for information and a source of help regarding school homework. As for peer communication, they indicate that especially Messenger or a cell phone helps them to keep in contact with friends, but is not so useful in love relationships; only helping at the beginning of a love relationship. More frequently cited uses for the computer were: to talk with friends (Messenger and Hi5), to download music and movies or to see movies through YouTube. Regarding Electronic Media Communication, they estimated that the average use has to be a measure of how often a day as the use will seldom be less than that. Regarding sending SMS, it should not be a question of whether they send messages to friends, but how often during a day they send messages.

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Furthermore, it is important to state that there are people who show a natural ability in the use of one or a combination of the following electronic media; the cell phone, Internet, Messenger, Hi5, YouTube, SKYPE Voip, etc., PlayStation games, online games, MP3 and MP4, or all digital formats. They clearly state that they are more skilled than their parents and teachers concerning such EMC. This study highlights the importance attributed to friendship, peer groups, peer activities during leisure and to EMC. Although it is now too late for changes in the mandatory items, we recommend, in view of making this question non-obsolete, that the partial option is added to EMC questions allowing that, when the answer is daily, it becomes possible to further assess how frequent during a day. This would be a simple extra modality that will give much and relevant information for the next survey.

4. Summary of previous work


Two different papers were submitted to an IJPH special issue regarding data obtained through HBSC. The results from Kuntsche et al. (in press/IJPH HBSC special issue) show that from 2002 to 2006 Electronic Media Communication (EMC) increased in almost all participating countries. Particularly high increases were found in Eastern Europe. Across countries, the higher the frequency of EMC, the higher the number of afternoons and evenings spent with friends. Moreno et al. (submitted/IJPH HBSC special issue) found that those adolescents with better communication in family and social contexts were the ones showing less psychological complaints. They also showed that good communication with peers while there is no good communication with parents does not lessen their experience of psychological complaints. Kuntsche and Delgrande Jordan (2006) found that for both cannabis use and drunkenness the association with substance-using peers was strongly related to individual substance-use. Moreover, a higher level of students own cannabis use and a closer relation between association with cannabis-using peers and the students own cannabis use were found in classes where students saw others coming to school intoxicated by cannabis or taking cannabis while on school premises. However, the association with peers who drink excessively appears not to change the relation between parental variables (such as family structure, parental drinking habits and family bonding) and adolescent alcohol use as reported by Kuntsche and Kuendig (2006).

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Kuntsche and Gmel (2004) found that solitary adolescents have a low self-worth, low life satisfaction, frequent depressive moods and they are more likely to become victims of bullying. These effects were even more pronounced when the solitary adolescents used alcohol riskily on single occasions (were binge drinkers). Gaspar and Matos (2008) studied tobacco and alcohol use, number of friends and perception of happiness and concluded that adolescents that have no friends tend to smoke and use alcohol more frequently and perceive themselves as more unhappy. Simes et al. (2008) defined an explanatory model for substance use in adolescence and concluded that peer support and communication have a significant positive impact on subjective well-being and that the latter is a mediator to substance use (alcohol and drugs). Cristini et al. (2007) compared the influences of different sources of social support (parents and friends) with respect to their effects on early adolescents psychosocial well-being. Results showed that older boys and girls perceived less social support from parents and more social support from friends (measured by ease of communication), with the latter being a stronger protective factor against life dissatisfaction and psychological symptoms. Tom et al. (2008) studied substance use and perception of loneliness and concluded that adolescents who have no friends tend to use illicit drugs more frequently and tend to feel lonelier. Vieno et al. (2007) investigated influences of different sources of social support (parents and friends), a sense of school community and self-efficacy on psychosocial well-being (measured by self reported life satisfaction and psychological symptoms) in an integrative model. Selfefficacy and a sense of school community were found to mediate the effects of social support from parents and peers on psychosocial adjustment. Friends` support (measured by ease of communication, number of friends and time spent with friends) resulted to be positively associated with psychosocial wellbeing directly and through the mediation of self efficacy and school sense of community. Nation et al. (2008) studied the development of bullying and victimization in school. They investigated the sense of interpersonal empowerment with parents, friends (how do you and your friends decide what to do together) and teachers. Chronically bullied students were found to have lower social competence in all age cohorts, while a relatively small percentage of students reported imbalance in the decision-making process with friends (a factor that does not make a significant contribution in predicting bullying behaviours).

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Ferreira et al. (2008) studied musical taste, urban tribes and externalizing behaviours, and concluded that particular musical tastes were associated with belonging to specific urban tribes.

5. Research questions
Mandatory items 1. What is the role played by peer relationships on health? Should peer influence be seen only in terms of peer pressure for antisocial behaviour? Can peers be a protective factor for adolescents against risk situations? Are results different depending on gender and age? 2. What are the implications on health of not having a close friend? Does having a close friend (or not) make a difference in engaging in risk behaviours? What is the connection between the quality of close friendship and health? 3. Trends of communication with friends and use of EMC across time: 2002-2010.

Optional items 1. Is there a link between family relationship types and peer relationship types? What happens when there are risk elements in both contexts? What happens when peer and family relationships diverge? Is the family a protection element against adolescents engagement in risk peer groups? Can the peer group work as a compensating context when families do not provide care, security and stimulation? 2. What is the role played by social competence in the quality of peer relationships? Are less socially competent boys and girls more prone to engage in risk behaviours? Is social competence a protective factor? 3. What are the factors that are related to more quality relationships? In terms of healthy living, what does it mean to have good peer relationships? 4. What is the role of music in adolescents health and socialization? 5. Which factors can predict good relationships with peers and good social competences? The role of the neighbourhoods social capital.

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6. Instrument
6.1 Mandatory items
HBSC has shown an interest in the social experience of adolescents since its very beginning and some of the constructs mentioned here have been present since the first HBSC surveys. This is the case for items related to time spent with peers and ease of talking with friends.

6.1.1 Number of close friends The number of close friends is measured by two items (see item box M Q36). The question was introduced in the 1993/94 survey with the aim of gathering information on the informal social network of peers. In 2001/02, the question was revised to identify the gender of friends. It has been useful for finding out the proportion of adolescents of each gender who have friends of their own, the other or both genders. Placement of items: it is particularly important to follow the general rule of placing mandatory items before optional ones in the questionnaire. In particular, the mandatory questions should be separate from the optional ones in PC OP1 on the peer group. Item box 1
MQ36 At present, how many close male and female friends do you have? Please tick one box each column Males
1 2 3 4

Females
1 2 3 4

None One Two Three or more

None One Two Three or more

Source: HBSC 1993/94, 1997/98, 2001/02(revised), 2005/06

At the last rationale, the Peer Culture group pointed out that the inclusion of this item as mandatory should be re-examined in future HBSC surveys. Adolescents tend to overestimate the number of friends they have when asked such a question. It is possible that even fewer adolescents will report having no friends when the question itself implies that the number of friends is an important thing: the phrase How many ? does not encourage participants giving the answer None, especially in an age bracket so concerned with friendship. It should be noted that when comparing the responses to the MQ 36 question and the optional PC3.1 question (question on special friendships) using the Spanish 2005/06 data, the result showed that 1% of adolescents responded that they have no close friends on MQ 35 and
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6% responded that they have no close friends on PC3.1. Based on the previous argument and Spanish result, it is advised to be cautious when interpreting the findings for this item. Moreover, this question poses certain translation problems, at least in some countries. Those adolescents especially concerned with intimacy might be very reluctant to say and report just one friend, whereas those group-oriented adolescents might report many close friends. This issue needs to be taken into account in the translation process, for example, by using an inbetween adjective for close to reflect an average demand level which would allow respondents to think beyond their very intimate friends or to include two lexical terms in order to state clearly that a proximity (but not an intimacy) is questioned.

6.1.2 Peer contact frequency Not without reason do three of the mandatory items in the peer package relate to the frequency with which peers have contact with one another. Adolescents spend a huge amount of their waking time with other adolescents. HBSC 2001-2002 data show a connection between time spent with friends, especially in the evenings, and risk behaviours (Settertobulte / Matos 2004). Such analyses, however, should be extended as this relationship could be moderated if the quality of the relationship is taken into account. Given that the increase in peer contact occurs from mid-childhood onwards, it is considered appropriate to maintain these items in the mandatory package for all ages (10-15). The items on time spent with friends are relevant for all age groups, given that the increase in peer contact occurs from midchildhood onwards. In relation to these and other items on peers, their assessment among younger children could be a way of gaining more key information on the effect of their early inclusion within typical adolescent routines. Frequency of peer contact is measured by three questions. The first two questions (1 item each; see item boxes MQ37 and MQ38) were designed with the aim of assessing the frequency with which adolescents have contact with their peers out of school, regardless of the place in which this time is spent, whether they are close friends or whether they are frequently together. Consequently, we should offer them the opportunity of stating how much time they spend with any friend or group of friends outside school. For this reason, the translation of this question should be as unrestrictive as possible and include any place where they could spend time together (indoors or outdoors). In those countries where the interpretation of the question MQ 37 would include time spent until after 22.00 hours, it might be useful to include

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another question on time spent with friends after 22.00 hours or to clarify the difference between evening and night if this is not clear in a certain idiom. Item box 2
MQ37 How many days a week do you usually spend time with friends right after school?
1 2 3 4 5 6 7

Source: HBSC 1985/86, 1989/90, 1993/94, 1997/98, 2001/02 (revised), 2005/06

Item box 3
MQ38 How many evenings per week do you usually spend out with your friends?
1 2 3 4 5 6 7 8

Source: HBSC 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, 2005/06

The third question consists of 1 item (see item box MQ38) and measures contact frequency through electronic media. The question was developed by the Peer Culture FG in 2001/02 and was revised and updated in 2005/06 to include contact through the Internet (such as MSN, chat rooms, etc.) as this form of communication is increasingly popular. A paper on electronic media by Kuntsche et al. (in press) shows that from 2002 to 2006 Electronic Media Communication (EMC) has increased in almost all participating HBSC countries. Particularly high increases were found in Eastern Europe. At present, we strongly propose, although it was not possible to include it in the mandatory package, that countries include an extra set of questions where the use of telephone, phone messages and internet is covered using three different questions (see optional package EMC, PC4.1-PC4.3). Furthermore, we strongly encourage HBSC researchers to add a further extra option, in case the answer is daily, which asks how many times a day. The Focus Group has a strong suspicion that a ceiling effect will be reached for the current mandatory items. Item box 4
MQ39 How often do you talk to your friend(s) on the phone or send them text messages or have contact through the Internet? Rarely or never 1 or 2 days a week 3 or 4 days a week 5 or 6 days a week Every day

1 2 3 4 5

Source: HBSC 2001/02, 2005/06

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The items on time spent with friends are relevant for all age groups, given that the increase in peer contact occurs from mid-childhood onwards. In relation to these and other items on peers, their assessment among younger children could be a way of gaining more key information on the effect of childrens early inclusion within typical adolescent routines.

6.2 Optional items


The optional packages listed below can be found in the item bank on the HBSC website. Optional package 1: Peergroup configuration and functioning Optional package 2: Peer group activities and behavioural characterisation Optional package 3: Friendship and social competence Optional package 4: EMC (Electronic Media Communication)

7. References
Allen, J. P., Moore, C., Kuperminc, G., y Bell, K. (1998). Attachment and Adolescent Psychosocial Functioning. Child Development, 69 (5), 1406-1419. Aoki, K., & Downes, E. J. (2003). An analysis of young peoples use of and attitudes toward cell phones. Telematics and Informatics, Volume 20, Issue 4, Pages 349-364. Armsden, G. C., y Greenberg, M. T. (1987). The Inventory of Parent and Peer Attachment: Individual Differences and their Relationship to Psychological Well-being in Adolescence. Journal of Youth and Adolescence, 16 (5), 427-453. Bender, D., & Loser, F. (1997). Protective And Risk Effects Of Peer Relations And Social Support On Antisocial Behaviour In Adolescents From Multi-Problem Milieus. Journal of Adolescence, 20, 661678. Berndt, T. J. (2002). Friendship Quality and Social Development. Current Directions in Psychological Science, 11, no. 1, pp. 7-10(4) Brown, B. B. (2004). Adolescents' relationships with peers. In R. M. Lerner & L. Steinberg (Eds.), Handbook of adolescent psychology (pp. 364-394). New Jersey: Wiley. Chou, C. & Peng, H. (2007). Net-friends: adolescents attitudes and experiences vs. teachers concerns. Computers in Human Behaviour, 23, Issue 5, Pages 2394-2413. Ciairano, S., Bo, G., Jackson, S., & Van Mameren, A. (2002). The Mediator Role Of Friends In Psychological Well-Being And The Use Of Psychoactive Substances During Adolescence: A Comparative Research In Two European Countries. Paper presented at the 8th EARA, Oxford. Claudino, J., Cordeiro, R., & Arriaga, M. (2006). Depresso e suporte social em adolescentes e jovens adultos um estudo realizado junto de adolescentes pr-universitrios. Revista do ISPV, 32, 185196. Corsano, P., Majorano, M., & Champretavy, L. (2006). Psychological well-being in adolescence: The contribution of interpersonal relations and experience of being alone. Adolescence, 41(162), 341353

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Cristini, F., Santinello, M., Dallago, L. (2007). Linfluenza del sostegno sociale dei genitori e degli amici sul benessere in preadolescenza (Social support from parents and peers and early adolescents wellbeing). Psicologia Clinica dello Sviluppo, 3, 501-521. David-Ferdon, C. & Hertz, M. F. (2007). Electronic Media, Violence, and adolescents: An Emerging Public Health Problem. Journal of Adolescent Health, 41, Issue 6, Supplement 1, Pages S1-S5 Dorius, C. J., Bahr, S. J., Hoffmann, J. P., & Lovelady, E. H. (2004). Parenting Practices as Moderators of the Relationship Between Peers and Adolescent Marijuana Use. Journal of Marriage and Family, 66, 163-168. Due, P., Lynch, J., Holstein, B., & Modvig, J. (2003). Socio-economic health inequalities among a nationally representative sample of danish adolescents: the role of different types of social relations. Journal of Epidemiology and Community Health, 57, 692-698. Felner, R, Lease, A., Phillips, R . (1990). Social competence and the language of adequacy as a subject matter for psychology: a quadripartite trilevel framework. In Gullotta, T., Adams, G. & Montemayor, R. (Eds.). Developing Social Competence in Adolescence. London: Sage. Ferreira, M., Matos, MG., Pessoa, M.& Diniz, JA (2008) Preferncias musicais e culturas Juvenis e o Consumo de substncias nos adolescentes, (233-256) in Matos, M., (ed) ( 2008) Uso de substncia: estilo de vida ou procura de um estilo. Lisboa:IDT Field, T. (2002). Adolescentsparent and peer relationships. Adolescence. Rertieved: 12 December 2007 from www.findarticles.com. Gaspar, T. & Matos, MG. (2008) Consumo de substncias e sade/bem-estar em crianas e adolescentes portugueses, (45-70) in Matos, M., (ed) ( 2008) Uso de substncia: estilo de vida ou procura de um estilo. Lisboa:IDT Gauze, C., Bukowski, W. M., Aquan-Assee, J., & Sippola, L. (1996). Interactions between family environment and friendship and associations with self-perceived well-being during early adolescence. Child Development, 67, 2201-2216. Graziani, A.N., Rubini, M., & Palmonari, A. (2007). Nei gruppi conosciamo noi stessi": Le funzioni dei gruppi adolescenziali ("Through group membership we know ourselves": The functions of adolescent peer groups.). Eta-Evolutiva, 88, 31-41. Hansen, D.M., Larson, R.W., & Dworkin; J.B. (2003). What Adolescents Learn in Organized Youth Activities: A Survey of Self-Reported Developmental Experiences. Journal of Research on Adolescence, 13(1), 25-55. Hartup, W. (2005). Peer interaction: What causes what? Journal of Abnormal Child Psychology. Retrieved 18 Januari 2007, from www.findarticles.com. Hartup, W. W. (1992). Having Friends, Making Friends, and Keeping Friends: Relationships as Educational Contexts. Retrieved 21 August 2003, from www.findarticles.com. Kerr, M., Stattin, H., Biesecker, G., and Ferrer-Wreder, L. (2003). Relationships With Parents and Peers in Adolescence. In R. Lerner, M. A. Easterbrooks y J. Mistry (Eds.), Developmental Psychology (Vol. 6, pp. 395-419). Nueva York: Wiley. Kim H, Kim G, Park HW, Rice RE. (2007) Configurations of relationships in different Media: Ftf, Email, Instant Messenger, Mobile Phone, and SMS. Journal of Computer-Mediated Communication ,12:1183-207. Kuntsche, E. & Delgrande Jordan, M. (2006). Adolescent alcohol and cannabis use in relation to peer and school factors. Results of multilevel analyses. Drug and Alcohol Dependence, 84(2), 167-174. Kuntsche, E. N. & Gmel, G. (2004). Emotional well-being and violence among social and solitary risky single occasion drinkers in adolescence. Addiction, 99(3), 331-339. Kuntsche, E. N. & Kuendig, H. (2006). What is worse? A hierarchy of family-related risk factors predicting alcohol use in adolescence. Substance Use & Misuse, 41(1), 71-86. Kuntsche, E., Simons-Morton, B., Ter Bogt, T., Snchez-Queija, I., Muoz-Tinoco, V., Gaspar de Matos, M., Santinello, M., Lenzi, M. (in press) Trends of electronic media communication from 2002 to 2006 and links to face-to-face peer contacts among adolescents 31 European and North American countries and regions. International Journal of Public Health.

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Lacourse, E., Claes, M., & Villeneuve, M. (2001). Heavy metal music and adolescent suicidal risk. Journal of Youth and Adolescence, 30, 321-332. Laftman, S. B., & stberg, V. (2006). The pros and cons of social relations: An analysis of adolescents' health complaints. Social Science & Medicine, 63, 611-623 Lande, J. (2007). Social isolation, psychological health, and protective factors in adolescence. Adolescence, retrieved 20 October 2008 from www.findarticles.com. Madell DE, Muncer SJ. Control over Social Interactions: An Important Reason for Young Peoples Use of the Internet and Mobile Phones for Communication? Cyberpsychology & Behavior 2006;10:137-40. Matos, M. (ed.) (2005). Comunicaao, gestao de conflitos e sade na escola. Lisboa.CDI: Faculdade de Motricidade Humana Matos, M.G., Baptista, M. I., Simes, C., Gaspar, T., Sampaio, D., Diniz, J. A., Goulo, J., Mota, J., Barros, H., Boavida, J. & Sardinha, L. (2008). Portugal: from research to practice promoting positive health for adolescents in schools. In Social cohesion for mental well-being among adolescents. WHO/HBSC FORUM 2007 McFall, R. M. (1982). A review and reformulation of the concept of social skills. Behavioral Assessment (4), 1-33. Meeus, W., Helsen, M., Vollenbergh, W. (1996). Parents and peers in adolescence: from conflict to conectedness. In Verhofstadt-Deneve, I., Kienhorst, C.& Braet (Eds.). Conflict and development in adolescence, pp. 103-116. Leiden Dwo Press. Miranda, D. & Claes, M. (2004). Rap music genres and deviant behaviors in French-Canadian adolescents. Journal of Youth and Adolescence, 33(2), 113-122 Moreno, M.C., Muoz Tinoco, V. and Prez, P. (2003), Hbitos de vida y empleo del tiempo libre en adolescentes y jvenes sevillanos. In Educacin y Ciudadana. Sevilla: Servicio de Publicaciones del Ayuntamiento de Sevilla. Moreno, M.C., Muoz Tinoco, V. and Prez-Moreno, P, Snchez-Queija, I. (2004). Incidencia del maltrato entre iguales durante la adolescencia en Espaa. Portularia (4), 307-316. Moreno, M.C., et al. (submitted). Cross-national associations between parent and peer communication and psychological complaints. International Journal of Public Health. Nation, M., Vieno, A., Perkins, D.D., Santinello, M. (2008). Bullying in School and Adolescent Sense of Empowerment: An Analysis of Relationships with Parents, Friends, and Teachers. Journal of Community & Applied Social Psychology, 18, 211-232. North, A.C., Hargreaves, D.J. & ONeill, S.A. (2000). The importance of music to adolescents. British Journal of Educational Psychology, 70, 255-272. Oliva, A., Parra, A. and, Snchez-Queija, I (2002). Relaciones con padres e iguales como predoctoras del ajuste emocional y conductual durante la adolescencia. Apuntes de Psicologa, 20 (2), 225-242 Prez, J., Maldonado, T., Andrade, C., & Diaz, D. (2007). Judgments expressed by children between 9 to 11 years old, about behaviors and attitudes that lead to acceptance or social rejection in a school group. Revistas Diversitas- Perspectivas en Psicologia, 3 (1), 81-107. Prezza, M., Pacilli, M., & Dinelli, S. (2004). Loneliness and new Technologies in a group of Roman adolescents. Computers in Human Behavior, 20, 691-709. Punamaki, R., Wallenius, M., Nygard, C., Saarni, l., & Rimpela, A. (2006). Use of information and communication technology (ICT) and perceived health in adolescence: The role of sleeping habits and waking-time tiredness. Journal of Adolescence, retrieved in 1 February 2007 from www.sciencedirect.com. Raskauskas, J. & Stoltz, A. D. (2007). Involvement in Traditional and Electronic Bullying Among adolescents. Developmental Psychology, 43, Issue 3, Pages 564-57 Rubin, K.H., Coplan, R.J., & Bowker, J.C.(2008). Social Withdrawal in Childhood. Annual Review of Psychology, 60, 11.1-11.31. Settertobulte, W. & Matos, M. (2004). Peers and health. In Currie, C., Roberts, C. Morgan, A.. Smith, R. Settertobulte, W. Samdal, O. & Rasmussen, V. B. (Eds). Young people's health in context. Health Behavior in School-aged Children (HBSC) Study: International report from the 200172002 Survey. Copenhagen. World Health Organization.

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Shulman, S., Laursen, B., Kalman, Z., y Karpovsky, S. (1997). Adolescent Intimacy Revisited. Journal of Youth and Adolescence, 26(5), 597-617. Simes, C., Matos, MG. & Batista-Foguet, J. (2008) Consumo de substncias na adolescncia: reviso de um modelo explicativo (301-318) in Matos, M., (ed) ( 2008) Uso de substncia: estilo de vida ou procura de um estilo. Lisboa:IDT Soares, I. (2007). Relaes de vinculao ao longo do desenvolvimento Teoria e avaliao. Editora: Psicoequilbrios Sussman, S., Unger, J., Dent, C. (2007). Peer group self-identification among alternative high school youth: A predictor of their psychosocial functioning five years later. Journal of Clinical and Health Psychology, 4(1), 9-25 Ter Bogt, T. (2004). Tijd onthult alles: Popmuziek , ontwikkeling, carrires. [Time is a revelator: Pop music, development, careers]. Amsterdam: University of Amsteram/Vossius Press. Tom, G., Matos, MG.& Diniz, JA (2008)Consumo de substncias e isolamento social durante a adolescncia, (95-126) in Matos, M., (ed) ( 2008) Uso de substncia: estilo de vida ou procura de um estilo. Lisboa:IDT Vieno, A., Santinello, M., Pastore, M., & Perkins, D.D. (2007). Social Support, Sense of Community in School, and Self-Efficacy as Resources During Early Adolescence: An Integrative Model. American Journal of Community Psychology, 39, 177190. Willoughby, T. (2008). A Short-Term Longitudinal Study of internet and Computer Game Use by adolescent Boys and Girls: Prevalence, Frequency of Use, and Psychosocial Predictors. Developmental Psychology, Volume 44, Issue 1, Pages 195-204. Zhao S.(2006) Do internet users have more social tie? A call for differentiated analyses of internet use. Journal of Computer-Mediated Communication,11:844-62.

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II.2.6 Leisure Time Activities


Leversen, I, Samdal, O, Moreno, C., Muoz-Tinoco, V, Wold, B

1. Scope and purpose


When analysing childrens and adolescents socialization and learning, there is a tendency to focus mainly on formal contexts (such as school), or on those contexts which explicitly have education among their main aims (such as family, for example). A developing research focus is, however, children and adolescents leisure time or free time. Research done so far on the issue shows, that free time is far from meaning empty time, and on the contrary it is a time period full of opportunities for socialization and learning (Larson 2000). Ongoing research suggests that there is a wide range of styles as to how free time is spent. This is clearly seen when analysing its structural elements: amount of time, places gone to, activities engaged in and with whom this time is spent (Moreno / Muoz 1999, Prez et al. 2000; the HBSC study has included some of these aspects among its contents in previous surveys). As for the amount of hours spent on free time, we know for example that the sleep/awake rhythm changes with age and with geographical settings and seasons. Furthermore, different school schedules (for example intensive schooling only in the mornings) or different self-care habits (for example, meal times) determine the amount of free time available. Variability is obvious as to the people with whom they spend their free time. In this way, free time can be spent alone or with others, be it with family (increasingly less during adolescence; see for example Larson et al. 1996), be it with peers or with a boyfriend or girlfriend. Lastly, a central aspect of analysing free time is that related to the activities engaged in. In this sense, we know that in certain occasions this time evolves around highly organised time and activities as is the case of time spent in a sports centre or mastering a musical instrument. On other occasions, however, free time evolves around pure enjoyment, around the flow of relationships (Csikzentmihalyi 1988) or doing nothing time.

2. Objectives
The majority of adolescents participate in leisure time activities and some spend quite a few hours each week in such activities. Participation in leisure time activities thus constitutes a

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huge and important part of young peoples lives, justifying the need for assessing how adolescents spend their leisure time. Overall, leisure time is learning time and also a time with developmental relevance (Flammer et al. 1999, Hendry et al. 1993). In this sense, it thus becomes clear that it is not only necessary to design a context with educational aims (as is the case of school or family) for there to be many other learning possibilities emerging from more informal and improvised contexts. That is, adolescents also shape their lives around their leisure time internalising values, learning different relationship forms and life habits. With a focus on all kinds of activities, both organised and unorganised, like physical activities, cultural activities and computer activities we want to broaden the picture of young peoples leisure time use.

3. Theoretical framework
3.1 Organised leisure time activities and development of pro-social skills and initiative
By organised leisure time activities, we refer to activities that are characterized by structure, adult-supervision, and an emphasis on skill-building (Larson 2000). Organised leisure time activities can be different types of structured activities like playing with your football team or basketball team, and activities such as singing in a choir and playing in an orchestra/brass band. Organised activities are generally voluntary, have regular and scheduled meetings, and are organised around developing particular skills and achieving goals. They are often characterized by challenge and complexity that increase as participants abilities develop. Achieving competencies through organised activities allows an individual to take advantage of personal and environmental resources that promote positive functioning. Participation in organised activities can provide children with constructive, adult-supervised ways of spending time that offer opportunities for developing pro-social skills and reducing the likelihood of involvement in problem behaviour (Casey et al. 2005). Organised activities typically offer a context of safety during the after school hours, often provide opportunities for skill building and efficacy, and are frequently important contexts of supportive relationships with adults and peers (Mahoney et al. 2005). Participation may thus boost young peoples self-efficacy through mastery experiences and also provide an important basis for integration among peers. According to Larson (2000) the great majority of adolescents' time is spent in two opposite experiential situations. In schoolwork they experience concentration and challenge without necessarily being intrinsically motivated. In most leisure, including watching TV and interacting

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with friends, they experience intrinsic motivation, but not in a context of concentration and challenge. There is, however, one segment of adolescents time that combines intrinsic motivation and concerted attention. This is the category we call organised voluntary activities. Further, Larson (2000) proposes that participation in organised activity may contribute to the development of initiative based on three core elements of the activities. The first element involves intrinsic motivation, the experience of wanting to be doing an activity and being invested in it. The second requirement is that this intrinsic motivation is experienced in association with concerted engagement in the environment, with exertion of constructive attention in a field of action involving the types of constraints, rules, challenges, and complexity that characterize external reality. The third requirement is that this motivation and concerted engagement occur over time. For initiative to develop, Larson believes that all three of these elements need to come together. An individual needs to experience the three in consort and learn to regulate them. Despite its root in "initiate", initiative is not just starting things but sticking with them. Initiative is the devotion of cumulative effort over time to achieve a goal. Leisure time of adolescents is not only innocuous time, quite the opposite. It offers adolescents clear protection from risks and thus promotes optimum development. In this regard structured and supervised time is considered important to prevent negative effects of free time, and it is also desirable that adolescents have access to a wide range of ways to spend their leisure time (Benson 1997, Damon 1997, Moreno / Oropesa 2002, Osgood et al. 1996). Closely related to this is the evidence showing that variability in how leisure time is organised depends on the adolescents psychological profile, and that in this sense, variability becomes an indicator of mental health and life satisfaction (see, for example, Grob et al. 1999, Larson et al. 1990). Rates of unorganised socializing are related to group differences relevant to problem behaviour. For example, boys are more likely than girls to spend time in unorganised socializing (Flannery et al. 1999, Osgood et al. 1996).

3.2 The relation between participation in organised leisure time activities and mental health
Building on the principles of how participation in organised activities can stimulate intrinsic motivation and initiative it is reasonable to assume that it is strongly associated with mental health outcomes. Several studies have identified participation in organised leisure time activities a possible contributor to well-being and good mental health, and increasing the likelihood of healthy adjustment in the future (Brown et al. 2002, Caldwell 2005, Casey et al.

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2005, Larson 2000, Larson et al. 2002, Mahoney et al. 2005, Osgood et al. 1996). A systematic structure around how leisure time is spent may also reduce the risk of developing psychological health problem and problem behaviours such as drinking and aggressive behaviour and increase the likelihood of healthy adjustment in the future (e.g. Mahoney / Bergman 2002). A number of studies further indicate that participation in organised activities is associated with reduced problem behaviours across adolescence and into young adulthood. More recent developmental research in the United States shows that involvement in organised activities reduces the likelihood of developing problems with alcohol and drugs (e.g. Youniss et al. 1999), aggression, antisocial behaviour, and crime (e.g. Rhodes / Spencer 2005), or becoming a teenage parent (e.g. Allen et al. 1997). Research has consistently shown that children and youth who spend more time socializing with peers (not in organised activities) engage in more problem behaviour (Osgood et al. 2005). Findings indicate that children and adolescents have higher rates of a variety of problem behaviours when their after-school activities are less often supervised by adults, are less structured, and include more socializing with peers (Osgood et al. 2005). For instance, opportunities for problem behaviour should be very unlikely at a basketball game that is part of an organised league, where the sequence of activities is highly scripted. The risk of problem behaviour would be greatest for youth who are hanging out, in a setting such as park or a street corner, doing nothing in particular (Osgood et al. 2005). However, the risk for externalizing and internalizing behaviour is not higher only in unorganised activities. In a study by Endresen and Olweus (2005), they found that certain aspects or types of sports participation (both organised and unorganised) contribute to an increased likelihood of aggression and antisocial behaviour in every day life. The conclusion of the two-year longitudinal study suggests that participation in sports like kickboxing, wrestling, and weightlifting among preadolescent and adolescent boys leads to an increase or enhancement of antisocial involvement outside the sports situations (Endresen / Olweus 2005). This indicates that type of activity may be an important aspect when addressing the relationship between participation in organised leisure time activities and mental health and life satisfaction. Children from low-income families have been shown to be less likely to participate in organised out-of-school programs or enrol in centre-based care than children from middle- or higher income families (Casey et al. 2005, Villaruelle et al. 2005). Participation in organised leisure time activities thus also becomes an indicator of social inequality. Structured time, structured activities and greater variety in the activities adolescents engage in are more

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frequently found among adolescents from more favoured social sectors and areas (Carnegie 1992, Entwistle / Alexander 1992, Larson / Verma 1999, Moreno 1999, Moreno / Muoz 1999, 2001).

4. Summary of previous work


Both school and leisure time are of great importance for adolescents health, and by adding the topic of leisure time activities to the HBSC study the aim is to provide a holistic perspective in the understanding of the important aspects of adolescents health. Assessment of young peoples participation in leisure time activities is also a way of facing future challenge to offer guidelines on how to reduce risk time, how to increase the opportunities of making good use of time, and in short, on how to increase the amount of time adolescents spend on situations leading to healthy development. The topic of leisure time activities as an optional package was introduced in the HBSC data collection in 2005/06. All questions are new from the 2005/06 study. When exploring what young people do in their leisure time there has been a focus in HBSC on physical activity. Computer use has also been addressed earlier, but mainly described as a passive, sedentary activity. Adding to physical activity, other leisure time activities like music and drama activities (e.g. singing in a choir, and playing in a band) will constitute an important part of what young people do in their leisure time and which type of activities they participate in. An important aim of this optional package is therefore to broaden the picture of young peoples leisure time use by including different types of music and drama activities (individual activities and activities together with others), sports activities individual and in team and other group activities (church activities, scouting).

5. Research questions
There are several interesting and important questions that we will be able to explore in this optional package. For instance: 1. What are the typologies of leisure time patterns of adolescents?
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What kind of leisure time activities do they participate in? What characterizes adolescents who participate in leisure time activities and those who do not?

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Are there any gender differences or differences related to socio economic background?

2. What is the relationship between the identified activity typologies and reported mental health and life satisfaction?
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Do the adolescents who participate in leisure time activities report fewer psychological problems and higher satisfaction with life than the adolescents who do not?

Are adolescents that do not participate in leisure time activities more engaged in problem behaviour than adolescents that do?

Is there a cross-national difference in the relationship between participation in leisure time activities, and mental health and life satisfaction?

6. Instruments
The optional packages/items listed below can be found in the item bank on the HBSC website. Participation in leisure time activities Participation in Different Groups of Organised Leisure Time Activities

7. References
Allen, J, Philliber, S, Herrling, S & Gabriel, K (1997). Preventing teen pregnancy and academic failure: Experimental evaluation of a developmentally based approach. Child Development. Vol. 64, 729742. Benson, P. L. (1997). All kids are our kids: what communities must do to raise caring and responsible children and adolescents. San Francisco: Jossey-Bass. Caldwell, L.-L. (2005). Leisure and health: Why is leisure therapeutic? British Journal of Guidance and Counselling, 33(1), 7-26. Carnegie Foundation, C. (1992). A matter of time: risk and opportunity in the nonschool hours. New York: Carnegie Foundation. Casey, D, Ripke, M & Huston, A (2005). Activity Participation and the Well-Being of Children and Adolescents in the Context of Welfare Reform. In Mahoney, J, Larson, R & Eccles, J, (Eds.). Organized Activities as Contexts of Development. Extracurricular Activities, After-School and Community Programs. Lawrence Erlbaum Associates, Publishers. Mahwah, New Jersey, London. Csikszentmihalyi, M & Csikszentmihalyi, I (1988). Optimal experience. Psychological studies of flow in consciousness. Cambridge University Press. Damon, W. (1997). The youth charter: how communities can work together to raise standards for all our children. New York: Free Press.

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Endresen, I & Olweus, D (2005). Paricipation in power sports and antisocial involvement in preadolescent and adolescent boys. Journal of Child Psychology and Psychiatry. Vol. 46, No. 5, 468-478. Entwistle, D. R., & Alexander, K. L. (1992). Summer setback: race, poverty, schoolcomposition, and mathematics achievement in the first two years of school. American Sociological Review, 57(1), 72-84. Flammer, A., Alasaker, F. D., & Noack, P. (1999). Time use by adolescents in an international perspective. I: The case of leisure activities. In F. D. Alsaker & A. Flammer (Eds.), The adolescent experience. European and American adolescents in the 1990s (pp. 33-60). New Jersey: LEA. Flannery, D, Williams, L & Vaszonyi, A (1999). Who are they with and what are they doing? Delinquent behaviour, substance use, and early adolescents after-school time. American Journal of Orthopsychiatry. Vol. 69, No. 2, 247-253. Grob, A., Stetsenko, A., Sabatier, C., Botcheva, L., & Macek, P. (1999). A crossnational model of subjective well-being in adolescence. In F. D. Alsaker & A. Flammer (Eds.), The adolescent experience. European and American adolescents in the 1990s (pp. 115-130). New Jersey: LEA. Hendry, L. B., Shucksmith, J., Love, J. G., & Glendinning, A. (1993). Young people's leisure and lifestyles. London: Routledge. Larson, R. W., Raffaelli, M., Richards, M. H., Ham, M., & Jewel, L. (1990). Ecology of depression in late childhood and early adolescence. A profile of daily states and activities. Journal of Abnormal Psychology, 99(1), 92-102. Larson, R. W., Richards, M. H., Moneta, G., Holmbeck, G., & Duckett, E. (1996). Changes in adolescents daily interactions with their families from ages 10 to 18: disengagement and transformation. Developmental Psychology, 32(4), 744-754. Larson, R. W., & Verma, S. (1999). How children and adolescents spend time across the world. Work, play, and developmental opportunities. Psychological Bulletin, 125(6), 701-736. Larson, Reed (2000). Toward a Psychology of Positive Youth Development. American Psychologist. Vol. 55, Issue 1, 170-183. Larson, R.-W., Suzanne, W., Brown, B. B., Furstenberg, F.-F., Jr., & Verma, S. (2002). Changes in adolescents' interpersonal experiences: Are they being prepared for adult relationships in the twenty-first century? Journal of Research on Adolescence, 12(1), 31-68. Mahoney, J & Bergman, L (2002). Conceptual and methodological considerations in a developmental approach to the study of positive adaptation. Journal of Applied Developmental Psychology. Vol. 23, 409-418. Mahoney, J, Larson, R, Eccles, J & Lord, H (2005). Organized Activities as Developmental Contexts for Children and Adolescents. In Organized Activities as Contexts of Development. Extracurricular Activities, After-School and Community Programs. Edited by Mahoney et al. Lawrence Erlbaum Associates, Publishers. Mahwah, New Jersey, London. Moreno, M. C. (1999). Hbitos de vida y empleo del tiempo libre en adolescentes y jvenes: una reflexin en torno a la igualdad de oportunidades. In Foro "Andaluca en el Nuevo Siglo". Sevilla: Consejera de la Presidencia, Junta de Andaluca. Moreno, C. & Muoz, V. (1999). Adolescents: a study on their use of time. Paper presenteat IXth European Conference on Developmental Psychology. Island of Spetses, Greece,September 1-5. Moreno, C. & Muoz, V. (2000). Sleeping and waking hour patterns of Spanish teenagers in two 24 hour periods (a working day and a weekend day). Paper presented at the VIIth Biennial Conference of the European Association for Research on Adolescence (EARA). Jena, Germany, May 31June 4. Moreno, C. y Muoz, V. (2001). Daily routines of adolescent and their available resources. Paper presented at Xth European Conference on Developmental Psychology. Uppsala, Sweden. Moreno, M.C. y Oropesa, F. (2002). Life routines in adolescent students from Seville and its relation with risk and protective factors. Paper presented at the VIIIth Biennial Conference of the European Association for Research on Adolescence (EARA). Oxford, England, September 3-7.

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Prez, F.; Muoz, V. & Moreno, C. (2000). Applying automatic classification techniques to the analysis of teenager activities and their use of leisure. Paper presented at the VIIth Biennial Conference of the European Association for Research on Adolescence (EARA). Jena, Germany, May 31June 4. Osgood, D. W., & others. (1996). Routine activities and individual deviant behavior. American Sociological Review, 61, 635-655. Osgood, D, Anderson, A & Shaffer, J (2005). Unstructured Leisure in the After-School Hours. In:Mahoney et al. (Eds.). Organized Activities as Contexts of Development. Extracurricular Activities, AfterSchool and Community Programs. Lawrence Erlbaum Associates, Publishers. Mahwah, New Jersey, London. Rhodes, J & Spencer, R (2005). Someone to Watch Over Me: Mentoring Programs in the After-School Lives of Children and Adolescents. In Mahoney, J, Larson, R & Eccles, J, (Eds.). Organized Activities as Contexts of Development. Extracurricular Activities, After-School and Community Programs. Lawrence Erlbaum Associates, Publishers. Mahwah, New Jersey, London. Ryan, Richard M. (1995). Psychological Needs and the Facilitation of Integrative Processes. Journal of Personality. Vol. 63, No. 3, 397-427. Villaruelle, F, Montero-Sieburth, M, Dunbar, C & Outley C (2005). Dorothy, There Is No Yellow Brick Road: The Paradox of Community Youth Development Approaches for Latino and African American Urban Youth. In Mahoney, J, Larson, R & Eccles, J, (Eds.). Organized Activities as Contexts of Development. Extracurricular Activities, After-School and Community Programs. Lawrence Erlbaum Associates, Publishers. Mahwah, New Jersey, London. Youniss, J, McLellan, J, Su, Y & Yates, M (1999). The role of community service in identity development: Normative, unconventional, and deviant orientations. Journal of Adolescent Research. Vol. 14, 248-261.

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II.3 Developmental context of health and health behaviour


II.3.1 Pubertal status and timing
Candace Currie, C, Nmeth, , Kknyei, G

1. Scope and purpose


Puberty is the initial period of adolescence during which fundamental biological changes take place and as a result the fertile adult organism evolves from the childs body. The underlying biological processes resulting in physical changes have clear intellectual, emotional, social and behavioural implications, many of which result in health-related outcomes. The onset of puberty varies between individuals, as does the pace of physical changes. Some reach puberty well before others, and this has been attributed to the influence of a wide range of factors: genetic and biological influences, stress, socioeconomic status, environmental toxins, nutrition and diet, exercise, amount of body fat, body weight and chronic illness (Kipke 1999) as well as the family social environment (Maestripieri et al. 2004). The variance in timing of onset and rate of progress of pubertal change means that even although the same chronological age, young people may appear, feel and behave differently according to their stage of maturation. While chronological age is one of the main individual characteristics used to compare groups of young people. In most school systems encountered in HBSC participating countries, children are strictly graded according to chronological age with the majority differing by no more than 12 months, yet in terms of physical maturation they may differ by a much greater time span. For example, menarche in girls may happen as early as 10 or as late as 15 with about 5% of the population reporting even earlier or later onset (Silbereisen / Kracke 1997). There are also distinct gender differences in the timing of events related to physical maturation including an almost two year later growth spurt in boys than girls as previously mentioned (Santrock 1997). From a policy and practice perspective, there is growing interest in the area as early puberty, occurring in primary school, has implications for the provision of health education, particularly related to personal relationships and sex (Coleman, Coleman 2002), and also the promotion of positive self-esteem and body image, healthy eating and physical activity (Cooke et al. 2005a).

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A key aspect is the appreciation of puberty as an underlying process with important implications for health, well-being and behaviour of pupils.

2. Objectives
The integration of pubertal development into the HBSC conceptual framework seems critical as biological development interacts with psychosocial processes (Saxbe / Repetti 2008), and has substantial impact on mental and somatic health as well as health behaviour. Beyond the opportunity to examine relationships between pubertal development and subjective well-being as well as health-related behaviour, analysis of how structural factors such as family socioeconomic status and family composition may affect pubertal timing also will be possible using HBSC data as will modelling of the associations between body mass index and puberty. HBSC provides a unique opportunity to study the importance of pubertal timing on adolescent adjustment in different social and cultural contexts. Cultures may vary in acceptance of deviations from the typical pace of maturation depending on social norms and media representations concerning appearance and behaviour. There is known to be variation in the social freedom experienced, or perhaps allowed, to girls and boys by different cultural groups. HBSC finds evidence for this in the extent to which young people across North America and different parts of Europe spend time out in the evening with friends (Settertobulte / Gaspar de Matos 2004). Some cultures, particularly in southern and eastern Europe appear to be more protective of girls as they become sexually mature (see Sexual health chapter) as indicated by the finding that they spend less time out with friends in the evening. It would therefore be of interest to explore differences in health, well-being and behaviour related to pubertal timing across the HBSC countries. HBSC has the potential to contribute to this growing body of scientific knowledge. Although limited by the cross-sectional study design which hampers the investigation of causal relationships in a developmental process, HBSC has the advantage of being an international study. The experience of puberty may vary across our study countries. While a great deal of research has examined the effect of pubertal timing on health-related outcomes in adolescence in the United States and some western European countries, little cross-national research especially including southern and eastern countries in Europe has been carried out (Wang / Adair 2001). HBSC therefore provides a unique opportunity to study

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aspects of the impact of puberty on health and behavioural outcomes across a large number of countries. The findings will be of importance to schools and parents due to the wide-ranging and relevant associations between pubertal timing and a number of health and behavioural outcomes.

3. Theoretical framework
Puberty includes a period of very rapid skeletal growth (the adolescent growth spurt) accompanied by gradual development of reproductive organs and secondary sex characteristics (breast development in girls, facial hair growth in boys and the appearance of pubic hair in both sexes (Rogol et al. 2002). On average, the growth spurt reaches its peak around 12 among girls in the US (Santrock 1997) and occurs as an early event in girls development; in boys, fastest growth occurs around two years later in mid-puberty. For girls, menarche, the first menstrual period, occurs relatively late in puberty. Spermarche in boys marks the first ejaculation; it usually occurs in mid-puberty. The changes in bodily appearance that occur during puberty can present a major challenge of adjustment. Young people become increasingly body conscious (Richards et al. 1999). This increased self-awareness and focus can affect how they feel about themselves and relate to others, and ultimately influence their social and health-related behaviour. In line with body image (tightly related to biological changes) self-concept is shaped during this period (see chapter on Body Image). These changes are associated with emotional, cognitive and social processes as well. In relation with changing body and body perception typical behaviours can be observed. Boys generally try to become more muscular, whereas girls attempt to lose weight (e.g. McCabe / Ricciardelli 2004, Muris et al. 2005) according to the leading body ideal represented in media (e.g. Smolak / Stein 2006). Body change strategies to decrease weight or to increase muscles are related to negative affects (e.g. McCabe et al. 2001). Besides visible body changes, hormonal and other physiological processes also influence young peoples emotions, moods and psychological well-being, as well as their behaviour. Pubertal development is often associated with a higher level of depressive symptoms (e.g. Yuan 2007) and stress perception (e.g. Ge et al. 2001a, Huerta / Brizuela-Gamino 2002, Simon et al. 2003), problems in parent-child relationships (Laitinen-Krispijn et al. 1999, Paikoff / Brooks-Gunn 1991), increased level of sensation seeking and substance use (e.g. Harrell et al. 1998, Martin et al. 2002), and physical activity in boys (Simon et al. 2003), initiation of sexual activity (Mesche / Silbereisen 1997) and eating disturbances (e.g. Cotrufo et al. 2007, ODea / Abraham

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1999). Caspi and Moffit (1991) state that the crisis of puberty does not cause psychological and behavioural problems, but it can accentuate the existing individual differences. Young peoples capacity to adapt to the changes of puberty seems to depend at least in part on the timing of puberty in relation to the majority of their peers of the same age and a number of different theories have been proposed to explain this (Silbereisen / Kracke 1997). These theories rest on two basic conceptualisations, developed in the last 20 years or so, that have been used to guide the interpretation of empirical findings in many subsequent studies (Brooks-Gunn et al. 1985). The deviance hypothesis states that any deviance from the norm, whether earlier or later timing of maturation, results in difficulties in adaptation for the young person. These difficulties may be expressed through internalising, for example mental health or emotional problems, or externalising in the form of risk behaviours such as smoking or drinking. In contrast, the stage termination hypothesis predicts similar developmental problems arising from early maturation, because relative to age-mates, early developers have less time to adapt to their physical changes and the psychological and social challenges associated with these (Silbereisen / Kracke 1997). According to longitudinal studies, early maturing girls show the signs of poor adjustment, having more depressive symptoms (Ge et al. 2001a), being more dissatisfied with their body and engage in sexual activity more often (Michaud et al. 2006), being more physically inactive (Davison et al. 2007), reporting higher sedentary behaviour (van Jaarsveld et al. 2007), having more functional symptoms (Michaud et al. 2006), and more active in different substance use (Tschann et al. 1994), e.g. drink more alcohol (Costello et al. 2007), and smoke more cigarettes (Wiesner / Ittel 2002) comparing to on-time and late maturing peers. Early puberty is also associated with deviant behaviour in girls (Lynne et al. 2007). Some personality traits may have a role for engaging in health-compromising behaviour. Early maturing girls who are open to experiences at 5th grade were at risk for engaging in health-compromising behaviour (smoking, alcohol consumption and kissing) a year later (Markey et al. 2003). Cross-sectional studies also proved the relationship between early maturation and depressive symptoms (Kaltiala-Heino et al. 2003), more substance use, deviant behaviour (Obeidallah et al. 2004), early sexual intercourse (Currie / Nmeth 2004), vulnerability to sexual messages from media (Brown et al. 2005). Early onset of puberty can represent a health risk for girls in terms of negative body image. Since they have a greater proportion of body fat than their later maturing peers, they may be more likely to consider themselves too fat and in need of losing weight (Williams / Currie 2000, Currie / Nmeth 2004). This can result in a preoccupation with weight control and

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an unhealthy relationship with food, common among many young women (Kaltiala-Heino et al. 2001). For boys, the data is far from conclusive (Kaltiala-Heino et al. 2003). On the one hand early maturating boys have better social skills because of heightened self-esteem (Rowe et al. 2004) and body image as they are generally taller and more muscular than their peers and this can render them self-confident and socially dominant. In turn, late maturing boys are vulnerable from these points of view (Siegel et al. 1999). On the other hand early maturers use more substances than their peers (Tschann et al. 1994), e.g., drink more alcohol (Costello et al. 2007), initiate smoking earlier, associate with close friends who smoke (Drapela et al. 2006), smoke more (Wiesner / Ittel 2002), and initiate sexual activity earlier (Flannery et al. 1993). In a recent study both early and late maturing boys reported high dysfunctional eating patterns, victimization and depressive symptoms (Michaud et al. 2006). In boys, deviant behaviour and substance use in young adulthood was found to be related with late maturation (Graber et al. 2004). The above mentioned longitudinal studies have demonstrated that boys pubertal timing is associated with both positive and negative developmental outcomes in the short term, only few studies have investigated long term consequences of early puberty. Taga et al. (2006) found that among boys those who reached puberty earlier than their peers were more successful in their careers and in their marriages, and were not likely to smoke more cigarettes and drink more alcohol than their peers as adults. According to the stress-change hypothesis, change is inherently stressful, hence those who are in maturation process will experience troubles compared to youth in pre- and post-pubertal phase (Silbereisen / Kracke 1997). For example boys during transition to puberty had more depressive symptoms comparing to pre- and postpubertal boys (Yuan 2007).

4. Summary of previous work


The topic of puberty was included in the international survey questionnaire for the first time in 2001/02 with a single mandatory item (MQ120) to measure girls pubertal timing and status. The onset of menstruation (menarche) is a reliable indicator of puberty in girls (Ge et al. 2002). No suitable equivalent indicator was established for boys for the mandatory 2001/02 survey questionnaire. A choice of two optional items to measure boys pubertal development (P1.2(a)

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and P1.2(b)) has been introduced into the 2005/06 survey. These are an item on spermarche and an item on facial hair described below. The optional Pubertal Development Scale (PDS) introduced in the 2005/06 survey in the international study. As described in greater detail below, the scale was originally developed by Petersen et al (1988) as an interview-based puberty-rating scale and was adapted for selfadministration (Carskadon / Acebo, 1993). In addition, a single item on Perceived Pubertal Timing (Dubas et al. 1991) was proposed for the first time for the international survey in 2005/06. Finland, Scotland, Hungary and the USA have a historical interest in the topic of puberty and have each used various of the items offered for the 2005/06 international protocol in earlier national HBSC surveys. Menarche has been uniformly used for girls in these countries, while the item for boys has varied. Scotland used the Pubertal Development Scale in 2001/02 in HBSC and a related study. The new item on perceived pubertal timing (P1.1) was also included in the Scottish 2001/02 HBSC survey. Both optional packages were used in Scotland and Hungary in the 2005/06 survey. A number of publications already mentioned in the previous sections have arisen from this national HBSC research in Finland, Hungary, and Scotland (Williams / Currie 2000, Currie / Nmeth 2004, Nmeth et al. 2002, Ptsnen et al. 1993). These have analysed relationships among puberty, sexual behaviour, social background, body image, self-esteem, social relations and well-being. Early maturation in girls has been found to be a risk factor for smoking, negative body image, poor self-esteem, as well as early sexual activity with evidence supporting both the stage termination and deviance hypotheses (Williams / Currie, 2000). Significant direct relationship between pubertal development (measured with PDS scale) and subjective health complaints was found in a Hungarian sample (Nmeth et al. 2007). Among boys, besides health complaints, life satisfaction and depressive mood also showed significant connection with maturation, and there was an indirect relationship between maturation and the mentioned well-being variables mediated by body satisfaction (Nmeth et al. 2007). Furthermore, a Hungarian briefing paper addressing the associations between pubertal development and health-related outcomes was written for teachers and health educators (Nmeth 2009).

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5. Research questions
1. Is there variation between countries in pubertal timing according to age among boys and girls? 2. Does pubertal timing vary according to family factors such as family socioeconomic status and family composition? 3. What is the relationship between body mass index and pubertal status and are there gender, age and cross-national differences in these relationships? 4. What is the relationship between body satisfaction and pubertal status and are there gender, age and cross-national differences in these relationships? 5. Are pubertal status and perceived pubertal timing determinants of health and wellbeing among adolescent girls and boys, and are there gender, age and cross-national differences in these relationships? 6. Are there any mediators (such as body satisfaction) between pubertal timing (or pubertal status) and health outcomes (well-being and health-behaviours)? 7. Are there any moderators (such as gender or parental monitoring) between pubertal timing (or pubertal status) and health outcomes (well-being and health-behaviours)?

6. Instruments
6.1 Mandatory items
6.1.1 Onset of puberty: Menarche (mandatory) and spermarche (optional) Puberty is a continuous process involving a whole host of biological events many of which cannot be observed or perceived. In the case of girls the most obvious and memorable event is menarche and for boys its equivalent is spermarche. It should be noted that neither of these events marks the exact start of puberty but nevertheless indicate that puberty has begun. Both events, menarche and spermarche, are susceptible to self-report although with varying degrees of sensitivity in different cultures. To date the inclusion of menarche in the HBSC instrument has been acceptable in the vast majority of participating countries.

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Item box 1
GIRLS ONLY MQ54
1 2

Have you begun to menstruate (have periods)? No, I have not yet begun to menstruate Yes, I began at the age of ______ years and _______ months

Source: HBSC 2001/02, 2005/06

Coleman and Coleman (2002) have reviewed the validity of a wide range of puberty measures and conclude that age of menarche is a relatively salient and memorable event although they note there may be cultural variations in recall. Accuracy of recall in adult women is reduced as the time interval between the event and recall is increased. Given that the girls in the study are close to the event, recall is expected to be optimal. Ge et al. (2001b) reported highly accurate recall of menarche in years and months among girls in the 2-3 years immediately following menarche. In a study of Canadian girls only 59% were able to recall the exact month and year of their menarche and 77% were able to recall the date within one month of the originally reported date (Koo / Rohan 1997). In the 2001/2 cross-national survey age in years at menarche was asked. Following experience in Scotland of asking year and month of menarche it was proposed that month would also be asked in the mandatory questionnaire in 2005/06. The continuous distribution of scores that resulted allowed for more sophisticated statistical analyses of the timing of menarche (unpublished results).

6.2 Optional items


The optional packages listed below can be found in the item bank on the HBSC website. Optional package 1: Perceived pubertal timing and puberty in boys Optional package 2: Pubertal Development Scale (PDS) & perceived pubertal timing

7. References
Bond L, Clements J, Bertalli N, Evans-Whipp T, McMorris BJ, Patton GC, Toumbourou JW, Catalano RF. A comparison of self-reported puberty using the Pubertal Development Scale and the Sexual Maturation Scale in a school-based epidemiologic survey. J Adol 2006;29(5):709-20. Brooks-Gunn J, Petersen AC, Eichhorn D. The study of maturational timing effects in adolescence. J Youth Adol 1985;14:149-61.

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Brown JD, Halpern CT, L'Engle KL. Mass media as a sexual super peer for early maturing girls. J Adol Health, 2005;36(5):420-7. Carskadon MA, Acebo C. A self-administered rating scale for pubertal development. J Adol Health, 1993;14:190-95. Caspi A, Moffit TE. Individual differences are accentuated during periods of social change: the sample case of girls at puberty. J Person Soc Psychol 1991;61(1):157-68. Coleman L, Coleman J. The measurement of puberty: a review. J Adol 2002;25:535-50. Cooke C, Currie C, Inchley J, Mathieson A, Merson M , Young I. Growing Through Adolescence: A training pack based on a Health Promoting School approach to healthy eating. 2005a, NHS Health Scotland, Edinburgh. Costello EJ, Sung M, Worthman C, Angold A. Pubertal maturation and the development of alcohol use and abuse. Drug Alc Dep 2007;88:S50-9. Cotrufo P, Cella S, Cremato F, Labella AG. Eating disorder attitude and abnormal eating behaviours in a sample of 11-13 year-old school children: The role of pubertal body transformation. Eat Weight Disord 2007;12(4):154-60. Currie C, Nmeth . Puberty and health. In: Candace Currie et al (eds.) Young peoples health in context, Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Health Policy for Children and Adolescents, 2004; No. 4:196-204. Davison KK, Werder JL, Trost SG, Baker BL, Birch LL. Why are early maturing girls less active? Links between pubertal development, psychological well-being, and physical activity among girls at ages 11 and 13. Soc Sci Med 2007;64(12):2391-404. Drapela LA, Gebelt JL, McRee N. Pubertal development, choice of friends, and smoking initiation among adolescent males. J Youth Adol 2006;35(5):717-27. Dubas JS, Graber JA, Petersen AC. A longitudinal investigation of adolescents changing perceptions of pubertal timing. Dev Psych 1991;27: 580-586. Flannery DJ, Rowe DC, Gulley, BL. Impact of pubertal status, timing, and age: adolescent sexual experience and delinquency. J Adol Res 1993;8(1):2140. Ge X, Brody GH, Conger RD, Simons RL, MCBride MV. Contextual amplification of pubertal transition effects on deviant peer affiliation and externalizing behaviour among African-American children. Dev Psychol 2002;38(1): 42-54. Ge X, Conger RD, Elder Jr. GH. Pubertal transitions, stressful life events, and the emergence of gender differences in adolescent depressive symptoms. Dev Psychol 2001a;37(3):404-17. Ge X, Elder Jr. GH, Regnerus M, Cox C. Pubertal transitions, perceptions of being overweight and adolescents psychological maladjustment: gender and ethnic differences. Soc Psychol Quart 2001b;64:363-75. Graber JA, Seeley JR, Brooks-Gunn J, Lewinsohn PM. Is pubertal timing associated with psychopathology in young adulthood? J Am Acad Child Adol Psych 2004;43(6);718-26. Harrell JS, Bangdiwala SI, Deng S, Webb JP, Bradley C. Smoking initiation in youth: the role of gender, race, socioeconomics and developmental status. J Adol Health 1998;23(5):271-9. Huerta R, Brizuela-Gamino OL. Interaction of pubertal status, mood and self-esteem in adolescent girls. J Repr Med 2002;47(3):217-25. van Jaarsveeld CHM, Fidler JA, Simon AE. Persistent impact of pubertal timing on trends in smoking, food choice, activity and stress in adolescence. Psychosom Med 2007;69(8):798-806. Kaltiala-Heino R, Kosunen E, Rimpel M. Pubertal timing, sexual behaviour and self-reported depression in middle adolescence. J Adol 2003;26:531-45. Kaltiala-Heino R, Martunnen M, Rantanen P, Rimpela M. Early puberty is assocaieted with mental health problems in middle adolescence. Soc Sci Med, 2003;57:1055-64. Kaltiala-Heino R, Rimpel M, Rissanen A, Rantanen P. Early puberty and early sexual activity are associated with bulimic-type eating pathology in middle adolescence. J Adol Health 2001;28:34652.

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Kipke M. Adolescent development and the biology of puberty: summary of a workshop on new research, National Research Council, Institute of Medicine. Washington DC, National Academy Press, 1999. Koo MM, Rohan TE. Accuracy of short-term recall of age at menarche. Ann Hum Biol 1997;24:61-4. Laitinen-Krispijn S, Van der Ende J, Hazebroek-Kampschreur AAJM, Verhulst FC. Pubertal maturation and the development of behavioural and emotional problems in early adolescence. Act Psych Scand 1999;99(1):16-25. Lynne SD, Graber JA, Nichols TR, Brooks-Gunn J Botvin GJ. Links between Pubertal Timing, Peer Influences, and Externalizing Behaviors among Urban Students Followed Through Middle School. J Adol Health 2007;40(2): 181.e7-181.e13. Maestripieri D, Roney JR, DeBias N, Durante KM, Spaepen GM. Father absence, menarche and interest in infants among adolescent girls. Dev Scie 2004;7:560-6. Markey CN, Markey PM, Tinsley BJ. Personality, puberty, and preadolescent girls' risky behaviors: Examining the predictive value of the Five-Factor Model of personality. J Res Person 2003; 37(5):405-19. Martin CA, Kelly TH, Rayens MK, Brogli BR, Brenzel A, Smith WJ, Omar HA. Sensation seeking, puberty, and nicotine, alcohol and marijuana use in adolescence. Journal of the American Academy of Child and Adolescent Psychiatry, 2002;41(12);1495-502. McCabe MP, Ricciardelli LA, Banfield S. Body image, strategies to change muscles and weight, and puberty. Do they impact on positive and negative affect among adolescent boys and girls? Eat Behav 2001;2:129-49. Mesche LL, Silbereisen RK. The influences of puberty, family process, and leisure activities on the timing of first sexual experience. J Adol 1997;20:40318. Michaud PA, Suris JC, Deppen A. Gender-related psychological and behavioural correlates of pubertal timing in a national sample of Swiss adolescents. Mol Cell Endocrin 2006;254-55:172-8. McCabe MP, Ricciardelli LA. A longitudinal study of pubertal timing and extreme body change behaviors among adolescent boys and girls. Adol 2004;39:145-66. Muris P, Meesters C, van de Blom W, Mayer B. Biological, psychological, and sociocultural correlates of body change strategies and eating problems in adolescent boys and girls. Eat Behav 2005;6:11-22. Nmeth, . Puberty: associations of biological maturation, health and health behaviour. Briefing paper. 2008, National Institute of Child Health, Budapest. Nmeth , Bodzsr B, Aszmann, A. Maturation status and psychosocial characteristics of Hungarian adolescents (in English). Anthrop Kzlemnyek 2002;43:85-94. Nmeth , Kknyei Gy, Zakaris I. Mental health in adolescence: Relationship with pubertal development, body image, and parental monitoring. Anthrop Kzlemnyek 2007;48:105-49. Obeidallah D, Brennan RT, Brooks-Gunn J, Earls F. Links between pubertal timing and neighbourhood contexts: implications for girls violent behaviour. J Am Acad Child Adol Psych 2004;43(12): 14608. ODea JA, Abraham S. Onset of disordered eating attitudes and behaviors in early adolescence: interplay of pubertal status, gender, weight and age. Adol 1999;34(136):6719. Paikoff RL, Brooks-Gunn J. Do parent-child relationships change during puberty? Psychol Bull, 1991;110(1):47-66. Petersen AC, Crockett L, Richards M, Boxer A. A self-report measure of pubertal status: reliability, validity, and initial norms. J Youth Adol 1988;17: 117-33. Ptsnen, R. Kannas, L., Vlimaa, R. Teiniseksi heinladosta porttikongiin. (The association of social background to biologic maturation and sexual behaviour of Finnish teenagers.) (In Finnish with an English abstract.) In: Shemeikka, S., Nissinen, A. (ed) Terveyskasvatustutkimuksen vuosikirja 1992. Sosiaali- ja ter-veysministerin selvityksi,1/1993: 81-98 Richards MH, Boxer AM, Petersen AC, Albrecht R. Relation of weight to body image in pubertal girls and boys from two communities. Dev Psychol 1990, 26(2):31321. Rogol AD, Roemmich JN, Clark PA. Growth at Puberty. J Adol Health, 2002;31:192-200.

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Rowe R, Maughan B, Worthman CM, Costello EJ, Angold A. Testosterone, antisocial behaviour, and social dominance in boys: pubertal development and biosocial interaction. Biol Psych 2004;55:546-52. Santrock, JW. Life-span Development. 6th Edition, 1997. Brown and Benchmark Publishers, IA, USA. Saxbe DE, Repetti RL. Brief report: Fathers and mothers marital relationship predicts daughters pubertal development two years later. J Adol 2008; (in press). Schmitz KE, Hovell MF, Nichols JF, Irvin VL, Keating K, Simon GM, Gehrman C. Jones KL. A Validation Study of Early Adolescents Pubertal Self-Assessments. J Early Adol 2004;24(4), 357-84. Settertobulte W, Gaspar de Matos M. Peers and health. In: Currie C, Roberts C, Morgan A, Smith R, Settertobulte W, Samdal O, Barnekow Rasmussen V. (eds). Young People's Health in Context, Health Behaviour in School-aged Children study: International Report from the 2001/2002 Survey. Health Policy for Children and Adolescents, 2004, No.4, WHO Regional Office for Europe, Copenhagen, Denmark. Siegel JM, Yancey AK, Aneshensel CS, Schuler R. Body image, perceived pubertal timing and adolescent mental health. J Adol Health 1999;25:155-65. Silbereisen RK, Kracke B. Self-reported maturational timing and adaptation in adolescence. In: Schulenberg J, Maggs JL, Hurrelmann K. (eds) Health Risks and Developmental Transitions during Adolescence'. 1997, Cambridge University Press, Cambridge. Simon AE, Wardle J, Jarris MJ, Steggles N, Cartwright M. Examining the relationship between pubertal stage, adolescent health behaviours, and stress. Psychol Med 2003;33:1369-79. Smolak L, Stein JA. The relationship of drive for muscularity to sociocultural factors, self-esteem, physical attributes gender role, and social comparison in middle school boys. Body Im 2006;3:121-9. Taga KA, Markey CN, Friedman HS. A Longitudinal Investigation of Associations Between Boys' Pubertal Timing and Adult Behavioral Health and Well-Being. J Youth Adol 2006;35(3): 401-11. Tanner JM. Growth at adolescence, 2nd ed. 1966, Oxford: Blackwell. Tanner JM. Sequence, tempo and individual variation in growth and development of boys and girls aged twelve to sixteen. In: Kagan J, Coles R, (eds) Twelve to sixteen: Early Adolescence. 1971, New York: Norton, 1-24. Tschann JM, Adler NE, Irwin CE, Millstein SG, Turner RA, Kegeles SM. Initiation of substance use in early adolescence: the roles of pubertal timing and emotional distress. Health Psychol 1994;13(4): 326 33. Wang Y, Adair L. How does maturity adjustment influence the estimates of overweight prevalence in adolescents from different countries using an international reference? Int J Ob 2001;25:550558. Wiesner M, Ittel A. Relations of pubertal timing and depressive symptoms to substance use in early adolescence. J Early Adol 2002;22(1):5-23. Williams JM, Currie C. Self-esteem and physical development in early adolescence: pubertal timing and body image. J Early Adol 2000, 20:129149. Yuan ASV. Gender differences in the relationship of puberty with adolescents' depressive symptoms: Do body perceptions matter? Sex Roles 2007;57(1-2):69-80.

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II.4 Health and wellbeing


Ravens-Sieberer, U, Torsheim, T, Ottova, V, Mazur, J, Schnohr, C, Vlima, R, van Dorsselaer, S, Vollebergh, W

1. Scope and Purpose


In modern societies, several of the currently most challenging health problems can be described as problems of functional limitations rather than defined medical disease (Stein et al. 1993). Examples of such health problems are muscular-skeletal pain, chronic fatigue, and major depression. Additionally, mental health problems are becoming more relevant (Palfrey et al. 2005) and now shape the modern morbidity spectrum. Looking at health as a resource, public health investment is not only an issue of curing or preventing disease, but also an issue of enabling people to function optimally according to the demands and challenges they face during life. Conventionally, data on health were obtained from national morbidity and mortality statistics. While morbidity and mortality are important indicators of health, they may offer limited information in childhood and adolescence, since illness and death rates are usually very low during this life period (WHO 2005a). However, current trends show that there are large interand intra-country variations in childrens health regarding age, gender, socioeconomic status and geography (WHO 2005b). Research and monitoring of young peoples health and well-being is particularly important in a period of profound societal changes (Mortimer / Larson 2002). Young people of today grow up in societies with aging populations, increasing inequalities, changing family structures, more demanding school-to-work transition, and an extended period of socialization into adulthood (Mortimer / Larson 2002). The diffusion of information and communication technology has created completely new patterns of social interaction, and offers new opportunities for learning (Katz / Rice 2002). While these changes offer new opportunities, they also pose new demands that require strong adaptive skills in young people. Understanding how these dramatic societal processes affect young peoples health is essential for building healthy policies. The thematic and cultural diversity of the HBSC study offers unique opportunities to study how these ecological changes impact upon young people's health and well-being. Monitoring and documenting trends and cross-national differences in the psychological, social, and physical well-being of young people may serve as a first important step in making public
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health services adapt to the rising burden of mental health problems. For this reason, epidemiological data is a prerequisite for public policy and program development (Remschmidt / Belfer 2005).

2. Objectives
Underscoring the need for more comprehensiveness, the aim of this section on positive health is to assess young peoples health through the use of subjective indicators derived from young peoples perceptions and reports. The goal is to identify differences and conduct cross-cultural comparisons in terms of prevalence of physical and mental health problems in children and adolescents. A further aim is to identify time trends in the prevalence rates across countries, the strength of the association between subjective health and its determinants, as well as the differences in the strength of their association over time (trends in the HBSC studies). These investigations serve the purpose to examine health inequalities in school children in the context of their school environment, their peer culture and their family system. Another focus is on the role of social contextual factors, such as familial affluence, but also on cross-cultural differences. The role of intervening variables such as health-risk behaviour could be and will be studied also within such analyses.

3. Theoretical Framework
Today, a multitude of health definitions exist (Manderbacka 1998), making the identification of a common and widely accepted definition of health and illness difficult (Zemp-Stutz / Buddeberg-Fischer 2004, Ziegelmann 2002). A basic distinction is made between negative and positive health with negative definitions of health pointing towards the absence of ill health, whereas positive definitions add more to health for example, enjoying good health, feeling fit (e.g. von Wright 1963, 1955). Health definitions also differ depending on the cultural background and the actual perspective (medical, psychological, sociological, ethnological, philosophical and legal) (Schumacher / Brhler 2004). The individual perspective is focussed on the subjective experience of health and illness (Schumacher / Brhler 2004). Within the past decades this individual perspective has increasingly been recognized by health professionals and public health research and policy. For example, the WHO definition of health as a state of complete physical, mental and social well-being and not only the mere absence of illness and disability strongly incorporates such a subjective perspective. The concepts of subjective

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health, health-related quality of life and well-being are associated and can hardly be separated from one another (Leplege / Hunt 1997, Radoschewski 2000). The WHO definition also makes clear that health is a resource and not the objective of living (WHO 1986, n.p.). In line with these conceptualisations, this proposal follows a dynamic and multifaceted model of health. This means that to be in good health includes the:
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Relative absence of emotional distress and chronic conditions Presence of well-being and/or overall positive evaluation of health

A more distinct definition of health is not possible as, depending on the research interest, different aspects may be stressed. In addition, health as a subjective experience is situational and individuals vary in their own explanations of health and illness depending on their current circumstances, sex, social class, and ethnicity (Blaxter 1990, Stainton-Rogers 1991). Rather than defining health as a state, it could be determined as a dynamic, lifelong process. For example, Blaxter (1989, 1990) distinguishes between health status (a relatively long-term property of individuals) and health state (a shorter term property). In youth health research this categorisation is particularly useful when analysing the relationship between health and contextual factors. The relationship between health status and the social environment would be more fixed over the childyouth transition, while health state would be more likely to fluctuate with changing social circumstances (West / Sweeting 2004). In Blaxters classification disease/impairment and fitness (based on physiological measurements) reflect different dimensions of health status; and psychosocial malaise and illness (symptoms) reflect health state. In the study by West and Sweeting (2004), measures reflecting health status were longstanding illness and self-rated health and measures reflecting health state were physical and malaise symptoms and accidents/injuries. This broader view of health and multiple health questions is useful when formulating analytical tools in health research. The basic concept of this study, health, is a complex one that includes biological, psychological and social dimensions. The way health is conceptualised has relevance in both the way it should be measured and in the way results of empirical studies are interpreted. Furthermore, the way the respondents understand health has a bearing on the way they answer survey questions concerning it.

Theory/ Model Within the HBSC study, three mandatory and four optional package items are used to assess Positive Health in Children and Adolescents. As outlined in the background information, health

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is a complex and difficult to define concept involving a variety of aspects as well as perspectives. For this reason, it is necessary to differentiate between physical and psychological standpoints on health. Physical position is covered by means of the Health Complaints Index, the Physical Disability and Chronic Conditions item and the Medicine Use item (this item is dealt with in a separate chapter). The psychological perspective is found in the mandatory items Self-rated Health and Life satisfaction, and in the Global Wellbeing (KIDSCREEN) and the Strengths and Difficulties Questionnaire. Figure 1 shows the different positive health items and how they relate to each other. At the top are the two core items of positive health, namely self-rated health and life satisfaction. Self-rated health indicates the health status of the child according to the childs/adolescents perspective. Life satisfaction focuses on describing the overall content, not just the healthoriented satisfaction with life, i.e. the childs/adolescents current situation. These two items are the roof of the positive health construct which houses a variety of other related items. These other items can be subdivided into physical well-being and psychological well-being items forming the two bubbles in Figure 1 below. Two of these items, the health complaints index and the global well-being (KIDSCREEN), can function as screening instruments (in conjunction with the two mandatory items mentioned above). Particularly important is that these two bubbles, although distinct, are not completely separate from each other, as global well-being contains a dimension on physical well-being (i.e. is not just limited to mental and psychological well-being aspects), and vice versa physical well-being, i.e. the health complaints index also contains aspects of psychosocial health. The four optional package items fall under either of these categories, helping to portray a more complete depiction of positive health.

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General single Positive Health Items Self-rated health (M), Life satisfaction (M)

Physical well-being Health Complaints Index (M)

Psychological well-being Global well-being (Kidscreen) (OP)

Burden of diseases: Medicine use (OP) Illness and disability items (OP)

Mental health: Strengths and Difficulties Questionnaire (SDQ) (OP)

Figure 1 Overview of the items in the Positive Health Model (M=mandatory, OP=optional package)

The variables used to measure Positive Health within the HBSC study will be described individually, i.e. one section per variable. These sections follow the general structure of the protocol chapters (i.e. they begin with the scope and purpose of the item, its objectives, the theoretical framework for the variable, a summary of previous work, research questions, followed by a description of the instrument and a list of the planned papers by the PH Focus Group on this particular variable). Each section concludes with a list of references. First, the mandatory variables (Self-rated Health and Life Satisfaction, Health Complaints Index), and then the optional package items will be described. The optional package items are subdivided into Physical Well-being items and the Mental and Psychological Well-being category items. The physical well-being section includes the Health Complaints Index (HBSC Symptom Checklist) - a mandatory item, the Physical disability and chronic conditions (optional package item) and Medicine Use (optional package) which is covered in a separate chapter. The mental and psychological well-being is represented by two optional package items, namely the global well-being item (KIDSCREEN) and the Strengths and Difficulties Questionnaire the latter is described in detail in a separate chapter and can also be found on the item bank.

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II.4.1 Self-rated Health


1. Scope and purpose
Self-rated health is based on individuals perception and evaluation of his or her health, and is usually founded on age-peer comparison either consciously or unconsciously (Bjorner et al. 1996). Self-rated health can be distinguished form more specific health constructs in that it captures an overall conception of health, rather than a summation across specific domains of health. The relevance of such general perceptions has been demonstrated in a number of empirical studies in which self-reported health has been an independent predictor of mortality, even after accounting for known demographic, social and medical risk factors. A summary of twenty-seven community studies (Idler / Benyamini 1997) showed impressively consistent findings in relating self-reported health with future mortality, which persisted when numerous health indicators and other relevant covariates were included in the analysis. Other studies have also addressed the relationship between self-reported health and cause-specific mortality (Benjamins et al. 2004) indicating that a high number of causes are specifically associated with perceived health. In particular, diabetes, infectious and respiratory diseases show a strong association, while so-called social pathologies (accidents, suicides, and homicides) were not. The relationship with gender has also been explored, pointing out a quite strong gender difference which should be explored in more depth. It seems therefore quite important to keep this item, given the fact that gender differences in perceived health have already been documented in the HBSC data and this domain of research seems to be a most interesting one for the future.

2. Objectives
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To explore the association between self-reported (perceived) health and cause-specific mortality further

To explore the gender differences with specific pathologies (such as accidents, suicide, homicide, but also diabetes, infectious and respiratory disease)

To identify trends and conduct country comparisons on this item.

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Explore the role of social and cultural background on perceived health and identify similarities / differences

3. Theoretical framework
Self-rated health is central to the WHO definition of health. According to this definition, health cannot be reduced to simply the absence of disease, nor to the mere presence of well-being. From a systems perspective, health is more than the sum of constituent parts, but rather how the different parts interact. For example, chronical disease might have a strong impact on health if such disease impairs the persons life opportunities, or impairs opportunities for a healthy lifestyle. This indicates a need for a holistic construct of health, tapping the overall state of the person. The concept of self-rated health indicates that the state of the system cannot be determined from isolated parts. Importantly self-rated health, as it is typically operationalised, covers a continuum, ranging from what has been termed negative health to positive states, depending on the overall state of the system. In adolescence, health is a particularly important resource and poor health may result in longterm negative effects which may continue throughout adulthood (WHO 2006). As they develop, young people must deal with a variety of challenges. Being in good health physically, emotionally and socially helps young people deal productively with these challenges (Burt 2002). Thus, promoting young peoples health can have long-term benefits for individuals and societies, especially as it contributes to the health of future generations (WHO 2005). However, adolescence, in particular mid-adolescence, is the typical age of onset for a range of mental disorders (Hoven et al. 2008). For example, hazard rates for unipolar depression peak at the age of 15, suggesting that adolescence is a vital period in shaping patterns of mental health (WHO 2000). Monitoring and documenting trends and cross-national differences in the psychological, social, and physical well-being of young people may serve as a first important step in making public health services adapt to the rising burden of mental health problems.

4. Summary of previous work


Self-rated health has been addressed in several publications within the HBSC. Cavallo et al. (2006) reported a gender by age interaction in self-rated health, with girls reporting poorer

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health across ages 11 to 15. The gender by age interaction was also observed for health complaints. Kelleher et al, using the 1998 material, found psychosocial, demographic, and health-related correlates of self-rated health. Adolecsents with self-rated poor health had more health complaints, lower life satisfaction, were less physically active and had more diffculties making friends. In a second study on the 1997/98 material, Torsheim et al reported a strong relationships between material circumstances at individual,school,and country level on selfrated poor health. Non-HBSC studies confirm that there are multiple independent correlates of adolescent selfrated health (Breidablik et al. 2009) , and that age-related increase in poor health can be observed during adolescence (Wade / Vingilis 1999).

5. Research questions
1. Is worsening in the level of subjective health indicators between age of 11 and 16 a developmental phenomenon and how can it be reduced? 2. Are there any interactions between risk and protective factors as determinants of subjective health indicators? 3. What are the trends in self-reported health?

6. Instruments
6.1 Mandatory Items
Self-reported health which measures perceived health status has been included in all previous HBSC surveys. In the 1997/98 survey self-reported health was measured by the item 'How healthy do you think you are?' (Response options were: very healthy - quite healthy - not very healthy). A problem experienced by several countries with this item was that the response format produces little variance. Therefore, beginning with the HBSC survey 2001/2002 the protocol proposed substituting the above item with a well-established measure on selfreported health. This item has been proven to work well in large epidemiological surveys (Idler / Benyamini 1997), and now included four response categories excellent good fair poor. Since the introduction of the item, it has been known that there are variations in the

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translation of the fair, which in some countries had a positive slant (leaning towards excellent and good) while in other countries, the translation had a negative slant, leaning towards poor. For more information on this, see section on Red Flag Items. The item has remained unchanged since the 2001/02 survey. Item box 1
MQ41
1 2 3 4

Would you say your health is? Excellent Good Fair Poor

Source: Idler, E. L. & Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health and Social Behavior, 38, 21-37. HBSC 2001/02

Item placement In the questionnaire it is located in the section II.4.1 Positive health, following section III.3.1 on Puberty.

Validation work The self-rated health item has not been subject to structured validation studies in the HBSC, but several studies are relevant to making claims about validity. First, in line with the assumption of a meta-construct of health, self-rated health has shown multiple independent health-related correlates, including medical diagnosis, health complaints, and social, as suggested in a recent cohort study. Second, relevant to the issue of reliability, self-rated health show some degree of stability across periods, suggesting that these self-reports are not simply a fluctuating subjective impression. The item was analysed in terms of its feasibility and psychometric robustness using the 2001/02 data set from all countries involved (Cavallo et al. 2006). In particular, as a main outcome, the results confirm the already reported trend of an increasing perception of poor health with increasing age in the pre-adolescence phase. They also confirm the higher risk for girls to perceive a poorer health, independently of age (Cavallo et al. 2006). For the first time these results are documented in such a large number of countries, comprising almost the whole of Europe, plus North America and Israel.

7. References
Benjamins, M.R., Hummer, R.A., Eberstein, I.W., Nam, C.B. (2004). Self-reported health and adult mortality risk: an analysis of cause-specific mortality. Social Science and Medicine 59: 1297-1306.

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Bjorner, J.P., Kristensen, T.O., Orth-Gomer, K., Tibblin, G., Sullivan, M., Westerholm, P. (1996). Self-rated health. A useful concept in research, prevention and clinical medicine. Forskningsrdsnmnden. Uppsala: Ord & Form AB. Breidablik, H.J., Meland, E., Lydersen, S. (2009). Self-rated health during adolescence: stability and predictors of change (Young-HUNT study, Norway). European Journal of Public Health 19(1): 7378. Burt, M.R. (2002). Reasons to invest in adolescents. J Adolesc Health 31 (suppl 2): 136-52. Cavallo, F., Zambon, A., Borraccino, A., Raven-Sieberer, U., Torsheim, T., Lemma, P. (2006). Girls growing through adolescence have a higher risk of poor health. Qual Life Res 15(10): 1577-1585. Hoven, C. et al. (2008). Worldwide child and adolescent mental health begins with awareness: a preliminary assessment in nine countries. Int Rev Psychiatry 20(3): 261-70. Idler, E.L., Benyamini, Y. (1997). Self-rated health and mortality: A review of twenty-seven community studies. Journal of Health And Social Behavior 38: 21-37. Murray, C.J.L., Lopez, A.D. (eds) (1996). The Global Burden of Disease: a comprehensive assessment of mortality and disability from diseases, injuries, and risk factors in 1990 and projected to 2020. Cambridge, MA: Harvard University Press. Wade, T.J., Vingilis, E. (1999). The development of self-rated health during adolescence: An exploration of inter- and intra-cohort effects. Canadian Journal of Public Health-Revue Canadienne De Sante Publique 90(2): 90-94. World Health Organization (WHO) (2000). Cross-national comparisons of the prevalences and correlates of mental disorders. Bulletin of the World Health Organization 78 (4): 413-26. World Health Organization (WHO) (2003). Caring for children and adolescents with mental disorders. Setting WHO directions. Geneva, Switzerland. World Health Organization (WHO) (2005a). European strategy for child and adolescent health and development. Copenhagen, Denmark. [Online] URL: http://www.euro.who.int/document/E87710.pdf (27-10-2008) World Health Organization (WHO)/HBSC Forum (2006). Addressing the socioeconomic determinants of healthy eating habits and physical activity levels among adolescents. [Online] URL: http://www.nuigalway.ie/hbsc/documents/whohbsc_forum_2006.pdf (14-10-2008)

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II.4.2 Life Satisfaction


1. Scope and purpose
The conceptualisation of life satisfaction largely draws upon psychological and sociological research, with an emphasis on the evaluative aspects of subjective well-being. Relevant theories view life satisfaction as being structured by goals (e.g. Emmons 1986). The basic assumption is that resources that lead to achievement of developmental tasks have a major positive impact on overall life satisfaction. Such resources may exist both at the individual and the contextual level. According to Hurrelmann (1990), adolescence can be characterised by four main developmental tasks:
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Scholastic achievement to qualify for further education Development of social and sexual relationships Building up a consumer lifestyle Building up ethical and political system of values.

In adult research on life satisfaction, a one-item scale has proved to be a valid measurement of this concept (Cantril 1965). Minor wording change was conducted on the original item to facilitate its use in 11 year olds and this revised version was piloted in five countries in spring 2001. In all but one country the scale seemed to work well. Based on the feedback of the pilot some design changes have been made to the presentation.

2. Objectives
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To explore the trends in life satisfaction in adolescents To assess happiness in schoolchildren To explore differences in life satisfaction between groups of healthy and unhealthy children (according to self-reported general health)

Happiness of children in different family settings

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3. Theoretical framework
Well-being is multifaceted (Diener 1984, Wilkinson / Walford 1998). Absence of distress is a major component, but equally important is the presence of positive affective states, such as happiness and excitement. An important cognitive aspect of well-being is the overall evaluation of life, i.e. life satisfaction. Determinants of life satisfaction were not studied until early 1990s (Suldo et al. 2006). In a study on bullying and subjective health of adolescents in Latvia and Lithuania conducted by Gobina et al. (2008), bullying was associated with both, low subjective health as well as low life satisfaction. Life satisfaction is a global assessment of ones life and is thought to be relatively stable over time, compared with spontaneous feelings related to ones immediate experiences (Pavot / Diener 1993). Among adults it is associated with depression, anxiety, suicide, work disability, fatal accidents and all-cause mortality (Fiscella / Franks 1997, Helliwell 2007, KoivumaaHonkanen et al. 2001, Koivumaa-Honkanen et al. 2002, Koivumaa-Honkanen et al. 2004a, Koivumaa-Honkanen et al. 2004b). Studies of life satisfaction have found that during adolescence, life satisfaction is strongly influenced by life experiences and relationships, particularly within the context of the family (Edwards / Lopez 2006, Gohm et al. 1998, Rask et al. 2003).

4. Summary of previous work


Previous works have looked at life satisfaction in association with school. In their study, Huebner and colleagues looked at school as one of the goal domains with the largest impact on overall life satisfaction (Huebner et al. 1998). Previous HBSC-based studies have also shown a strong link between psychosocial resources in school and school satisfaction (Samdal et al. 1998). Suldo et al. (2006) looked at academic correlates of life satisfaction in a literature review. They failed to find an association in American students; however, the authors suggest that culture may be moderating this effect. A key research question is to evaluate the impact of school-related resources on overall life satisfaction as one of the important developmental goals in adolescence is to achieve scholastic competence for further education (Hurrelmann 1990). Resources that help to achieve this goal may be relevant for overall life satisfaction. Also the association between social and material resources and their contribution to life satisfaction was studied in the previous HBSC survey and will be further deepened in the next survey. In research on adults, two competing perspectives on the role of material resources

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have dominated: the relativistic and the absolute-level view. According to the latter view, it is the absolute level of resources that is of importance to individual life satisfaction. In contrast, the relativistic perspective maintains that it is the resources relative to a given standard (e.g. neighbours, workmates) that is of importance to life satisfaction. Evidence for the absolutelevel hypothesis was reported by Diener and colleagues (1995) in a study on national subjective well-being of adults. They found that average purchase power was strongly predictive of average level of life satisfaction. However, others have found support for the relative position (Kennedy et al. 1998), suggesting that also within-group comparisons of resources may be important to well-being. Using multilevel modelling, the different kinds of effects found within and between countries can be clearly established in the HBSC study, as 35 countries will provide efficient estimates at individual, school, and country levels. In addition to these perspectives, which are related to a) needs-theory and b) relative standards theory, there are perspectives focussing on c) individual goals and d) cultural approaches. Despite empirical support for each of these theories, there are data contradicting a simple formulation of each model. No stand-alone approach can by itself explain all of the empirical findings. Diener and Lucas (2000) demanded for both applied and theoretical reasons, to determine the types of societal characteristics that enhance subjective well-being. They proposed the Evaluation Theory model which assumes subjective well-being to depend on peoples evaluation of self-relevant information. Evaluations are likely to be influenced by chronically accessible and salient information, which in turn is influenced by the person's needs, goals, and culture. Examples of macro-level perspective on health have only recently emerged in the HBSC. Levin et al. (submitted) found a nonlinear association between family affluence and Life Satisfaction. In this study there was also an interaction between individual family affluence and gini of income. These findings call for increased attention to the interactive effects of micro-level influences on Life Satisfaction. Other previous work included the study of self-reported health and life satisfaction in children from Poland and other countries (Woynarowska et al. 2004), and analyses in risk behaviours syndrome in association with subjective health and life satisfaction in 15-year-olds (Mazur / Woynarowska 2004).

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5. Research questions
1. To examine the impact of school-related resources on overall life satisfaction 2. What resources (social and material) are particularly relevant for overall life satisfaction? 3. How does wealth and other defined macrolevel factors (e.g. Human development) influence Life satisfaction? 4. How do macro-level factors interact with individual factors?

6. Instruments
6.1 Mandatory items
The item is a measure of general life satisfaction and functions as an indicator of well-being. As the Cantril ladder is an item-efficient measure of life satisfaction, it is included in the mandatory part of the questionnaire. It has remained unchanged since the 2001/02 survey. Item box 1
MQ42 Here is a picture of a ladder. The top of the ladder 10 is the best possible life for you and the bottom 0 is the worst possible life for you.In general, where on the ladder do you feel you stand at the moment? Tick the box next to the number that best describes where you stand. 10 9 8 7 6 5 4 3 2 1 0 Worst possible life Best possible life

Source: Cantril, H. (1965). The pattern of human concern. Rutgers University Press. Adapted for HBSC survey 2001/02, 2005/06

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Item placement The item should be placed after the self-rated health question.

Validation work The Cantril ladder has not been subject to structured validation studies in the HBSC. Still, observed relationships with quality of life and with self-rated health are in the expected range, and support claims about validity. In a Polish study life satisfaction was predicted by all subcomponents of the Kidscreen. There are also results suggesting that adolescent reports at aggregate country level correlate strongly with adult reports (Mazur, personal

communication). Analyses carried out on former HBSC surveys showed the item to be associated with the general health item and the HBSC symptom checklist (Cavallo et al. 2006).

Guidance on analysis The item is either analyzed in terms of the actual item answer category, leading to a score between 0 and 10. On the other hand it is possible to categorize the responders into those with normal to high life satisfaction (6-10) and those with low life satisfaction (0-5).

7. References
Cantril, H. (1965). The pattern of human concern. Rutgers University Press. Cavallo, F., Zambon, A., Borraccino, A., Raven-Sieberer, U., Torsheim, T., Lemma, P. (2006). Girls growing through adolescence have a higher risk of poor health. Qual Life Res 15(10): 1577-1585. Diener, E. (1984). Subjective well-being. Psychological Bulletin 95: 542-575. Diener, E., Diener, M. , Diener, C. (1995) Factors predicting the subjective well-being of Nations. Journal of Personality and Social Psychology 69: 851-864. Diener, E., Lucas, R.E. (2000). Explaining Differences in Societal Levels of Happiness: Relative Standards, Need Fulfillment, Culture, and Evaluation Theory. Journal of Happiness Studies 1(1): 41-78. Emmons, R.A. (1986). Personal strivings: an approach to personality and subjective well-being. Journal of Personality and Social Psychology 51: 1058-1068. Gobina, I. et al. (2008). Bullying and subjective health among adolescents at schools in Latvia and Lithuania. Int J Public Health (epub ahead of print) Hurrelmann, K., Lsel, F. (1990). Basic issues and problem of health in adolescence. In K. Hurrelmann & F. Lsel (eds.). Health hazards in adolescence. Berlin: Walter de Gruyter, pp. 1-21. Kennedy, B.P., Kawachi, I., Glass, R., Prothrow-Stith (1998). Income disitribution, socioeconomic status, and self-rated health in the United States: multilevel analysis. British Medical Journal 317: 917921.

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Levin et al. (submitted). Adolescent life satisfaction, family structure, family affluence and gender differences in parent-child communication. Mazur, J., Woynarowska, B. (2004). [Risk behaviors syndrome and subjective health and life satisfaction in youth aged 15 years]. Med Wieku Rozwoj 8(3Pt1): 567-583. Samdal, O., Nutbeam, D., Wold, B., Kannas, L. (1998): Achieving health and educational goals through schools : A study of the importance of school climate and students' satisfaction with school. Health Education Research 13(3): 383-397. Suldo, S.M., Riley, K.N., Shaffer, E.J. (2006). Academic Correlates of Children Adolescents Life Satisfaction. School Psychology International 27(5): 567-582. Wilkinson, R.B., Walford, W.(1998). The measurement of adolescent psychological health: One or two dimensions? Journal of Youth and Adolescence 27: 443-455. Edwards, L.M., Lopez, S.J. (2006). Perceived family support, acculturation, and life satisfaction in Mexican American youth: A mixed-methods exploration. Journal of Counselling Psychology 53: 279-287. Fiscella, K., Franks, P. (1997). Does psychological distress contribute to racial and socioeconomic disparities in mortality? Social Science & Medicine 45: 18051809. Gohm, C., Oishi, S., Darlington, J., Diener, E. (1998). Culture, parental conflict, parental marital status, and the subjective well-being of young adults. Journal of Marriage and the Family 60: 319334. Helliwell, J.F. (2007). Well-being and social capital: Does suicide pose a puzzle? Social Indicators Research 81: 455-496. Koivumaa-Honkanen, H., Honkanen, R., Viinamaki, H., Heikkila, K., Kaprio, J., Koskenvuo, M. (2001). Life satisfaction and suicide: A 20-year follow-up study. American Journal of Psychiatry 158: 433-439. Koivumaa-Honkanen, H.T., Honkanen, R., Koskenvuo, M., Viinamaki, H., Kaprio, J. (2002). Life satisfaction as a predictor of fatal injury in a 20-year follow-up. Acta Psychiatrica Scandinavica 105: 444450. Koivumaa-Honkanen, H.T., Kaprio, J., Honkanen, R., Viinamaki, H., Koskenvuo, M. (2004a). Life satisfaction and depression in a 15-year follow-up of healthy adults. Social Psychiatry and Psychiatric Epidemiology 39: 994-999. Koivumaa-Honkanen, H.T., Koskenvuo, M., Honkanen, R., Viinamaki, H., Heikkila, K., Kaprio, J. (2004b). Life dissatisfaction and subsequent work disability in an 11-year follow-up. Psychological Medicine 34: 221-228. Pavot, W.G., Diener, E. (1993). Review of the Satisfaction with Life Scale. Psychological Assessment 5: 164-172. Rask, K., Asted-Kurki, P., Paavilainen, E., Laippala, P. (2003). Adolescent subjective well-being and family dynamics. Scandinavian Journal of Caring Sciences 17: 129138. Woynarowska, B, Tabak, I, Mazur, J (2004). Self-reported health and life satisfaction in school-aged children in Poland and other countries in 2002. Med Wieku Rozwoj. 8(3): 535-550.

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II.4.3 Health Complaints


1. Scope and purpose
In the last years researchers in health sciences have become more and more aware of increasing health complaints in childhood and adolescence. Health complaints do not only encompass somatic symptoms such as headache or backache, but also psychological symptoms, such as nervousness or irritability. It is agreed upon that psychosomatic complaints constitute a stress reaction based on psychosocial tensions. Subjective health complaints is used to describe a wide range of phenomena, which may range from occasional health complaints i.e. those that most young people experience every once in a while to clinical manifestations of health complaints which may impair everyday functioning. It is a term that does not reflect any pre-assumptions about aetiology. Subjective health complaints represents an account of the fact that health complaints tend to cluster together (Starfield et al. 1984, Alfven 1993, Klepp et al. 1996, Mikkelsson et al. 1997, WHO/HBSC Forum 2006) and as a consequence, can cause immense burden on the individual as well as on the health care system, it is particularly important that in-depth analyses look at the underlying dimensions (Haugland et al. 2001).

2. Objectives
-

To study the underlying dimensions of health complaints and their burden on individuals

To identify trends within and across countries in terms of psychosomatic complaints To conduct comparisons in the prevalence of health complaints between countries and within countries according to age, gender, SES, and other factors

To study the association between health complaints and current trends in chronic conditions and physical as well as mental impairments

3. Theoretical framework
The HBSC symptom checklist (HBSC-SCL) has been used in all previous surveys since 1986. The scale is a measure of subjective health and includes headache, abdominal pain, backache,

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feeling low, irritability or bad mood, feeling nervous, sleeping difficulties and dizziness (Haugland et al. 2001). Previous (Haugland et al. 2001) and ongoing research (Hetland et al. 2002) suggests that the scale reflects two facets - one psychological and one somatic facet. But overall, the scale can be considered as measuring along a uni-dimensional latent trait of psychosomatic complaints (Ravens-Sieberer et al. 2008; Hagquist / Andrich 2004). The scale is flexible in that statistical analyses are meaningful both on single-item level (Torsheim / Wold 2001) and on sum score level (Haugland et al. 2001). Other studies on the topic have used different numbers of symptoms, resulting in 2-factor (Hopland et al. 1993), as well as 3-factor solutions (Hurrelmann et al. 1988). Various other studies used the Psychosomatic Symptom Checklist (PSC) covering 17 complaints. Comparability between studies is generally difficult due to differences in the methodology (Haugland et al. 2001).

4. Summary of previous work


A WHO multi-centre study involving 14 countries found large national differences in the prevalence of somatisation and sub-clinical manifestations of somatic complaints (Gureje et al. 1997). These differences suggest that cultural and societal factors may play an important role in adults presentations of somatic complaints. It is important to document similar effects in young people; as such evidence may point to the need for culturally sensitive efforts in primary and secondary prevention. Research on the HBSC 1997/98 data as well as on the 2005/06 data suggests a significant between-country variance in health complaints (Torsheim et al. 2004; Ravens-Sieberer et al. 2008). Woynarowska et al. (2004) used HBSC 2001/2002 data and found that the lowest health ratings as well as the lowest satisfaction with life were in countries of the former Soviet Union. Multiple health complaints on the other hand were reported most often in Greece, Italy, Israel and Spain. Previous analyses of the 2005/2006 survey revealed similar results (Ravens-Sieberer et al. 2008). Previous HBSC study analyses have revealed distinct age and gender patterns. Torsheim et al. (2006) were able to show that gender differences were present, however, varied by country. Also, 15 year old girls had a particularly increased risk for health complaints regardless of country of origin. On the basis of two studies conducted in Poland, strong social bonds appeared to be a protective factor against recurrent health complaints in low income families (Mazur et al.

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2008), and good family relationships were recognized as protective factors reducing influence of negative perception of peer environment on adolescent subjective health (Mazur/Tabak 2008). Previous work on the health complaints has been dominated by variable-centred strategies, which are useful at identifying broad dimensions of symptoms, and at describing the distribution and covariance across these dimensions. Variable-centred strategies are however less useful for identifying heterogeneous subgroups. For example, some individuals might display a pattern of high levels of headache and backache. Others might present headache with affective symptoms, but without backache. To be able to detect and validate the status of such specific patterns, it is necessary to shift from a variable-centred to a person-centred approach. Such specific qualitative patterns require a person-centred approach.

5. Research questions
1. What differences can be found in the prevalence of health complaints crossculturally? Which societal and cultural factors can explain these differences? A multilevel analysis model will be specified and tested. 2. Is there cross-cultural variability in the strength of association of social inequality, school-environment and family culture with health complaints and self-rated health? A multilevel model of association will be specified and tested. 3. Are there trends in the prevalence of health complaints? What cross-national and gender differences in these trends can be detected? Which factors (e.g. changes in social inequality, changes in national indicators of welfare, changes in national school and health policy) can explain the observed trends? A longitudinal multilevel research design will be applied.

6. Instruments
6.1 Mandatory items
The scale used in the HBSC study is a non-clinical measure of mental and physical health. The list includes physical and psychological symptoms. (Note: this measure is also referred to as the HBSC symptom checklist and psychosomatic complaints). The item has remained unchanged since the 2001/2002 survey.

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Item box 1
MQ40 In the last 6 months: how often have you had the following.? Please tick one box for each line More than About About once a every every day week week
1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3

About every month


4 4 4 4 4 4 4 4

Rarely or never
5 5 5 5 5 5 5 5

Headache Stomach-ache Back ache Feeling low Irritability or bad temper Feeling nervous Difficulties in getting to sleep Feeling dizzy

Source: HBSC 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, 2005/06

Item placement The item should be placed in the questionnaire behind the questions on life satisfaction and mental health.

Validation work Haugland and colleagues performed an important line of studies on the validity of the HBSC symptom checklist (Haugland / Wold 2001, Haugland et al. 2001). Qualitative semi-structured interviews with early adolescents revealed that adolescents perceive the symptoms to be aversive physical and psychological states that interfere with daily functional ability and wellbeing. In these interviews, adolescents were also consistent in how they defined different symptoms, suggesting that adolescents have a common frame of reference when they rate their frequency of symptoms (Haugland / Wold 2001). Interestingly however, adolescents differed in their lay perspectives on the causes of such symptoms. In some cases explanations were consistent with a stress-model of health complaints. In other cases adolescents attributed their health complaints to developmental processes, such as growing pain, or ergonomic factors such as low quality of air in classrooms etc. Using quantitative data, Haugland and Wold (2001) also found acceptable test-retest reliability for the HBSC symptom scale as a whole (Pearson-r = .79), and somewhat lower reliability for the single symptoms (Pearson-r = 0.61 to 0.76). Several studies have examined the factor structure of the HBSC symptom checklist. Using the HBSC 1993/94 data, Haugland and colleagues (2001) found that a one factor solution fitted the

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data reasonably well. However, a correlated two-factor model fitted the data significantly better in all samples. According to the two-factor model, the symptom checklist reflects one psychological subdimension (feeling nervous, feeling low, irritability, difficulties in getting to sleep) and one somatic subdimension (headache, abdominal pain, backache and dizziness). Hetland et al. (2002) reported similar findings, with evidence for two highly correlated dimensions. In both of these studies, the correlation between the two dimensions was very strong, suggesting that the scale reflected one general higher order factor. The strong correlation might indicate that a distinction between subfactors provides little extra information compared to that of a total symptom score. The sum score of the HBSC symptom checklist has been validated in 12 European countries within the large field study of a European project (n=22,000). Moderate to high correlation with scales measuring Psychological well-being (r=-.47), Depressive Moods (r=.53) and Physical well-being (r=-.42) have been observed (Ravens-Sieberer et al. 2007).

Guidance on use in analyses a) First method of scoring: Creating a Subjective Health Complaints Index The index was developed based on a RASCH measurement analysis which proved that the items are indicators of a uni-dimensional latent trait called Subjective Health Complaints. Furthermore, the individual persons can be ordered on the latent trait continuum depending on their responses to the items. Originally 8 items however, the index is calculated using only 7 out of the 8 items. The item sleeping difficulties is not used because it shows differential item functioning (DIF) across countries. The scale enables to get a concise summary of individual health complaints. In order to calculate the index it is necessary to sum up the 7 items (see above). Values range from 1 to 35. Then the sum score can be transformed nonlinearly into RASCH person parameter values which then can be linearly converted into Tvalues. Higher values indicate fewer and less severe health complaints. b) Second method of scoring: Multiple recurrent health complaints (all 8 items are included) The percentage of students can be calculated who experience two or more subjective health complaints at the same time several times a week or daily.

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7. References
Alfven, G. (1993). The covariation of common psychosomatic symptoms among children from socioeconomically differing residential areas: an epidemiological study. Acta Paediatr 82(5): 484-487. Gureje, O., Simon, G., Ustun, T.B., Goldberg, D.P. (1997). Somatization in Cross-Cultural Perspective: a World Health Organization Study in primary care. American Journal of Psychiatry 154: 989-995. Hagquist, C., Andrich, D. (2004). Measuring subjective health among adolescents in Sweden. Social Indicators Research 68 (2): 201-220. Haugland, S., Wold, B., Stevenson, J., Aaroe, L.E., Woynaroska, B. (2001). Subjective health complaints in adolescence. A cross-national comparison of prevalence and dimensionality. Eur J Public Health 11(1): 4-10. Haugland, S., Wold, B. (2001). Subjective health complaints in adolescence--Reliability and validity of survey methods. Journal of Adolescence 24(5): 611-624. Hetland, J., Torsheim, T., Aaro, L.E. (2002). Subjective health complaints in adolescence: dimensional structure and variation across gender and age. Scand J Public Health 30(3): 223-230. Hopland, K., Aaroe, L.E., Wold, B. [Social network, loneliness and everyday complaints: an epidemiological survey among adolescents]. Tiddsskr Nor Psykologfor 30: 1174-1181. Hurrelmann, K., Engel, U., Holler, B., Nordlohne, E. (1988). Failure in school, family conflicts, and psychosomatic disorders in adolescence. J Adolesc 11: 237-249. Klepp, K.I., Aas, H., Maeland, J.G., Alsaker, F. (1996). [Self-reported health problems among schoolstudents: a three-year follow-up study]. Tidsskr Nor Laegeforen 116(17): 2032-2037. Mazur, J., Tabak, I. (2008). Resilience: From theory to empirical research. Medycyna Wieku Rozwojowego 12(2 pt 1): 599-605. Mazur, J., Tabak, I., Kololo, H. (2008). Risk and protective factors among determinants of subjective complaints among 15-year-old adolescents. Przegld Epidemiologiczny 62: 633-641. Mikkelsson, M., Salminen, J., Kautiainen, H. (1997). Non-specific muskuloskeletal pain in preadolescents: prevalence and 1-year persistence. Pain 73: 29-35. Ravens-Sieberer U., Gosch A., Rajmil L., Erhart M., Bruil J., Power M., Duer W., Auquier P., Cloetta B., Czemy L., Mazur J., Czimbalmos A., Tountas Y., Hagquist C., Kilroe J. & the KIDSCREEN Group (2007). The KIDSCREEN-52 Quality of Life Measure for Children and Adolescents: Psychometric Results from a Cross-Cultural Survey in 13 European Countries. Value Health. Ravens-Sieberer U, Torsheim T, Hetland J, Nickel J, Vollebergh W, Cavallo F, Jericek H, Alikasifoglu M, Vlimaa R, Ottova V, Erhart M, & the HBSC Positive Health Focus Group. (in press 2008). Subjective health, symptom load and quality of life of children and adolescents in Europe. Accepted for International Journal of Public Health. Ravens-Sieberer, U., Erhart, M., Torsheim, T., Hetland, J., Freeman, J., Danielson, M., Thomas, C. and the HBSC Positive Health Group (2008). An international scoring system for self-reported health complaints in adolescents. European Journal of Public Health 18(3): 294-299. Starfield, B., Katz, H., Gabriel, A., et al. (1984). Morbidity in childhood: a longitudinal view. N Eng J Med 310(13): 824-829. Torsheim, T., Wold, B. (2001). School-related stress, support, and subjective health complaints among early adolescents: a multilevel approach. Journal of Adolescence 24(6): 701-713. Torsheim, T., Vlimaa, R., Danielson, M. (2004). Health and Well-being. In: Currie et al (eds.). Young peoples health in context. Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. pp. 55-63. Torsheim, T., Ravens-Sieberer, U., Hetland, J., Vlimaa, R., Danielson, M., Overpeck, M. (2006). Crossnational variation of gender differences in adolescent subjective health in Europe and North America. Soc Sci Med 62(4): 815-827.

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II.4.4 Physical Disability and Chronic Conditions (Optional package)


1. Scope and purpose
Decrease in the prevalence of chronic illnesses and alleviation of the primary and secondary symptoms are currently considered as the most demanding challenges of public health (Ebrahim 2008). Among children and adolescents chronic illnesses are usually different than in adult etiology, since they are often a consequence of involuntary causes such as congenital and developmental defects, metabolic conditions, premature birth and neonatal disorders (Sawyer et al. 2007). As the the scale of the phenomenon is increasing in developed countries, societies have found it necessary to provide children affected with chronic illnesses not only with greater chances of survival and rehabilitation, but also opportunities to fully participate in social life, also in case of disability (McConachie et al. 2006). The inclusion of questions about chronic illnesses and disability into HBSC study provides a unique opportunity to compare subjective health, life style and the psycho-social environment of ill and healthy school children. Young people with chronic illnesses are liable to suffer from secondary health problems resulting from changes in mobility and energy level, worse selfesteem, lower level of self-confidence and growing up with a sense of uncertainty (Stevens et al. 1996, Vitulano 2003). Common secondary conditions include also more physical aspects: recurrent episodes of pain, altered physiologic function, overweight, underweight, respiratory problems, muscle and joint pain and gastrointestinal problems. One limitation of HBSC as a source of information on the prevalence of chronic conditions is the fact that it is school-based study. Unlike household studies, a certain underestimation of the phenomenon in total population may be expected, since the study omits young people who cannot attend school on a normal basis due to a high level of physical disability or mental retardation.

2. Objectives
-

To compare the prevalence of chronic conditions and physical disability between countries and within countries according to age, gender, SES and other relevant factors

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To study the health and well-being of children with chronic conditions and physical disabilities in different contexts of their everyday life and in different countries (cultures).

To compare health behaviours represented by children with and without chronic conditions and physical disabilities

Further work on conceptualization and operationalisation in this research area. To stress the need for specific interventions designed to improve psychosocial functioning of adolescent with chronic illness and to avoid secondary conditions

To clarify and quantify the relationship between chronic diseases and children performance at school for policy purposes

3. Theoretical framework
Many different approaches and definitions as well as terms have been used to measure chronic conditions in childhood. Prevalence of chronic conditions in adolescents varies considerably from one survey to another, showing that 10-20% of adolescents may be affected. An unequivocal definition of the concept of chronic health conditions in childhood has been lacking, and, as a consequence, operationalisations to measure the prevalence are diverse. Based on a recent literature review the most frequently used terms in this research area are chronic conditions, chronic health conditions, chronic illness and children with special health care needs. The authors conclude that because of the complexity of the concept and the diversity in methods used in studies on this subject, there is, at present no such thing as a proper way to combine prevalence rates quantitatively (van der Lee et al. 2007). Definitions of chronic diseases usually consider the duration of a disease (usually at least 3 or 12 months), the age of onset, whether it is congenital or acquired, its influence on the everyday functioning and expected survival or actual possibilities of complete recovery. Chronic disease and disability are concepts closely linked to each other, since one may be a result of the other. WHO documents distinguish the concept of impairment from disability and handicap. According to WHO classification disability is defined as any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being. The ICF (International Classification of Functioning, Disability and Health) was developed under the auspices of the World Health Organization. In this model, the components of functioning and disability can be classified in three different dimensions: body

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structures and functions, performance of activities, and participation in communal life. A more extended model includes 5 domains: pathophysiology, impairment, functional limitations, difficulty with maintaining social role and societal limitations (Msall et al. 2003). A comprehensive framework for chronic conditions should allow for differences in definitions related to different research goals. According to van der Lee et al. (2007) the framework might consist of the following concepts: 1) The most comprehensive level: children with chronic conditions; 2) A limitations-oriented second level; comprising a subset of the firs level; children with limitations in ordinary activities due to chronic conditions; 3) A health care use-oriented third level, a subset of levels one and two: children with chronic conditions in need of medical care related services in addition to what is usual in this age; 4) The group children with special health care needs. There are also several methods on how to determine the prevalence of chronic diseases among children and adolescents and obtain reliable statistical data that could be used to monitor the phenomenon. The first disease-specific method is based on registers of diseases, mainly utilising data provided by health service sector. The second one is based on results of population health surveys, with self-reported data, or in the case of younger children information provided by their parents or guardians. The third method treats the use of medical services as a proxy measure of morbidity rate. In the case of questionnaire surveys there are two approaches described in the literature as categorical and non-categorical. The first approach uses a pre-prepared list of diseases, while the other is intended to describe the general burden of disease, regardless of the clinical diagnosis. The second one places main emphasis on the human being, not a case, and multiple chronic diseases could be considered (Kuhlthau et al. 2002). Numerous studies indicate that children and young people suffering from chronic diseases have similar problems, so the crucial issue is to focus on the overall impact of the illness rather than on exact medical diagnosis. The approach based on the list of illnesses is criticized by researchers interested in psychological and social correlates, for conceptual and pragmatic reasons. A number of tools have been developed to assess the level of functioning and medical needs which are applicable to population health surveys. These include highly elaborate questionnaires such as Child Health and Illness Profile - CHIP, with a separate version for parents and adolescent youths, and Questionnaire for Identifying Children with Chronic Conditions - QuICCC, which is in principle to be completed by parents. In case of multidimensional studies short and flexible instruments are considered optimal, if only they have enough good discriminatory features which enable to distinguish healthy and ill

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individuals. An example is the Children with Special Health Care Needs - CSHCN questionnaire developed by Bethell et al. (2002) which is very popular in the US and was also applied in 2003 in Europe, in a large KIDSCREEN study embracing 13 countries. In this project parents were asked about chronic diseases in their children, and simultaneously a much simpler version of the question was put to children, which enabled a comparison of the answers. It was demonstrated that children above 11 years of age provide reliable information about their health. The tool here recommended in HBSC research protocol belongs to the non-categorical consequence-specific category, and is to be adapted to the cognitive level of an 11 year old respondent. Thus in proposed HBSC optional package in comparison with the CSHCN the aspect of frequent use of medical services was omitted; similarly, unlike in previous Canadian studies, no question was asked about which functions are actually impaired (e.g. sight, hearing, movement, speech, etc.). However, younger children may still find it difficult to distinguish a chronic illness from an acute disease, and medicines taken on a permanent basis from those taken ad hoc. As such in the definition of a chronic illness emphasis was placed on the fact that it is a long lasting illness which was confirmed by a doctor, giving examples of several diseases. At the same time the term medical condition was used, which is more general and may be more comprehensible for a young respondent.

4. Summary of previous work


Physical disability and chronic conditions was first introduced as an optional package in the HBSC survey 2005/06 and was used by 13 countries (Austria, Bulgaria, Canada, Finland, France, Germany, Ireland, Italy, Latvia, Netherlands, Poland, Portugal, Wales). However, to our knowledge, at least three countries (Canada, Finland, Poland) were interested in this subject before, and appropriate questions were applied in these countries beyond international protocol. Finland has used a question of long-term illnesses diagnosed by a doctor in the HBSC Study since 1984 (Have you got any chronic illness or disability diagnosed by a doctor? NO; YES, describe shortly what kind). In Poland, students surveyed in 2002 were asked if they have a chronic illness or medical condition and then to specify this disease in an open-ended question. In the 2001/02 survey Canada and Finland used a more specific question with emphasis on difficulties caused by long-term illness, disability or medical condition in everyday life activities. (Do you have a long-term illness, disability or medical condition such as cerebral

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palsy, diabetes, arthritis, or allergy (IN FINLAND: diagnosed by a doctor)? Please do not include learning disabilities? (Yes/ No). If yes to above, does this disability, illness or medical condition cause you to have (Yes/No): Difficulty seeing things (Does not include prescription eye glasses); Difficulty hearing others?; Difficulty speaking to others?; Difficulty in moving around?; Difficulty in handling objects?; Difficulty in breathing?; Epileptic seizures (fits)?) (Rintala et al. 2004). There are several examples of studies focused on specific conditions conducted as a supplement to HBSC standard surveys or only using HBSC methodology. The idea of these studies came from the difficulties to capture a large sample of children with determined diseases within mainstream survey. During 2001/02 survey six countries (Belgium, Canada, Denmark, Finland, France and the Netherlands) included HBSC-Asthma Scale in their national survey (Hublet et al. 2007). In the Canadian study conducted during 1993/94 survey an additional group of children with serious health problems (such as spina bifida, cerebral palsy, muscular dystrophy, arthritis) were included (Kalnins et al. 1999). A number of previously published papers may be indicated in Canada, Finland and Poland, which among others analyzed the physical activity of young people suffering from chronic illnesses (Rintala et al. 2004), their liability to injury (Raman et al. 2007, Mazur / Woynarowska, 2006), as well as the quality of their social contacts (Stevens et al. 1996). Boyce et al. used Finnish and Canadian data from 2001/02 survey to compare the prevalence of subjective complaints among children with self-identified disability or chronic conditions. Results showed that disability severity play an important role in the emotional health of adolescents (Boyce et al. 2009). The results of studies conducted in 2005/06 in 12 European countries and in Canada have not been published so far, but a core international paper is in progress. In Poland on the basis of 2006 survey attempts have been made to study the social determinants of chronic illnesses, and results point to a stronger impact of the material status of the area of residence rather than family wealth. A higher prevalence of chronic illnesses was also stated among young people living in cities, which may be a result of better access to diagnostic facilities. Using the German data of the 2005/06 HBSC survey the first, general item about chronic diseases incidence was analysed. Results showed pupils from secondary school to a lesser extent report such a condition compared with their peers from primary school.

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5. Research questions
1. What forms of health compromising behaviours can be found in children with and without long-term-illness, disability or medical condition? 2. What are the positive health practices in children with and without long-term-illness, disability or medical condition? 3. The health-related quality of life, mental health and well-being in children with and without long-term-illness, disability or medical condition differ? 4. To what extent do children with a long-term illness, disability or medical condition use specific medication; and do they use more medication for headache, stomach-ache, difficulties in getting to sleep or nervousness than other children? 5. School perceptions: does long-term illness make a difference? 6. What factors of parental social support among children with or without long-term illness, disability or medical condition can be identified? 7. Are peer relations and social support different among children with or without longterm illness, disability or medical condition? 8. Is it reasonable to include chronic condition and disability status as independent variable in different models describing subjective health and health behaviours in school-children (interaction, modification or mediation?)

6. Instruments
This instrument was designed to identify children with long lasting illness regardless of its medical diagnosis. The first item describing general prevalence of chronic diseases or disability is followed by two items measuring selected health consequences. These consequences include limitations in the ability to perform usual school activities and ongoing need for prescription medications. Children who gave affirmative response to the first question and met criteria of at least one consequence are expected to experience more serious health problems.

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Item box 1
PH3.1
1 2

Do you have a long-term illness, disability, or medical condition (like diabetes, arthritis, allergy or cerebral palsy) that has been diagnosed by a doctor? Yes No

Source: new items for HBSC 2005/06 (adapted from Finnish and Canadian HBSC national surveys)

Item box 2
PH3.2
1 2 3

Do you take medicine for your long-term illness, disability or medical condition? I do not have a long-term illness, disability or medical condition Yes No

Source: new items for HBSC 2005/06 (adapted from Finnish and Canadian HBSC national surveys)

Item box 3
PH3.3 Does your long-term illness, disability or medical condition affect your attendance and participation at school? I do not have a long-term illness, disability or medical conditio Yes No

1 2 3

Source: new items for HBSC 2005/06 (adapted from Finnish and Canadian HBSC national surveys)

Item placement This item should be placed as the last question in the section II.4 Health and wellbeing and it should follow the question II.4.3 on Body image.

Validation work These items were adapted from Finnish and Canadian HBSC surveys conducted in 2001/02 described elsewhere (Boyce et al. 2009). Also the items PH3.1 and PH3.3 were applied in a large European health survey on 22,000 children and adolescents from 13 European countries. Analyzes showed respondents reporting a long-term illness disability or medical condition to display lower health-related quality of life and mental health and well-being on the KIDSCREEN instrument in the self-report as well as the parent report version (Ravens-Sieberer et al. 2008).

Guidance on analysis In the analysis and interpretation of the results of the survey it is recommended to provide a break-up of answers to each question separately, as well as an overall analysis of the answers.

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It seems reasonable to develop an indicator which will enable the assessment of the percentage of those who gave a positive answer to the first question and at least to one of the two others (PH3.1 and PH3.2 or PH3.3). If a person who did not indicate at first that he or she is suffering from a chronic illness subsequently admitted to taking medicines and absence from school for health reasons, we may be dealing with temporary or superficial health problems. On the basis of these questions it is difficult to distinguish disabled persons from chronically ill ones, in accordance with the definition of disability provided by the WHO, as well as to draw any conclusions about the occurrence of disability itself. However, a positive answer to all three questions points to a risk group much more affected by health problems. On the experiences of 2005/06 HBSC survey some inconsistency in answers could be expected. A cleaning procedure should be applied before data analysis. As was mentioned before, results of the study could be generalised only for the population of adolescents who normally attend schools, as children with serious disabilities and mental retardation are not included in the mainstream education system, and have no opportunity to participate in school-based surveys.

7. References
Bethell, C.D., Read, D., Stein, R.E., Blumberg, S.J., Wells, N., Newacheck, P.W. (2002). Identifying children with special health care needs: development and evaluation of a short screening instrument. Ambul Pediatr. 2(1): 38-48. Boyce, W., Davies, D., Raman, S., Tynjl, J., Vlimaa, R., King, M., Gallupe, O., Kannas, L. (2009). Emotional health of Canadian and Finnish students with disabilities or chronic conditions. International Journal of Rehabilitation Research; 32(2):154-61. Ebrahim, S. (2008): Chronic diseases and calls to action. Int J Epidemiol. 37(2), 225-30. Hublet, A., de Bacquer, D ., Boyce, W., Godeau, E., Schmid, H., Vereecken, C., de Beats, F., Maes, L. (2007). Smoking in young people with asthma. Journal of Public health 29(4): 343-349. Kalnins, I., Steele, C., Stevens, E., Rossen, B., Biggar, D., Jutai, J., Bortolussi, J. (1999). Health survey research on children with physical disabilities in Canada. Health Promotion International 14(3): 251-259. Kuhlthau, K.A., Beal, A.C., Ferris, T.G., Perrin, J.M. (2002). Comparing a diagnosis list with a survey method to identify children with chronic conditions in an urban health center. Ambul Pediatr 2(1): 58-62. Mazur, J., Woynarowska, B. (2006). Relationship between chronic diseases and nonfatal injuries among school-aged children and some modifying factors. Pediatria Polska 81(2): 80-86 (in Polish). McConachie, H., Colver, A.F., Forsyth, R.J., Jarvis, S.N., Parkinson, K.N. (2006). Participation of disabled children: how should it be characterised and measured? Disabil Rehabil 28(18): 1157-64. Msall, M.E., Avery, R.C., Tremont, M.R., Lima, J.C., Rogers, M.L., Hogan, D.P. (2003). Functional disability and school activity limitations in 41,300 school-age children: relationship to medical impairments. Pediatrics 111(3): 548-53.

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Raman, S., Boyce, W., Pickett, W. (2007). Injury among 1107 Canadian students with self-identified disabilities. Disabil Rehabil 29(22): 1727-35. Ravens-Sieberer, U., Erhart, M. (2008). Die Beziehung zwischen sozialer Ungleichheit und Gesundheit im Kindes- und Jugendalter. In: Richter, M., Hurrelmann, K., Klocke, A., Melzer, W., Ravens-Sieberer, U. (eds.). Gesundheit, Ungleichheit und jugendliche Lebenswelten: Ergebnisse der zweiten internationalen Vergleichsstudie im Auftrag der Weltgesundheitsorganisation WHO. Weinheim: Juventa, pp. 39-66. Ravens-Sieberer, U., Gosch, A., Rajmil, L., Erhart, M., Bruil, J., Power, M., Duer, W., Auquier, P., Cloetta, B., Czemy, L., Mazur, J., Czimbalmos, A., Tountas, Y., Hagquist, C., Kilroe, J., & the KIDSCREEN Group (2008). The KIDSCREEN-52 Quality of Life Measure for Children and Adolescents: Psychometric Results from a Cross-Cultural Survey in 13 European Countries. Value Health 11(4): 645-658. Rintala, P., Vlimaa, R., Ojala, K., Tynjl, J., Villberg, J., Kannas, L. (2004). Physical activity in adolescents with or without long-term illness or disability. Sport & Science 6: 21-26. Sawyer, S.M., Drew, S., Yeo, M.S., Britto, M.T. (2007). Adolescents with a chronic condition: challenges living, challenges treating. Lancet 369(9571): 1481-9. Stevens, S.E., Steele, C.A., Jutai, J.W., Kalnins, I.V., Bortolussi, J.A., Biggar, W.D. (1996). Adolescents with physical disabilities: some psychosocial aspects of health. J Adolesc Health 19(2): 157-64. van der Lee, J.H., Mokkink, L.B., Grootenhuis, M.A., Heymans, H.S., Offringa, M. (2007). Definitions and measurement of chronic health conditions in childhood: a systematic review. JAMA 297(24): 2741-51. Vitulano, L.A. (2003). Psychosocial issues for children and adolescents with chronic illness: self-esteem, school functioning and sports participation. Child Adolesc Psychiatr Clin N Am 12(3): 585-92.

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II.4.5 Global well-being (KIDSCREEN) (Optional package)


1. Scope and purpose
Psychological well-being is increasingly acknowledged as an important health outcome measure in both paediatric and epidemiological research. There is growing interest in the inclusion of psychological well-being outcome measures in monitoring health in a population. Furthermore, monitoring population health status should permit the tracking of health trends, thus identifying inequities in health, planning preventive strategies and, consequently, the improvement of population health. The KIDSCREEN project (Ravens-Sieberer et al. 2001) which was funded by the European Commission produced the first index to assess psychological wellbeing using a methodology for use in children and adolescents. It was an opportunity to apply the latest techniques for the development and cross-cultural validation of psychological wellbeing, such as structural equation modelling and Item Response Theory. The process of development of the index ensured cultural, legislative/political and personal acceptance in 13 European countries, which are representative for the majority of the countries already participating in the HBSC study. The resulting index has 10 items which represent a global uni-dimensional latent trait of psychological well-being. The index enables the assessment of school-aged childrens general well-being. It is especially sensitive for affective, cognitive, and psycho-vegetative, as well as psychosocial aspects of mental health not covered by other mandatory HBSC-indicators, thus filling this important gap. On the other hand, the index is less focused on externalized behaviour, such as bullying others and risk behaviour, aspects which are already covered by well-functioning indicators in the HBSC-study. The instrument assesses important aspects of school-childrens psychological well-being relevant for all countries from a political as well as a scientific point of view.

2. Objectives
-

To proceed with the study of psychological well-being in children and adolescents and to explore the possible underlying factors further

To apply the KIDSCREEN instruments in more countries to enable more extensive cross-country comparisons

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To identify trends in psychological well-being

3. Theoretical framework
Palfrey et al. (2005) have used the term New Morbidity to describe the changing trend in the morbidity spectrum, i.e. the reduction of infectious disease and the rise of chronic conditions which have now become the more dominant form of disease and which are the source of great burden on micro- as well as macro level. While in the past chronic diseases did not surface until later adulthood, symptoms and signs of chronic illness are now more often recognized in younger population groups as well. Parallel to this trend, experts are also noticing a shift in disease prevalence. Physical disorders leading to functional limitations and impairments are no longer the only form of disease. Mental health problems have a strong subjective component and thus subjective measures of health are required. Health-related quality of life instruments, such as the generic instrument KIDSCREEN, which is suitable for assessing the health-related quality of life in healthy as well as chronically-ill children and adolescents, are designed to measure subjective health and wellbeing. According to the WHO definition (WHO 1948), health is a state of complete physical, mental and social well-being and not only the mere absence of illness and disability. Here, the subjective perspective comes out clearly and shows that concepts of subjective health, healthrelated quality of life and well-being are associated and can hardly be separated from one another (Leplege / Hunt 1997, Radoschewski 2000). The WHO definition further points out that not only the physical component, but also aspects of mental and social health play an important role and need to be accounted for.

4. Summary of previous work


The KIDSCREEN-10 index for measuring global well-being was first used in the HBSC study in the 2005/06 survey. This optional package item was employed in 17 countries including Austria, Belgium, Bulgaria, Germany, Greenland, Luxembourg, Portugal, Romania, Russian Federation, Slovenia, Spain, Switzerland, Turkey, Macedonia, England, Wales, and Scotland. The results show that KIDSCREEN-10 has good psychometric properties in all 17 European

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countries and would be a suitable screening instrument for mental health problems and impaired well-being, in national as well as international studies (Erhart et al., in press). Furthermore, the KIDSCREEN 10-index was recently included in the Eurobarometer as an indicator for child and adolescent mental health. The KIDSCREEN-10 Index was applied in all 27 EU countries within the Flash Eurobarometer Survey which was carried out in September 2008 (Gallup Organization 2009). The results showed large variation between countries with highest average level found in countries with high national wealth like the Netherlands, Austria and Luxembourg whereas the lowest levels were found in countries with low national wealth. In general, it was found to be culturally, legislatively, politically and personally acceptable in all 27 EU countries. Further information on the methodology of the KIDSCREEN project, the psychometric properties and methodological considerations behind the KIDSCREEN questionnaires, as well as some first results, have been published and are available (Ravens-Sieberer et al. 2005, Ravens-Sieberer et al. 2006, Ravens-Sieberer et al. 2007, Ravens-Sieberer et al. (submitted), Robitail et al. 2006).

5. Research questions
1. How strongly are mental health problems associated with other factors (e.g. substance use, delinquency)? 2. How many different kind of groups of children and adolescents with specific features and varying levels of health-complaints, life satisfaction and mental health problems can be empirically identified? Which factors are associated with these patterns of positive health (e.g. social inequality, school-environment, family-culture, risk behaviour)? 3. What societal characteristics can be identified among adolescents that enhance subjective well-being, and under which circumstances? 4. Which theoretical perspective can best explain the empirical findings under which circumstances?

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6. Instruments
The 10 item index is a non-clinical measure of childrens and adolescents mental health status and psychological well-being. It consists of 10 items with 5-point answer-categories. The measure is applicable for healthy and chronically ill children and adolescents from 8 to 18 years. The ten items of the index covers affective (e.g., Have you felt sad?), cognitive (e.g., Have you been able to pay attention?), psycho-vegetative (e.g. Have you felt full of energy?) as well as psychosocial aspects (e.g., Have you got on well at school?) of mental health. Item box 1
PH1.1 Thinking about the last week Never*(Not at all) Have you felt fit and well?* Have you felt full of energy? Have you felt sad?
1

Seldom*(Sli ghtly)
2

Quite often *(Modrately)


3

Very often *(Very)


4

Always *(Extrmely)
5

Have you felt lonely? Have you had enough time for yourself? Have you been able to do the things that you want to do in your free time? Have your parent(s) treated you fairly? Have you had fun with your friends? Have you got on well at school? * Have you been able to pay attention?

Source: Ravens-Sieberer, U. and the European KIDSCREEN group (2006). The KIDSCREEN questionnaires. Quality of life questionnaires for children and adolescents handbook. Lengerich: Papst Science Publisher.

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Item 1+2: These items explore the level of the childs/adolescents physical activity, energy and fitness. Level of physical activity is examined with reference to the childs/adolescents ability, to get around the home and school, to play or do physically demanding activities such as sports, the capacity for lively or energetic play and the extent to which a child or adolescent feels unwell and complains of poor health. Item 3+4: These items cover how much the child/adolescent experiences depressive moods and emotions and stressful feelings. They specifically reveal feelings such as loneliness, sadness, sufficiency/insufficiency and resignation. Furthermore, these items take into account how distressing these feelings are perceived to be. Item 5+6: These items look at the opportunity given to a child or adolescent to create his/her social and leisure time. They examine the childs/adolescents level of autonomy, i.e. freedom of choice, self-sufficiency and independence. Item 7: This item examines the relation to the parents and the atmosphere in the home of the child/adolescent, including the quality of the interaction between child/adolescent and parent/carer, and the childs/adolescents feelings towards parents/carers. Aspects, such as whether the child/adolescent feels loved and supported by the family, whether the atmosphere at home is comfortable or not and if the child/adolescent feels treated fairly, are studied. Item 8: This item examines the nature of the childs/adolescents (social) relationships with peers. The quality of the interaction between the child/adolescent and peers, and the perceived support are studied. Other important aspects are acceptance, the ability to form and maintain friendships and communication with others. Positive group feelings, belonging to a group and respect are further issues covered by this item. Item 9+10: These items explore a childs/adolescents perception of his/her cognitive capacity comprising learning and concentration and his/her feelings about school. It includes the childs/adolescents satisfaction with his/her ability and performance at school. General feelings about school, such as whether school is an enjoyable place to be, are also considered.

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Item placement The mental health index (KIDSCREEN-10) should be placed after the Cantril Ladder of life satisfaction and before the optional package 2

Validation work The instrument has a strong theoretical foundation as its development is based on an extensive review of the international literature on mental health and well-being in children and adolescents, and several formal techniques, such as Delphi expert consultation and card sorting exercises (Ravens-Sieberer et al. 2001, Herdmann et al. 2002). The item content was derived from qualitative interviews and focus groups with children and adolescents of the targeted age-range and cultural diversity (Detmar et al. 2006). The KIDSCREEN-10 Index is based on the probabilistic Rasch Measurement Model (Rasch 1960) which resides on a strong mathematical formulation and explicit psychological meaningful assumptions about the relation between the actual response behaviour and the measured trait (Embretson/Reise 2000). The construct validity of the index was demonstrated in several ways, including empirical construct-validation in the representative KIDSCREEN survey in 13 European countries (n=22,000) by testing a priori specified hypothesis about the relationship with measures of mental health problems (SDQ: r = .50), psychosomatic complaints (HBSC-symptom checklist: r = .52) and by comparing adolescents with and without psychological disorders (d effect size = .67). The a priori hypotheses could be confirmed. Results were stable across the different countries. The high correlations between the index and the childrens and adolescents health status can be considered as a good basis for potential responsiveness. The index provides a good discriminatory power along the psychological well-being-traitcontinuum, and shows only few ceiling/floor effects. The good internal consistency reliability (Cronbachs Alpha = .82) and the good test-retest reliability / stability (r=.73; ICC=.72) enables a precise and stable measurement. Additional statistical analyses show that the KIDSCREEN index is able to differentiate between different groups. Children and adolescents with a low score on the family affluence scale (FAS, effect size d=.47), with behavioural problems (SDQ, effect size d=.1.30) and with a high number of psychosomatic complaints (d=1.69) display significantly lower mental health in comparison to the respective reference group. These results were confirmed in the HBSC-2005/06 survey where the KIDSCREEN-10 Index was applied in 15 countries as an optional package: The items fitted the data well according to the
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Rasch Measurement Model, thus confirming the assumption that the items are indicators of the same unidimensional latent trait continuum of mental health and well-being. Results for Cronbachs alpha (.81), correlation with HBSC-SCL (.48) and ES for FAS (.46) were almost identical with that issued from the KIDSCREEN survey (Erhart et al., in press). To summarize, the KIDSCREEN-10 Index to a large extent fulfils the criteria of a mandatory questionnaire: The simultaneous cross-national development process ensures that the index is essential to the scientific and conceptual integrity and cross-national health relevance of the HBSC study. The index is robust and was validated within the context of HBSC as it was applied as an optional package in 15 HBSC countries in the last survey (2005/06).

Guidance on use in analyses The items of the index fulfil the assumptions of the Rasch-Model, thus providing an intervalscaled measurement, enabling the precise estimation of individual trait-level and measurement error as well as the identification of responders with inconsistent response patterns. The index provides an overall score of mental health status; the Rasch-scores can be defined by the clinical meaningful content of the items. An automatic syntax is available for the scoring. In general, the following steps are necessary: 1. Negatively formulated items need to be recoded since most of the items are formulated positively and a higher score should reflect a higher mental and psychological well-being. Items to be recoded are item 3 and 4 (Have you felt sad? Have you felt lonely?); 2. The items of the scale need to be summed up (scale raw score). Note: only values from persons with complete data, with every item of the scale answered, can be summed up. 3. The scale raw score needs to be transformed into Rasch-Person-Parameter values; 4. Lastly, the Rasch-Person Parameter values need to be transformed into Tvalues having a mean of 50 and a standard deviation of 10 with higher values indicating higher mental and psychological well-being. These T-values are based on data from the international representative survey sample from twelve European countries. National individual reference values for girls and boys, as well as for children and adolescents are available as T-values and /or percentiles to facilitate the interpretation of the scores.
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7. References
Detmar, S.B., Bruil, J., Ravens-Sieberer, U., Gosch, A., Bisegger, C., & the European KIDSREEN Group (2006). The Use of Focus Groups in the Development of the KIDSCREEN HRQL Questionnaire. Quality of Life Research 15: 1345-1353. Embretson, S.E., Reise S.P. (2000). Item Response Theory for Psychologists. Mahwah, USA: Lawrence Erlbaum Associates. Erhart, M., Torsheim, T., Hetland, J., Nickel, J., Vollebergh, W., Cavallo, F., Jericek, H., Alikasifoglu, M., Vlimaa, R., Ravens-Sieberer, U., & the HBSC Positive Health Focus Group, & the KIDSCREEN Group Europe (in press). Measuring Mental health and well-being of school-children in 15 European countries: Results from the KIDSCREEN-10 Index. Accepted for International Journal of Public Health. Gallup Organization (2009). Parents views on the mental health of their child. Analytical report. Flash Eurobarometer report 246. Brussels: European Commission, DG Communication, Public Opinion. Herdman, M., Raimil, L., Ravens-Sieberer, U., Bullinger, M., Power, M., Alonso, J., & the European KIDSREEN Group, & DISABKIDS Group (2002). Expert consensus in the development of a European health-related quality of life measure for children and adolescents: a Delphi study. Acta Paediatr 91: 1385-1390. Leplege, A., Hunt, S. (1997). The problem of Quality of life in Medicine. JAMA 278: 47-50. Palfrey, J.S., Tonniges, T.F., Green, M., Richmond, J. (2005). Introduction: Addressing the Millennial MorbidityThe Context of Community. Pediatrics115: 1121-1123. Radoschewski, M. (2000). Gesundheitsbezogene Lebensqualitt Konzepte und Mae. Entwicklungen und Stand im berblick. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 43: 165-89. Rasch, G. (1960). Probabilistic Models for some Intelligence and Attainment Tests. Copenhagen, Denmark: Institute for Educational Research. Ravens-Sieberer, U., Erhart, M., Auquier, P. Gosch, A., Rajmil, L., Bruil, J., Power, M., Duer, W., Cloetta, B., Czemy, L., Mazur, J., Czimbalmos, A., Tountas, Y., Hagquist, C., Kilroe, J., and the European KIDSCREEN Group (submitted). The KIDSCREEN-10 Quality of Life Index for children and adolescents displayed validity and good psychometric results in a cross-cultural survey in 13 European countries. Ravens-Sieberer, U., Erhart, M., Wille, N., Wetzel, R., Nickel, J., Bullinger, M. (2006). Generic healthrelated quality-of-life assessment in children and adolescents: methodological considerations. Pharmacoeconomics 24(12): 1199-1220. Ravens-Sieberer, U., Gosch, A., Abel, T. et al. (2001). Quality of life in children and adolescents: a European public health perspective. Soc Prev Med 46: 297-302. Ravens-Sieberer, U. & the European KIDSCREEN group (2006). The KIDSCREEN questionnaires. Quality of life questionnaires for children and adolescents handbook. Lengerich: Papst Science Publisher. Ravens-Sieberer, U., Gosch, A., Rajmil, L., Erhart, M., Bruil, J., Duer, W., Auquier, P., Power, M., Abel, T., Czemy, L., Mazur, J., Czimbalmos, A., Tountas, Y., Hagquist, C., Kilroe, J. & the European KIDSCREEN Group (2005). KIDSCREEN-52 quality-of-life measure for children and adolescents. Expert Review of Pharmacoeconomics & Outcomes Research 5(3): 353-364. Ravens-Sieberer, U., Gosch, A., Rajmil, L., Erhart, M., Bruil, J., Power, M., Duer, W., Auquier, P., Cloetta, B., Czemy, L., Mazur, J., Czimbalmos, A., Tountas, Y., Hagquist, C., Kilroe, J., & the KIDSCREEN Group (2007). The KIDSCREEN-52 Quality of Life Measure for Children and Adolescents: Psychometric Results from a Cross-Cultural Survey in 13 European Countries. Value Health (Epub ahead of print) Robitail S, Simeoni MC, Erhart M, Ravens-Sieberer U, Bruil J, Auquier P; European Kidscreen Group (2006). Validation of the European proxy KIDSCREEN-52 pilot test health-related quality of life questionnaire: first results. J Adolesc health 39(4): 596: e1-e10. World Health Organization (WHO) (1948). Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946;

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signed on 22 July 1946 (Official Records of the World Health Organization, no. 2, p. 100); entered into force on 7 April 1948.

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II.4.6 Strength and Difficulties Questionnaire (SDQ) (Optional package)


1. Scope and purpose
Whereas in optional package 1 the items of the KIDSCREEN-index focus on general well-being, this optional package assesses several dimensions of mental health problems in children in order to get information on the areas on which young people experience mental health problems or problem behaviour. A limited Strengths and Difficulties Questionnaire- (SDQ) self-report version is proposed as optional package 2. In more detail those at risk for developing psychiatric disorders can be detected by the scores on the instrument. Most authors conclude that the instrument seems to present an efficient and economical screening instrument for preventive research on large community samples.

2. Objectives
-

To add more depth to the study of mental health in the context of health behaviours in children and adolescents.

To compare trends in the presence of mental health problems hereby taking account of age and gender differences

To identify subgroups at higher risks for developing mental health problems To identify and explain country differences in mental health problems

3. Theoretical framework
The SDQ has made a rather quick entry into psychiatric epidemiological research, and has been presented as a valid and reliable alternative to the much used Youth Self Report (YSR) and Child Behaviour Checklist (CBCL), that were originally developed by Achenbach (1991). The reliability and validity of the SDQ seem to be comparable to those of the YSR/CBCL, although the SDQ does not have the same research track record (not much prior research). SDQ-self report scores have the comparable AUC-values (area under curve) to YSR/CBCL-scores in predicting clinical diagnosis (Becker et al. 2004). Two marked advantages of the SDQ are that it

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is a much shorter instrument than the former screening instrument (YSR) and can be used free of charge in other surveys.

4. Summary of previous work


The psychometric properties of the SDQ have been studied in a large number of countries for each translated version of the instrument. The validity and reliability of the SDQ has repeatedly been assessed both in community and clinical samples in different countries (Hawes et al. 2004, Klasen et al. 2000, Mazur et al. 2007, Ronning et al. 2004, Smedje et al. 1999, Wiedefelt et al. 2003). The internal validity and factor structure of the SDQ are considered moderate to good although it is suggested that improvements can be made (Mazur et al. 2007, Ronning et al. 2004). For the level of agreement between diagnoses generated with the SDQ and clinical diagnoses, the SDQ is most commonly compared with the YSR or CLBL. These studies show that the SDQ performs comparably with the YSR/CBCL. Discriminant validity of the SDQ is considered good to detect children with emotional, conduct and hyperactivity disorders (Matai et al. 2004, Klasen et al. 2000). Because the instrument is translated into many languages it is possible to compare properties and scores with the SDQ in different countries. This is done in the Nordic and Southern European countries (Obel et al. 2004, Marzocchi et al. 2004) showing very similar scores across the Noridic countries and more variation in the southern countries. With HBSC data it will be possible to compare internal and external mental health problems between countries that are geographically spread over Europe and to detect countries with increased risk for these problems. Preliminary findings on the HSC-2005 data of six countries show higher problem scores to some SDQ scales in Central or Eastern European countries (Poland, Bulgaria, Slovenia and Romania) compared to two western European countries (The Netherlands and Sweden).

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5. Research questions
What is the level of mental health problems comparing different European countries? 1. What is the level of emotional and behavioural problems among young people in different European countries? 2. How strongly are different health problems associated with other factors (e.g. substance use, delinquency)? What are the differences in these associations for different kinds of mental health problems? 3. What are the associations between different mental health problems measured with the SDQ and other positive health outcomes as life satisfaction and subjective health complaints? 4. Which positive health types respectively risk groups with different configurations and levels of health-complaints, life satisfaction and mental health problems can be empirically identified? 5. Which factors are associated with these patterns of positive health (e.g. social inequality, school-environment, family-culture, risk behaviour)? 6. What factors help best to understand differences in mental health problems in different European countries, in particular the impact of factors on a personal level and factors on a country-level. 7. What are the societal characteristics among young people that protect against different mental health problems, and under which circumstances?

6. Instruments
Optional items can be found in the item bank on the HBSC website.

7. References
Achenbach, T.M. (1991) Integrative Guide to the 1991 CBCL/4-18, YSR, and TRF Profiles. Burlington, VT: University of Vermont, Department of Psychology Becker, A., Hagenberg, N., Roessner, V., Woerner, W., Rothenberger, A. (2004). Evaluation of the selfreported SDQ in a clinical setting: Do self-reports tell us more than ratings by adult informants? European Child and Adolescent Psychiatry 13(Suppl 2): 17-24.

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Hawes, D.J., Dadds, M.R. (2004). Australian data and psychometric properties of the Strengths and Difficulties Questionnaire. Australian and New Zealand journal of psychiatry 38: 644-651. Klasen, H., Woerner, W., Wolke, D., Meyer, R. et al. (2000). Comparing the German versions of the Strengths and Difficulties Questionnaire (SDQ-Deu) and the Child behavior checklist. European Child and Adolescent Psychiatry 9: 271-276. Marzocchi, G.M., Capron, C., Di Pietro, M., Tauleria, W., Duyme, M., Frigerio, A. et al (2004). The use of the Strengths and Difficulties Questionnaire (SDQ) in Southern European countries. European Child and Adolescent Psychiatry 13(Suppl 2): 40-46. Mathai, J., Anderson, P., Bourne, A. (2004). Comparing psychiatric diagnoses generated by the Strength and Difficulties Questionnaire with diagnoses made by clinicians. Australian and New Zealand journal of psychiatry 38: 639-643. Mazur, J., Tabak, I., Kololo, H. (2007). [Towards a better assessment of child and adolescent mental health status. Polish version of strengths and difficulties questionnaire. Experiences from two population studies]. Med Wieku Rozwoj 11(1): 13-24 Muris, P., Meesters, C., Berg, F. van den (2003). The Strengths and Difficulties Questionnaire. Further evidence for its reliability and validity in a community sample of Dutch children and adolescents. European Child and Adolescent Psychiatry 12: 1-8. Obel, C., Heiervan, W., Rodriguez, A. et al. (2004). The Strength and Difficulties Questionnaire (SDQ) in the Nordic countries. European Child and Adolescent Psychiatry 13(Suppl 2): 32-39. Ronning, J.A., Handegaart, B.H., Sourander, A., Morch, W.T. (2004). The Strength and Difficulties Questionnare as a screening instrument in Norwegian community samples. European Child and Adolescent Psychiatry 13: 73-82. Smedje, J., Broman, J.E., Hetta, J., Knorring, A.L. von (1999). Psychometric properties of a Swedish version of the Strengths and Difficulties Questionnaire. European Child and Adolescent Psychiatry 8: 63-70. Widenfelt, B.M. van, Goedhart, A.W., Treffers, P.D., Goodman, R. (2003). Dutch version of the Strengths and Difficulties Questionnaire (SDQ). European Child and Adolescent Psychiatry 12: 281-289.

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II.4.7 Oral health


Honkala, S

1. Scope and purpose


Oral diseases are very common throughout the world causing pain, discomfort and reducing quality of life. In addition, their treatment costs considerable amounts of money every year (Widstrm / Eaton 2004). The most common oral diseases, caries and periodontal diseases, could be prevented by the adoption of healthy behaviours (Le 2000). In order to maintain good oral hygiene and periodontal health, mechanical removal of dental plaque by toothrushing twice-a-day has been accepted as the international recommendation (Le 2000, Sheiham 1970). Dental caries and erosion of the teeth can be prevented by using fluoride toothpaste when brushing twice a day (Marinho et al. 2003) and by restricting the frequency of between-meal sugar consumption (Sheiham 2001). Brushing frequency plays an important role as a consistent and universal recommendation to the public for establishing a healthy habit. During childhood and adolescence, parents play a dominant role in encouraging the adoption of brushing habits in their children (Choo et al. 2001, Honkala et al. 1983, Poutanen et al. 2006). It has been shown that relatively stable patterns of toothbrushing are established during childhood and adolescence and that individuals who brush their teeth more than once a day seem to have a more stable habit than those who brush less often (Kuusela et al. 1996, strm / Jakobsen 1998). Smoking has considerable influence on oral health. According to several clinical studies, smoking has been identified as a major risk factor for poor periodontal health (Bergstrm 1990, Stoltenberg et al. 1993). About half of the periodontitis among the individuals under 30 years of age is thought to be associated with smoking (Page / Beck 1997). According to a previous study in Finland, adolescents who brushed their teeth less than twice a day reported a higher frequency of daily smoking than did those adolescents who brushed according to the recommendation (Honkala 2006). A number of studies have reported that health behaviours tend to cluster together (Camenga et al. 2006, Fisher et al. 1991, Raitakari et al. 1995, Rajala et al. 1980, Koivusilta et al. 2003). Smoking and use of alcohol have been shown to be related to irregular toothbrushing, whereas sport-oriented adolescents seemed to be habitual brushers (Rajala et al. 1980,

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Koivusilta et al. 2003). In addition, low consumption of sweets and frequent toothbrushing were associated (Currie et al. 1989, Rajala et al. 1980, Koivusilta et al. 2003). Neglecting oral health care may be associated with adolescent life-styles detrimental to health. In the Adolescents Health and Life-style study toothbrushing habits in adolescence have been shown to predict attained education level in early middle age. If the toothbrushing frequency was low at the age of 12 years, at the age of 2733 years these persons belonged to the less educated stratum of the society (Koivusilta et al. 2003).

2. Objectives
The objectives are to study
-

possible trends in toothbrushing habits associations between toothbrushing and family/individual characteristics an association between toothbrushing and smoking

3. Theoretical framework
Improvement of toothbrushing habits has been a target of oral health education for decades. However, oral health education seems to be ineffective with most health education programmes showing no convincing evidence of reduction of plaque levels (Kay / Locker 1998, Honkala E et al. 1999). Evidence from previous experiences indicates that improvement in oral health could be obtained only through adoption of programmes of oral health promotion that are based upon the common risk factor approach (CRFA) at the population level (Sheiham / Watt 2000). As shown in figure 1, the CRFA addresses risk factors (smoking, diets with high saturated fats and sugars, alcohol, environmental hygiene etc) common to many chronic diseases/conditions within the context of the wider socio-environmental milieu (Sheiham / Watt 2000). Since smoking and poor diet are risk factors for several chronic diseases, by promoting general health, oral health would also be improved. Health behaviours are not practiced independently of each other (Koivusilta et al. 2003). This also applies with general and oral hygiene.

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Diet

Obesity

Smokin

Diabetes

Cancers Stress Cardiovascular diseases Alcohol

Respiratory disease

Mental illness Control Dental caries Exercise

Periodontal diseases

Skin diseases Hygien Trauma,teeth & bones Injuries

Figure 1: The common risk factor approach (Sheiham, Watt 2000)

The strong association between different health-compromising behaviours is likely to be reflected in socio-economic health differences in adulthood. Behaviour of individuals is closely related to their social environment, and especially the family culture. When parents instruct regular toothbrushing to their children, they also seem to transmit principles of goal-directed behaviour, enabling their children to retain their (dental) health and to promote their school responsibilities. (Koivusilta et al. 2003).

4. Summary of previous work


Toothbrushing Previous results from the HBSC study show that prevalence of recommended toothbrushing, twice a day, varies considerably between different countries. Recommended toothbrushing is more frequent among girls, among adolescents who have very good school performance, who

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live in affluent families, and whose parents have high-status occupations (Honkala et al. 1988/1990, Kuusela et al. 1997, Maes et al. 2006).

Toothbrushing and family culture Parental monitoring and parental attachment (bonding) was analysed from HBSC 2006 data in Finland (Honkala et al. 2008). Both indicators were strongly associated with toothbrushing frequency.

5. Research questions
1. Are there any trends (improvement/deterioration) in toothbrushing habits of school children in different countries? 2. Is there any association between poor brushing and frequent smoking among 15-yearold adolescents in different countries? 3. How strong is the link between adolescents toothbrushing and family culture?

6. Instruments
6.1 Mandatory items
Toothbrushing frequency has been determined by the same question since the first study of the HBSC survey. This question has been used since 1977 in the Finnish nation-wide research program, the Adolescents Health and Life-style Survey, which has been conducted every second year. The reliability and validity of the question have been tested several times and have been shown to be good (Honkala et al. 1981, Honkala 2006, Kuusela et al. 1996). The HBSC mandatory question about toothbrushing is focusing on the pattern of toothbrushing, as a frequency of this habit. Item box 1
MQ11
1 2 3 4 5

How often do you brush your teeth? More than once a day Once a day At least once a week but not daily Less than once a week Never

Source: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, 2005/06

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7. References
strm AN & Jakobsen R. (1998) Stability of dental health behavior: a 3-year prospective cohort study of 15-, 16- and 18-year-old Norwegian adolescents. Community Dent Oral Epidemiol 26:129138. Bergstrm J. (1990) Oral hygiene compliance and gingivitis expression in cigarette smokers. Scand J Dent Res 98:497503. Camenga DR, Klein JD & Roy J. (2006) The changing risk profile of the American adolescent smoker: implications for prevention programs and tobacco interventions. J Adolesc Health 39:120.e1 120.e10. Choo A, Delac DM & Messer LB. (2001) Oral hygiene measures and promotion: review and considerations. Aust Dent J 46:166173. Currie C, Schou L & McQueen DV. (1989) Dental health-related behaviour in Scottish schoolchildren aged 11, 13 and 15 from Edinburgh City. Health Bull 47:182191. Fisher M, Schneider M, Pegler C & Napolitano B. (1991) Eating attitudes, health-risk behaviors, selfesteem, and anxiety among adolescent females in sub-urban high school. J Adolesc Health 12:377384. Honkala E, Rajala M & Rimpel M. (1981) Oral hygiene habits among adolescents in Finland. Community Dent Oral Epidemiol 9:6168. Honkala E, Kannas L, Rimpel M, Wold B & Gillies P. (1988) Dental health habits in Austria, England, Finland and Norway. Int Dent J 38:131138. Honkala E, Paronen O & Rimpela M. (1983) Familial aggregation of dental health habits in Finland. J Pedod 7:276290. Honkala E, Kannas L & Rise J. (1990) Oral health habits in 11 European countries. Int Dent J 40:211217. Honkala E, Sheiham A, Widstrm E, Watt R, Kuusela S, Schou L & Mautsch W. (1999) Effectiveness of oral health promotion. In The Evidence of Health Promotion Effectiveness. Shaping Public Health in a New Europe. PART TWO, EVIDENCE BOOK. Bobby D, Nutbeam D, Mittelmark M, editors. A Report for the European Commission by the International Union for Health Promotion and Education. Paris: Jouve Composition & Impression, p. 145155. Honkala S. (2006) Association between self-reported smoking and toothbrushing among adolescents in Finland. MSc thesis. Unit of Oral Health Services Research and Dental Public Health, Guys, Kings & St. Thomas Dental Institute, Kings College London, Faculty of Medicine, University of London, UK, 79. Honkala S, Tynjl J, Villberg J & Vlimaa R. (2008) Toothbrushing habits associated with family culture in Finland. The 86th IADR General Session & Exhibition, Toronto, Canada, 15.7.2008. [http://www.dentalresearch.org/] Kay E & Locker D. (1998) A systematic review of the effectiveness of health promotion aimed at improving oral health. Community Dent Health 15: 132144. Koivusilta L, Honkala S, Honkala E & Rimpela A. (2003) Toothbrushing as a part of adolescent lifestyle predicts educational level. J Dent Res 82:361-366. Kuusela S, Honkala E & Rimpel A. (1996) Toothbrushing frequency between the ages of 12 and 18 years longitudinal prospective studies of Finnish adolescents. Community Dent Health 13: 3439. Kuusela S, Honkala E, Kannas L, Tynjl J & Wold B. (1997) Oral hygiene habits of 11-year-old schoolchildren in 22 European countries and Canada in 1993/1994. J Dent Res 76:16021609. Le H. (2000) Oral hygiene in the prevention of caries and periodontal disease. Int Dent J 50: 129139. Maes L, Vereecken C, Vanobbergen J & Honkala S. (2006) Toothbrushing and social characteristics of families in 32 countries. Int Dent J 56: 159167. Marinho VCC, Higgins JPT, Sheiham A & Logan S. (2003) Fluoride toothpastes for preventing caries in children and adolescents. Cochrane Review. In: The Cochrane Library, Issue 1. Oxford, Update Software. Page RC & Beck JD. (1997) Risk assessment for periodontal diseases. Int Dent J 47: 6187.

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Poutanen R, Lahti S, Tolvanen M & Hausen H. (2006) Parental influence on children's oral health-related behavior. Acta Odontol Scand 64:286292 Raitakari OT, Leino M, Rakkonen K, Porkka KV, Taimela S, Rasanen L & Viikari JS. (1995) Clustering of risk habits in young adults. The Cardiovascular Risk in Young Finns Study. Am J Epidemiol 142:3644. Rajala M, Honkala E, Rimpel M & Lammi S. (1980) Toothbrushing in relation to other health habits in Finland. Community Dent Oral Epidemiol 8:106113. Sheiham A. (1970) Dental cleanliness and chronic periodontal disease. Br Dent J 129: 413418. Sheiham A & Watt RG. (2000) The Common Risk Factor Approach: a rational basis for promoting oral health. Community Dent Oral Epidemiol 28: 399406. Sheiham A. (2001) Dietary effects on dental diseases. Public Health Nutr 4:569591. Stoltenber JL, Osborn JB, Pihlstrom BL, Herzberg MC, Aeppli DM, Wolff LF & Fisher GE. (1993) Association between cigarette smoking, bacterial pathogens, and periodontal status. J Periodontol 64:12251230. Widstrm E & Eaton KA. (2004) Oral healthcare systems in the extended European union. Oral Health Prev Dent 2:155194.

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II.4.8 Body Mass


Ahluwalia, N, Nmeth,

1. Scope and purpose


Data on weight and height are important in order to determine body mass index (BMI). BMI is calculated as weight in kg divided by height in m2 (kg/m2). BMI is associated with direct measures of fatness (Roche et al. 1981) and is a commonly employed index of adiposity status (underweight, normal, or overweight). The use of BMI to evaluate overweight and obesity in children and adolescents is recommended by several expert committees, including the International Obesity Task Force (IOTF) (Bellizzi / Dietz, 1999, IOTF 2004), an Expert Committee on Obesity Treatment and Evaluation (Barlow / Dietz 1998) and an Expert Committee on Clinical Guidelines for Overweight and Adolescent Preventive Services (Himes / Dietz 1994). Weight and height are readily measured in the clinical or laboratory setting. While technically straightforward, measuring weight and height in large nationally representative samples and on a regular basis is impractical and cost-intensive, and therefore often infeasible. For these reasons, population-level surveillance and health research surveys including the HBSC survey regularly rely on self-reported weight and height.

Defining Overweight (preobesity and obesity) The most common method of classifying overweight in children and adolescents has been to use a distributional approach. For example, the 85th and 95th percentiles from nationally representative samples have typically been used to identify children as preobese and obese, respectively. A potential problem with this strategy is that the use of different approaches to classifying obesity over time (norm-references, data collection methods, etc.) makes the study of temporal trends of obesity difficult and leads to potential problems of misinterpretation. Further, the use of different BMI thresholds in different countries makes cross-national comparisons problematic. The second approach to identify overweight (preobese and obese) children and youth is the method of Cole et al. (2000), in which the age- and gender-specific percentile levels corresponding to a BMI of 25 kg/m2 (preobese) and 30 kg/m2 (obese), respectively, at age 18 were identified and projected backwards into childhood in a large international sample of

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children and youth. The development of these thresholds was endorsed by an expert committee convened by the IOTF and these age- and sex- specific cut-offs are often referred to as the IOTF cut-points (Bellizzi / Deitz 1999, Cole et al. 2000). Few studies have directly compared national BMI classification systems (e.g. 85th and 95th percentiles) to the IOTF standards (Janssen et al. 2005, Katzmarzyk et al. 2004); in some cases this is probably because national reference data/classification systems are unavailable, e.g. in Ireland (ONeill et al. 2007). In the two cited studies, the United States BMI standards and the IOTF thresholds had similar sensitivity and specificity in predicting cardiovascular risk factor clustering in childhood and the risk of future obesity and cardiovascular disease in young adulthood. In the literature there is often a lack of conformity in terms of the use of an international reference standard versus national normative data. For the surveillance of overweight and obesity in cross-national surveys, such as the HBSC study, it is logical to use the BMI thresholds of IOTF to classify children and youth as preobese and obese. These cut-points are less arbitrary and more internationally based than other alternatives (eg, 85th and 95th percentiles), and thus can be useful to provide internationally comparable prevalence rates of overweight in youth.

Public health importance of overweight in youth Overweight is a public health problem worldwide (WHO 1998). Obesity in childhood and adolescence is associated with increased risk for cardiovascular disease (type 2 diabetes, hypertension, and dyslipidemia) in later years (Katzmarzyk et al. 2003, Lawrence et al. 1991). Obese children are more likely to remain obese in adulthood (Guo et al. 2000, Serdula et al. 1993, Siervogel et al. 1991) and childhood and adolescent obesity are associated with psychosocial conditions such as depression (Kim 2001, Neumark-Sztainer et al. 2002), impaired health-related quality of life during childhood and adolescence (Williams et al. 2005), and impaired fertility in adulthood (Markus et al. 2008).

2. Objectives
The HBSC study enables the investigation of the prevalence and correlates of overweight in a wide range of industrialised countries. The main objective of these items is to identify the prevalence of overweight (preobese and obese) among 11, 13- and 15-year-old male and

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female adolescents. Based on these items, high-risk (overweight) groups can be identified to describe the prevalence of overweight and secular trends in overweight can also be examined. Associations between overweight and other health related behaviours (e.g. physical activity, sedentary behaviours, eating habits, smoking), psychological well-being (e.g. body image) and social factors (e.g. family affluence, family structure) can also be explored.

3. Theoretical framework
The challenges in understanding global prevalence and circumstances associated with overweight in children and adolescents include the methodological differences across studies such as approaches used to measure weight and height and criteria used to define overweight (preobesity and obesity), as well as the lack of representative data from different countries across age and gender. Furthermore, with globalization many countries are in transition from more traditional to westernized lifestyles which could impact the prevalence of overweight. Thus there is a need to provide updated information on the burden of overweight in youth across several nations on representative samples in young persons and to examine secular trends in overweight prevalence in international datasets using the same data collection methods and standardized definitions of overweight using the IOTF cutoffs (Cole et al. 2000). The HBSC survey offers the unique opportunity to not only examine the prevalence of overweight in several countries that use the same items and standardized methods, but also in the coming years to evaluate secular trends in overweight prevalence across European countries, USA and Canada.

Socio-demographic and lifestyle correlates of overweight There is a need to better understand the relationship of overweight with demographic and potentially modifiable lifestyle factors such as eating patterns, smoking and alcohol use habits, as well as physical activity and sedentary behaviours of youth (Caprio et al. 2008, Doak et al. 2006, Laitinen et al. 2001, Shaya et al. 2008). Although some work in this area using the HBSC data sets has commenced, further work is underway examining several factors concomitantly. Furthermore it would also be important to examine the association of overweight with individual factors such as body image, dieting behaviours, bullying and social network, particularly in the international context. If consistent associations are noted across nations such information could be highly useful in establishing preventive policies and programs to reduce overweight and associated ill-health effects. This is particularly important for young

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persons still experiencing growth as they would be more likely to return to normal growth following interventions, and because they may be more flexible to changing lifestyle patterns compared to adults.

Overweight and health concerns It is well-recognized that overweight negatively impacts the present and future psycho-social and physical aspects of health of youth (Ebbeling 2002, Reilly 2005, Williams 2005). Determining height and weight data in HBSC in conjunction with age and gender, allows for determination of overweight status. Because HBSC has a multidisciplinary approach, the relationship of overweight with life satisfaction, perceived health, medication use, and psychological wellbeing can be addressed.

Overweight and puberty Another interesting domain receiving current attention is the relation of BMI with puberty. Examining this association is important in order to develop preventive educational messages in light of the secular trend observed in the last few decades in many industrialized countries, in terms of the onset of puberty at younger ages. Early onset of puberty has consequences at individual and population level as it impacts the number of children a woman will have given the trend in many developed countries to have children at later ages and thereby on population dynamics (proportion of young adults compared to seniors) and the work-force. Assessment of nutritional status during puberty is particularly difficult as substantial changes take place in body size, body proportion and body composition. In general, there is an increase in both weight and BMI in adolescence. However, this does not necessarily reflect an increase in the amount or percentage of body fat (Maynard et al. 2001). In girls generally, there is an increase body fat before puberty followed by a relative fat loss during adolescence. After the pubertal growth spurt as girls reach menarche, significant fat accumulation starts again and the typical female body shape evolves. In boys after the prepubertal fat accumulation an absolute fat loss occurs, which means that increase in body weight and BMI during puberty in boys is due to a remarkable increase in lean body mass, mainly in the musculoskeletal system (Rogol et al. 2002). After the pubertal growth spurt in boys, percent body fat increases slightly until adulthood.

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There is a growing body of evidence that not only the pubertal process itself, but also its timing is associated with BMI and body fat (Dunger et al. 2006, Laitinen et al. 2001). There is a general agreement in the literature that in girls, early puberty is associated with higher BMI, higher body fat percent, and obesity (e.g. Beunen et al. 1994, Davison et al. 2003, Frisch/Revelle 1970,). The discovery of the leptin hormone provided a possible mediator between body fat and the brain that activates the central gonadotrophin secretion to start pubertal processes, thus elucidating a putative biological mechanism for this association. The causal link between higher percent body fat and early puberty, however, is still not clear. In boys, mixed results have been reported regarding whether early puberty is associated with higher or lower body fat percent (Dunger et al. 2006, Wang 2002). Given the complexity of the association of BMI with puberty, considerably more work needs to be done employing data from several countries with varying economic, cultural, and social systems, and lifestyle practices. The HBSC survey has enabled the examination of these issues over the 4 year study cycle periods and it offers a unique opportunity to address these complex multidisciplinary questions in the coming years.

4. Summary of previous work


Data on overweight in children relative to those in adults are limited (Janssen et al. 2005, Lobstein / Frelut 2003, Wang / Lobstein 2006,) and are lacking in many countries; however the HBSC survey has contributed to filling this gap in the literature. In the last 5 years, several studies reporting national prevalence of overweight in various countries participating in the HBSC survey (Al Sabbah et al. 2008, Due et al. 2007, Fonseca / Gaspar de Matos 2005, Karayiannis et al. 2003, Mikolajczyk / Richter 2008) as well as international comparisons across the countries (Haug et al. 2009, Janssen et al. 2005, Lissau et al. 2004) have been conducted based on the HBSC survey data. Several HBSC reports have focused on the association of socio-economic status (SES) and overweight prevalence, generally supporting an inverse relationship. SES has usually been assessed by the family affluence scale (Currie et al. 2008) while other groups have also considered mothers education (Al Sabbah et al. 2008), and parental occupation (Mikolajczyk, Richter 2008) as indicators of SES. Noteworthy is the report by Janssen et al. (2006) that examined the association of both individual- and area-level measures of SES with obesity in Canada; this group also reported a higher prevalence of overweight (both preobesity and obesity) in rural versus urban areas (Bruner et al. 2008).

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In recent years many HBSC reports have focused on the association of overweight with psychosocial, behavioural and lifestyle factors. Physical inactivity and sedentary behaviours (television-watching, computer use) have been positively related to overweight in several national HBSC datasets and in the international dataset (Haug et al. 2009, Janssen et al. 2005). Reported consumption of fruit, vegetables, soft drinks and breakfast have been related to overweight prevalence nationally (Schnohr et al. 2004) and using the international dataset (Haug et al. 2009, Janssen et al. 2005); a consistent negative correlation between regular breakfast consumption and overweight has been noted across countries. In addition, dieting, bullying behaviours, and perceived health have also been related to overweight in other national level data from the HBSC survey (Fonseca / Gaspar de Matos 2005, Janssen et al. 2004, Mikolajczyk / Richter 2008).

5. Research questions

What is the prevalence of overweight (preobesity and obesity) in youth, how does this vary by country and regions, and how has this changed since previous surveys?

What are the associations of overweight with demographic factors (age, sex, and socioeconomic indicators), health behaviours (e.g. dietary patterns, physical activity and sedentary behaviours) and psychosocial variables?

What is the relationship between BMI and puberty? Does this vary by country?

6. Instruments
The item description contains information on the source, reliability and validity (status quo and planned future work), history (including change over time), and indications for special coding of items.

6.1 Mandatory items


The respondents are asked:

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Item box 1
MQ 9 MQ 10 How much do you weigh without clothes? ______________ How tall are you without shoes? ______________________

Source: HBSC surveys 1997/98 (optional package), 2001/02 (mandatory).

The children are allowed to write down their height and weight in country appropriate units (cm versus inches, pounds versus kg), however, all the values should be finally (re)coded in cm and kg, respectively. In previous surveys a considerable number of children wrote only the number of centimetres on the questionnaire. Therefore, for countries where the measurement system is soley metric, it is suggested that the question on height is pre-printed with 1 metre and respondents need to insert centimetres only, ie: 1 metre .. cm Those who are 2 metres or more will probably not hesitate to correct the meters. Placement of the items: The items on height /weight should be placed separately from the items on food consumption, dieting and body image.

History of the Topic in the HBSC In the HBSC survey, questions on height and weight were asked for the first time in the 1997/98 survey in 15 of the countries who participated in that survey. A first paper of the international 1997/1998 survey data was published in 2004 (Lissau et al. 2004). One key paper has used the international 2001/02 data file (Janssen et al. 2005) and a similar paper is in press using the international 2005/06 data set (Haug et al. 2009). In addition, to date several papers have used national data files (Al Sabbah et al. 2008, Fonseca / Gaspar de Matos 2005, Janssen et al. 2004, Janssen et al. 2006; Lazzeri et al. 2008, Mikolajcyk / Richter 2008, Schnohr et al. 2004).

Missing Height and Weight Data As in the previous surveys, in the 2005/06 HBSC survey problems with incomplete or missing weight and height data were also noted in a number of countries. A high proportion of missing data on height and weight is common in this age group (Janssen et al. 2005, Mulvihill et al. 2004); however, the fact that ~17% of the sample had missing values on BMI deserves discussion. Ten countries (Belgium W, England, Greenland, Israel, Ireland, Lithuania, Malta,

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Norway, Scotland, and Wales), most in Northern-Europe, had missing data on age, height, or weight on > 20% of the sample; BMI could therefore be estimated for <80% of the sample surveyed in these countries. For example, in Ireland BMI could not be calculated for almost 70% of the students surveyed. Conversely, in some countries BMI could be calculated for 99% of those surveyed (Czech Republic). It is likely that in some countries youth in the age range studied, is simply more aware of their height and weight than in other countries due to cultural norms/practices, which in part could account for these differences in response rates. For instance, in some countries children have preventive medical examinations in school in which their heights and weights are measured (Kelly et al. 2006). Unfortunately, there are no feasible alternatives to overcome the issue of high non-response rate on body mass related variables in future HBSC surveys. Although the possibility that all countries use scales and stadiometers for precise measurements of weight and height respectively, can be considered; however, because of the high costs, additional training required, and logistical problems related to confidentiality and stigmatisation issues, this option is impractical for the large multi-national HBSC survey. It should also be noted that additional ethical considerations could arise if the HBSC survey were to obtain measured height and weight values (whether at school or at home) due to sensitivities that some young people may have about their body size and body image. Another option would be to send a letter to parents requesting them to weigh and measure their children in advance. This however, would also lead to increased costs, and many homes may not have the appropriate equipment for measuring weights and/or heights (especially low income homes where the prevalences of obesity would be expected to be higher). Furthermore, the reliability of parental reported height and weight measures has been reported to be no better than selfreports from adolescents (Phipps et al. 2004).

Reliability and validity of height and weight measurements and classification of BMI status based on self-reports The international BMI standards for youth recommended by the IOTF are derived from measured heights and body weights (Cole et al. 2000). In the HBSC survey; however, heights and weights are based on self-reports. Self-reported weight and height measures, like other self-reported variables, are not as precise as actual measurements taken by trained persons, and are subject to random error, and, more importantly, can be subject to systematic reporting bias. Several validation studies have compared self-reported versus measured heights and weights (Abalkhail et al. 2002, Brener et al. 2003, Himes et al. 2001, 2005, Strauss et al. 1999, Wang et al. 2002). In general, the results from these validation studies suggest that

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mean self-reported heights in adolescents are slightly greater than actual heights, and mean self-reported weights in children are slightly lower than measured weights. This self-report bias leads to an underestimation of mean BMI; this bias being generally greater in girls than boys, with increasing age in youth, and with increasing BMI values (Abalkhail et al. 2002, Elgar et al. 2005, Himes et al. 2001, 2005, Tokmakidis et al. 2007, Wang et al. 2002). Generally lower estimates of the prevalence of overweight (preobesity and obesity) are therefore obtained with self-reported measures (Abalkhail et al. 2002, Elgar et al. 2005, Himes et al. 2001, Tokmakidis et al. 2007, Wang et al. 2002). Some researchers have nonetheless concluded that self-reported height and weight are valid and acceptable for population-based studies (Goodman et al. 2000, Spencer et al. 2002). Strauss et al. reported that 94% of youth aged 1216 years are correctly classified as normal-weight or obese based on self-reported heights and weights (Strauss et al. 1999), although others have found less convincing results (Brener et al. 2003, Elgar et al. 2005, Tokmakidis et al. 2007). Importantly, the association between overweight and obesity with lifestyle habits (e.g., physical activity participation, and television viewing) in youth was not different when based on objectively measured or self-reported heights and weights (Strauss et al. 1999). Thus, there is sufficient evidence to support the use of prevalence rates for overweight (preobesity and obesity) derived from self-reported measures as fairly accurate proxies, particularly when such data cannot be obtained by actual measurements, and that selfreported heights and weights are suitable for identifying valid relationships in epidemiological studies (Goodman et al. 2000, Spencer et al. 2002). Several HBSC teams are in the process of carrying out validation studies at a national level. For instance, the Danish team is examining the extent of socially differentiated misclassification of height and weight, and thereby overweight status, based on self-reports of weight and height by schoolchildren aged 11, 13 and 15 years compared to objective data obtained by school nurses. Approximately 2,500 schoolchildren have been strategically sampled to ensure large proportions of children from ethnic minority groups and children from low socioeconomic position are included. A possibility would be to pool data from several such validation studies in the future to examine systemic bias in relation to age, height, weight, gender and overweight status and in terms of attenuation of associations. If sufficiently large pooled data are available, another possibility from such analyses would be to develop correction weights that could be applied to future surveys.

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7. References
Abalkhail BA, Shawky S, Soliman NK. Validity of self-reported weight and height among Saudi school children and adolescents. Saudi Med J. 2002;23(7):831-7. Al Sabbah H, Vereecken C, Abdeen Z, Coats E, Maes L. Associations of overweight and of weight dissatisfaction among Palestinian adolescents: findings from the national study of Palestinian schoolchildren (HBSC-WBG2004). J Hum Nutr Diet 2008 (in press) Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert committee recommendations. Pediatrics 1998;102:e29. Bellizzi MC, Dietz WH. Workshop on childhood obesity: summary of the discussion. Am J Clin Nutr 1999;70:173s-5s. Beunen GP, Malina RM, Lefevre JA, Claessens AL, Renson R, Vanreusel B. Adiposity and biological maturity in girls 6-16 years of age. Int J Obes Relat Metab Disord. 1994;18:542-6. Brener ND, McManus T, Galuska DA, Lowry R, Wechsler H. Reliability and validity of self-reported height and weight among high school students. J Adolesc Health 2003;32:281-7. Bruner MW, Lawson J, Pickett W, Boyce WF, Janssen I. Rural Canadian adolescents are more likely to be overweight and obese compared with urban adolescents. Int J Pediatr Obestity Published online: 18 June 2008. Caprio S, Daniels SR, Drewnowski A, Kaufman FR, Palinkas LA, Rosenbloom AL, Schwimmer JB. Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment: a consensus statement of Shaping America's Health and the Obesity Society. Diabetes Care. 2008 Nov;31(11):2211-21. Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000;320:1-6. Currie C, Molcho M, Boyce W, Holstein B, Torsheim T, Richter M. Researching health inequalities in adolescents: the development of the Health Behaviour in School-Aged Children (HBSC) family affluence scale. Soc Sci Med. 2008;66(6):1429-36. Davison KK, Susman EJ, Birch LL. Percent Body Fat at Age 5 Predicts Earlier Pubertal Development Among Girls at Age 9. Pediatrics 2003;111:815-21. Doak CM, Visscher TL, Renders CM, Seidell JC. The prevention of overweight and obesity in children and adolescents: a review of interventions and programmes. Obes Rev. 2006;7(1):111-36. Due P, Heitmann BL, Srensen TIA (2007) Prevalence of Obesity in Denmark. Obes Rev 2007; 8:187-9. Dunger, DB, Ahmed ML, Ong KK. Early and late weight gain and the timing of puberty. Mol Cell Endocrin. 2006;254-255:140-45. Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet 2002;360(9331):473-82. Elgar FJ, Roberts C, Tudor-Smith C, Moore L: Validity of self-reported height and weight and predictors of bias in adolescents. Journal of Adolescent Health 2005;37:371-5. Fonseca H, Gaspar de Matos M (2005) Perception of overweight and obesity among Portuguese adolescents: an overview of associated factors. Eur J Public Health 2005; 15 (3): 323-8. Frisch RE, Revelle R. Height and weight at menarche and a hypothesis of critical body weights and adolescent events. Science 1970;169:397-9. Goodman E, Hinden BR, Khandelwal S. Accuracy of teen and parental reports of obesity and body mass index. Pediatrics 2000;106:52-8. Guo SS, Huang C, Maynard LM, Demerath E, Towne B, Chumlea WC, Siervogel RM. Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the Fels Longitudinal Study.Int J Obes Relat Metab Disord. 2000;24(12):1628-35. Haug E, Rasmussen M, Samdal O et al. (in press). Overweight in school-aged children and its relationship with demographic and lifestyle factors: Results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) Study. Int J Public Health

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Himes JH, Dietz WH. Guidelines for overweight in adolescent preventive services: Recommendations from an expert committee. Am J Clin Nutr 1994;59:307-16. Himes JH, Faricy A. Validity and reliability of self-reported stature and weight of US adolescents. Am J Human Biol 2001;13:255-60. Himes JH, Hannan P, Wall M, Neumark-Sztainer D. FActors associated with errors in self-reports of stature, weight, and body mass index in Minnesota adolescents. Ann Epidemiol 2005;15:272-8. Janssen I, Craig WM, Boyce WF, Pickett W. Associations Between Overweight and Obesity With Bullying Behaviors in School-Aged Children. Pediatrics 2004;113 1187-94. Janssen I, Katzmarzyk PT, Boyce WF, et al. Comparison of overweight and obesity prevalences in schoolaged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes Rev 2005;6:123-32. Janssen I, Boyce W, Simpson K, Pickett W. Influence of individual- and area-level measures of socioeconomic status on obesity, unhealthy eating, and physical inactivity in Canadian adolescents. Am J Clin Nutr 2006; 83:139-45. Karayiannis D , Yannakoulia M , Terzidou M , Sidossis L S , Kokkevi A. (2003) Prevalence of overweight and obesity in Greek school-aged children and adolescents. Eur J Clin Nutr 2003;57:1189- 92. Katzmarzyk PT, Tremblay A, Prusse L, Desprs JP, Bouchard C. The utility of the international child and adolescent overweight guidelines for predicting coronary heart disease risk factors. J Clin Epidemiol 2003;56:456-62. Katzmarzyk PT, Srinivasan SR, Chen W, Malina RM, Bouchard C, Berenson GS. Body mass index, waist circumference, and clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents. Pediatrics 2004;114:e198-e205. Kelly C, Molcho M, Nic Gabhainn, S & Kelleher C. Self-reported weight and height: response rates from Irish schoolchildren. Proc Nutr Soc 2006;65: 39A. Kim O, Kim K. Body weight, self-esteem, and depression in Korean female adolescents. Adolescence 2001;36:31532. Laitinen J, Power C, Jarvelin MR. Family social class, maternal body mass index, childhood body mass index, and age at menarche as predictors of adult obesity. Am J Clin Nutr. 2001;74:287-94. Lawrence M, Arbeit M, Johnson CC, et al. Prevention of adult heart disease beginning in childhood: intervention programs. Cardiovasc Clin 1991;21:24962. Lazzeri G, Rossi S, Pammolli A, Pilato V, Pozzi T, Giacchi M. Underweight and overweight among children and adolescents in Tuscany (Italy). Prevalence and short-term trends. Journal of Preventive Medicine and Hygiene 2008;49:13-21 Lissau I, Overpeck MD, Ruan WJ, Due P, Holstein BE, Hediger ML and the Health Behaviour in Schoolaged Children Obesity Working Group. Body mass index and overweight in adolescents in 13 European countries, Israel, and the United States. Arch Pediatr Adolesc Med 2004;158:27-33. Lobstein T, Frelut M-L. Prevalence of overweight among children in Europe. Obesity Reviews 2003;4:195-200. Markus Jokela, Marko Elovainio, and Mika Kivimaki. Lower fertility associated with obesity and underweight: the US National Longitudinal Survey of Youth. Am J Clin Nutr 2008;88:886-93. Maynard LM, Wisemandle, W, Roche AF, Chumlea WC, Guo SS, Siervogel RM. Childhood Body Composition in Relation to Body Mass Index. Pediatrics 2001;107:344-50. Mikolajczyk RT, Richter M. Associations of behavioural, psychosocial and socioeconomic factors with over-and underweight among German adolescents. Int J Public Health. 2008;53:214-20. Mulvihill C, Nemeth A, Vereecken C. Body image, weight control and body weight. Young People's Health in Context: Health Behaviour in School-Aged Children (HBSC) Study. International Report from the 2001/2002 Survey. Currie,C., Roberts,C., Morgan,A., Smoth,R., Settertobulte, W., Samdal,O., Rasmussen, V. ed. Copenhagen, Denmark: WHO Regional Office for Europe; 2004:1209. Neumark-Sztainer D, Croll J, Story M, et al. Ethnic/racial differences in weight-related concerns and behaviors among adolescent girls and boys: findings from Project EAT. J Psychosom Res. 2002;53:96374.

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ONeill, J.L., McCarthy, S.N., Burke, S.J., Hannon, E.M., Kiely, M., Flynn, A., Flynn, M.A.T., and Gibney, M.J. (2007). Prevalence of overweight and obesity in Irish school children, using four different definitions. Eur J Clin Nutr 2007;61:74351. Phipps S, Burton P, Lethbridge L, Osberg L. Measuring obesity in children. Canadian Public Policy 2004;4:349-63. Roche AF, Sievogel RM, Chumlea WC, Webb P. Grading body fatness from limited anthropometric data.Am J Clin Nutr 1981;34:2831-8. Rogol AD, Roemmich JN, Clark PA. Growth at Puberty. J Adol Health 2002;31:192-200. Reilly, JJ. Descriptive epidemiology and health consequences of childhood obesity. Best Practice & Research Clinical Endocrinology & Metabolism 2005;19:32741. Schnohr C, Pedersen JM, Alcon MCG, Curtis T, Bjerregaard P. Trends in the dietary patterns and prevalence of obesity among Greenlandic school children. Int J Circumpolar Health 2004;63:2614. Serdula MK, Ivery D, Coates JR, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med 1993;22:16777. Shaya FT, Flores D, Gbarayor CM, Wang J.School-based obesity interventions: a literature review. J Sch Health. 2008;78(4):189-96. Siervogel RM, Roche AF, Guo SM, et al. Patterns of change in weight/stature from 2 to 18 years: findings from long-term serial data for children in the Fels Longitudinal Growth Study. Int J Obes 1991;15:47985. Spencer EA, Appleby PN, Davey GK, Key TJ. Validity of self-reported height and weight in 4808 EPICOxford participants. Public Health Nutr 2002;5:561-5. Strauss RS. Comparison of measured and self-reported weight and height in a cross-sectional sample of young adolescents. Int J Obes Relat Metab Disord 1999;23:904-8. Tokmakidis SP, Christodoulos AD, Mantzouranis NI. Validity of self-reported anthropometric values used to assess body mass index and estimate obesity in Greek school children. J Adolesc Health. 2007;40:305-10. Wang Y. Is Obesity Associated with Early Sexual Maturation? A Comparison of Associations in American Boys Versus Girls. Pediatrics 2002:110;903-10. Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. International Journal of Pediatric Obesity 2006;1:11-25 Wang Z, Patterson CM, Hills AP. A comparison of self-reported and measured height, weight and BMI in Australian adolescents. Aust N Z J Public Health. 2002;26:473-8. Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-related quality of life of overweight and obese children. JAMA. 2005;5:293(1):70-6. World Health Organization (WHO) (1998). Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity, Geneva, 35 June 1997. WHO/NUT/NCD/98.1. WHO: Geneva.

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II.4.9 Body Image


Nmeth, , Ojala, K

1. Scope and purpose


In line with the prevalence of overweight and obesity, body concerns, body weight dissatisfaction and other body image problems showed an increasing tendency in recent decades in westernized countries (Cash et al. 2004). However, having body image problems is not associated with being overweight or obese (or underweight) by necessity. Remarkable rates of populations with healthy weight and body proportions suffer from such problems. Body image is a multidimensional mental construct with attitudinal, perceptual and behavioural components (e.g. Verplanken / Velsvik 2008). This complex formation evolves and changes under biological, psychological, social and cultural influences (e.g. Clark / Tiggemann 2008, Shroff / Thompson 2007). The appearance culture, which is the exaggerated importance of looks in the recent times, is a large pressure on industrialized societies especially on youth and young adults. The influence is transmitted mostly by media images. Young people are especially responsive to media messages that display perfect and ideal body shapes and are at risk for preoccupation with physical appearance and developing a negative body image (e.g. Andrist 2003, Grabe et al. 2008). The majority of body image disturbances begin during adolescence, though their occurrence has been reported at younger ages in the scientific literature (Andrist 2003). Problems are more prevalent in girls than in boys, but this difference seems to be decreasing, as prevalence of negative body image among boys is increasing (McCreary / Sasse 2000). The majority of scientific papers reported worsening of body image among girls and stability or improvement in boys during adolescence (e.g. McCabe / Ricciardelli 2005). Body dissatisfaction and negative body image predict weight control behaviour which may manifest itself in both healthy (e.g. healthy diet, appropriate physical activity) and unhealthy (e.g. fasting, purging, smoking, extreme diets or training) manners (e.g. Knowles et al. 2008, Neumark-Sztainer et al. 2006, Smith et al. 2007). Body image problems and weight concerns are also related to substance use (e.g. Kaufman / Augustson 2008, Nieri et al. 2005), low selfworth (Tiggemann 2005, Verplanken / Velsvik 2008, Williams / Currie 2000) and poor mental health (Brausch / Muehlenkamp 2007, Daniels 2005, Meland et al. 2007).

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The majority of prevention and intervention strategies and programs designed recently and targeting young people showed low long-term effectiveness in preventing or reducing weight concerns and body image problems (e.g. Holt / Ricciardelli 2008). As body image is a multifactorial construct, development of strategies should consider as much as possible, biological, psychological and socio-cultural agents and should adopt environmental-ecological approaches beyond the individual level. Some successful programs involved participants (e.g. students, parents, teachers) in their development (Piran 1998) or placed an emphasis on interactivity, improving self-evaluation globally instead of passing on detailed information on body image and eating disturbances (ODea 2005). The WHO Cross-National study on Health Behaviour in School-Aged Children (HBSC) is a unique opportunity to examine young peoples body image, estimate prevalences and trends of body dissatisfaction in different cultures and reveal associations in a wide range of influencing factors in order to enhance knowledge in this area, which may serve information for development of effective health education and prevention strategies and programs.

2. Objectives
Within the HBSC study, international comparison is possible of the prevalences and trends of body weight perception and other body image aspects due to the common methodology in member countries. HBSC investigates a wide range of health behaviours, health aspects, relationships between different health behaviours, subjective health indicators as well as body image. Finally, the investigation of associations between body image and psycho-social background factors may serve to better understand body image formation and changes in young people.

3. Theoretical framework
Adolescence, or more precisely puberty, is a time when fundamental and rapid bodily changes occur in young peoples body size, proportions and composition, and is crucial pertaining body image and body satisfaction. Young people tend to inspect their bodies with an increasing concern during this time. The impact of pubertal development on adolescents body perception and evaluation is gender-dependent. There is a reasonable amount of evidence for this relationship in the

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literature regarding girls. The majority of them state that more developed pubertal status is associated with less positive body image, increased body dissatisfaction and increased internalization of thin ideal (e.g. Lindberg et al. 2007). Fewer studies addressed this question in boys and the results are not clear. Some of them found that maturation is associated with an improvement in body image (e.g. Jones 2004); most of them did not find a significant relationship (Barker / Galambos 2003, Lindberg et al. 2007, Smolak / Stein 2006), while Eisenberg et al. (2006) detected decreased body satisfaction parallel with pubertal development in a longitudinal study. In general, puberty seems to play a more salient role in girls than in boys body image. Pubertal timing is also perceived to have an impact on body perception and attitudes. Results are mixed, but the majority of them refer to early puberty in girls and late puberty in boys as risk factors for body dissatisfaction (e.g. Lien et al. 2006, Michaud et al. 2006). Some studies, however, also found early maturing boys to be vulnerable (Michaud et al 2006). Results suggest that body image changes during puberty are strongly mediated by weight and BMI changes, especially in girls (Muris et al. 2005). The typical gender difference stems from different socio-cultural expectations. In most westernised cultures the ideal female body shape is very slim and prepubescent-like, while the ideal physique for males is also slim, but muscular and wide-shouldered (McCabe et al. 2002). Normal growth and development results in a move from this ideal in girls as their body fat increases and their hips broaden. Boys, however, become more muscular with wider shoulders at the end of puberty, and fat loss often occurs. On the other hand, appearance in general seems to have greater importance for girls than for boys. Boys self-concept is related more to the perception of the physical operational effectiveness, particularly in terms of athletic skills and fitness than appearance (Smolak / Stein 2006). Nonetheless, the significance of physical appearance seems to be increased more recently for males too. In addition, body concerns nowadays are more common both among adult and adolescent males than some decades ago (Humphreys / Paxton 2004). As adolescents are often dissatisfied with their body development they tend to engage in methods to change their bodies. In general, boys want to increase their muscle mass and tone and decrease their fat mass, while girls want to loose weight (e.g. Smith et al. 2007, Stanford / McCabe 2005). Thus boys choose mainly physical activity whilst girls choose mainly dieting or other eating-related methods to change their weight (see chapter II.5.2). Neumark-Sztainer et al. (2006) stated in their study that negative body image predicted unhealthy rather than

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healthy weight management behaviours in dieting, fruit and vegetable consumption, physical activity and smoking. Smoking is a way of weight control on the one hand (Kaufman et al. 2007), but on the other hand negative body image itself is a predictor of substance use. Nieri et al. (2005) found that disliking ones looks in boys and negative weight perception in girls were the strongest body image risk factors for tobacco, alcohol and marijuana use. Body image has an important role in self-evaluation, mental health and psychological wellbeing. Tiggemann (2005) found that weight dissatisfaction and poor body image predicted low self-esteem but not vice versa in girls. Several studies reported a clear relationship between poor body image and depressive mood (Siegel 2002, Daniels 2005), suicidal ideation (Brausch et al. 2007) and eating disturbances (e.g. Johnson/Wardle 2005, Smith et al. 2007) especially in girls. A number of resource and risk factors for healthy body image are known. The main biological agent is body weight and BMI, respectively. Overweight and obese children and adolescents have lower body satisfaction than non-overweight peers (Downs et al. 2007, McCabe et al. 2005). Clark and Tiggemann (2008) found in their prospective study that higher appearance schemas, higher internalization of thin ideals and lower autonomy as individual psychological factors that predicted worsening body image in girls. The tripartiate influence model of body image and eating disturbance (Thompson et al. 1999) assign parents, peers and media influences as main direct socio-cultural factors predicting body image problems. Researches revealed typical gender differences in the importance and the mode of action of such factors. Media seems to be of higher importance in the influence of girls than boys body image (Humphreys / Paxton 2004, Jones et al. 2004, McCabe / Ricciardelli 2005). Perceived acceptance by the family and peers and good social relations are important resource factors for both boys and girls (Barker / Galambos 2003). Similarly, peer criticism is a risk factor for body dissatisfaction (Jones et al. 2004). Peer teasing predicts worsening of body image especially among overweight young people and underweight boys (Kostanski / Gullone 2007). Keerya et al. (2006) found in their study that perception of maternal dieting affects adolescents weight-related concerns in both genders. In other research (McCabe / Ricciardelli 2005) perceived messages to loose weight from peers and the media were higher for girls than boys, and messages to increase muscles from parents and female friends were higher for boys than girls. In general, media and peer influence for girls, whilst parental influence (especially in

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early adolescence) for boys proved to be the strongest factors for negative body image formation (e.g. Shroff / Thompson 2007, Stanford / McCabe 2005). An interesting study (Kelly et al. 2005) investigated adolescent girls with positive body image. These girls reported parental and peer attitudes encouraging healthy eating and exercising to be fit instead of dieting and loosing weight. Physical activity and sport involvement itself also proved to be a factor for promoting positive body-esteem and satisfaction (e.g. Burgess et al. 2006). Higher SES seems to be a risk factor for the development body dissatisfaction (Wang et al. 2005). Though neither HBSC trends (Currie et al. 2008, Mulvihill et al. 2004) nor other examinations on tendencies (e.g. Storvoll et al. 2005) show changes in average body image perception within the last one or two decades, Storvoll et al. detected a polarization in body image among Norwegian young people: an increase in very negative and very positive body image proportions. Authors ascribe the increase of very poor body image prevalence partly to the increase of prevalence of overweight children and the increase of importance of boys appearance.

4. Summary of previous work


Results on international body image data have been published in one paper by Ojala et al. (2007) and appear in international reports (Currie et al. 2008, Mulvihill et al. 2004). National publications are available on Dutch (Ter Bogt et al. 2006), Finnish (Ojala / Vlimaa 2001, Ojala et al. 2003, Ojala et al. 2007, Vlimaa 1995, Vlimaa / Ojala 2004, Vlimaa et al. 2005), Hungarian (Nmeth 2009, Nmeth et al. 2002, Nmeth et al. 2007), Irish (Nic Gabhainn et al. 2002) Italian (Vieno et al. 2006) Macedonian (Conteva / Mojanchevska 2005) Norwegian (Meland et al. 2007) Polish (Woynarowska / Mazur 2000), Portugese (Fonseca / Gaspar de Matos 2005), and Scottish (Williams / Currie 2000) young people. These papers contain descriptive data and analyses on the relationships among body image, puberty, subjective well-being, body mass index, weight control behaviour, eating habits, physical activity, and problem behaviour. Ojala et al. (2007) found across 30 HBSC countries in the 2001/2002 survey that perception of overweight is the strongest predictor of attempts to lose weight.

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Vlimaa (1995) reported that approximately half of the 11-, 13- and 15-year-old Finnish schoolboys were satisfied with their body weight in the 1993/94 data. Among girls the proportion was smaller. Compared to the actual body weight status, girls who were underweight were more likely to perceive themselves to be about the right size compared to boys who were underweight. In Finnish national trend study 1984-2002 nearly one half of 13 and 15-year-old girls felt that they were too fat, although the percentage of those feeling that they were fat decreased slightly towards the end of the study period (Vlimaa / Ojala 2004). In the 2001/02 Finnish data the level of physical activity did not have an effect on body dissatisfaction among 13 and 15-year-old girls (Ojala et al. 2003). Woynarowska and Mazur (2000) found that almost half of the boys and almost two-thirds of the girls aged between 11 and 15 were dissatisfied with their body in the 1997/98 survey in Poland. Proportions of dieters were 7% among the boys and 17% among the girls. Kololo and Woynarowska (2004a) analysed 2002 data of Polish girls and found similar proportion of dieting and about a further one-quarter of them wanted to loose weight. The prevalence of dieting and weight concerns was higher in older age groups, in urban girls and among girls from families with higher SES. In a trend analysis (1994-2002) increasing prevalence of body weight dissatisfaction and weight reduction behaviour was detected among girls in all age groups and among 15-year-old boys (Kololo / Woynarowska 2004b). In Portugal similar findings were reported (Fonseca / Gaspar de Matos 2005): age, BMI, involvement in dieting and attitude towards appearance was significantly associated with body image measured by a silhouette set. Meland et al. (2007) found body dissatisfaction to be a risk factor for negative health perception among Norwegian adolescents. In an interesting study Ter Bogt et al. (2006) revealed that both perception of being too thin and too fat was associated with problem behaviour. The Scottish and the Hungarian papers deal with pubertal effects on body image and selfesteem. Williams and Currie (2000) analysed 11- and 13-year-old Scottish schoolgirls data. They found that among 11-year-olds early maturation and poorer body image was related to lower self-esteem, and that body image had a mediating role between pubertal timing and self-esteem. In the older age group, late maturation and poorer body image were associated with lower self-esteem, and there was no evidence for mediation effect. Nmeth et al. (2002) analysed 11-, 13-, 15- and 17-year-old boys and girls data. They found that body dissatisfaction increased with age and pubertal maturation among girls, while the

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opposite tendency was detected among boys. Body image was significantly more positive among boys than among girls in all age-groups. The effect of gender on body image was stronger than that of either age or maturation. In the 2005/06 Hungarian sample body image was detected as a mediator between pubertal development and subjective well-being (health complaints, life satisfaction and depressive mood, Nmeth et al. 2007). Sweet consumption was associated with perception of being too thin and fruit and vegetable consumption with looking good in an analysis conducted in the 2005/06 sample (Nmeth 2007). Furthermore a Hungarian briefing paper addressing the associations between pubertal development and health-related outcomes (including body satisfaction) was written for teachers and health educators (Nmeth 2009).

5. Research questions
1. Is there cross-cultural variation in the age and gender differences known in weight concern and body image? 2. Are there changes over time in weight concerns and body dissatisfaction, and are there country differences in these variables? 3. What kind of risk and protective factors can be identified for body dissatisfaction? 4. What kind of gender differences can be found in the influencing factors (e.g. importance, mode of way)? 5. How is body image related to health-related behaviours and subjective well-being (e.g. food habits, physical activity, and substance use)?

6. Instruments
6.1 Mandatory items
This item measures body shape perception related to body weight and nutritional status including the satisfaction with it. This dimension of body image has particular importance as subjective well-being, weight-control and weight reduction behaviour are highly associated with it. Body weight satisfaction may change remarkably during adolescence (especially in
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puberty) due to quick and significant somatic changes, thus it may have impact on their mental well-being and behaviour. Item box 1
MQ8
1 2 3 4 5

Do you think your body is..? Much too thin A bit too thin About the right size A bit too fat Much too fat

Source: HBSC 1993/94, 1997/98, 2001/02, 2005/06 (revised in 2001/02: response category I do not think about itwas removed)

Preceding the 2001/2002 survey it was tested in Belgium Flanders (pilot test-retest N=560) and the Kappa statistic for this variable was .60: 71% of the respondents selected the same category on both occasions and 16% gave an adjacent answer. (In the Flemish test-retest, only 1.5% of the respondents selected the option I dont think about it on both occasions, while 10% changed from no opinion to one of the other 5 answer categories or vice versa). For many analyses, responses in this answer category are considered as missing: in the international dataset of 1997/98 this means a (at least partly avoidable) loss of 9.6% of the respondents (ranging from 3.3% for Greece to 25.9% for Greenland). In the Finnish test-retest survey 2005 (test-retest interval: 2 weeks, 7 schools, 14 classes, n=252; age group 11: n=58, 50 % of boys, M= 11.7 yr, SD=0.3 yr; age group 13: n=94, 54 % of boys, M=13.7 yr, SD=0.4 yr); age group 15: n=100, 41% of boys, M=15.6 yr, SD=0.3 yr), the Kappa statistic for this variable was 0.75, (0.04), 86% agreement (n=194) and intra-class correlation (ICC) 0.81 with confidence interval of (0.76-0.85), Spermans r=0.81.

6.2 Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. Looks Body Investment Scale, Body Image Subscale (BISs)

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7. References
Andrist LC. Media Images, Body Dissatisfaction, and Disordered Eating in Adolescent Women. Am J Maternal Child Nursing 2003;28(2):119-23. Barker ET, Galambos NL. Body dissatisfaction of adolescent girls and boys: risk and resource factors. J Early Adol 2003;23:141-65. Bearman SK, Presnell K, Martinez E. The skinny on body dissatisfaction: A longitudinal study of adolescent girls and boys. J Adol 2006;35: 21729. Ter Bogt TFM, van Dorsselaer SAFM, Monshouwer K, Verdurmen JEE, Engels RCM, Wolleberg WAM. Body Mass Index and Body Weight Perception as Risk Factors for Internalizing and Externalizing Problem Behaviour Among Adolescents. J Adol Health 2006;39(1): 27-34. Brausch AM, Muehlenkamp JJ. Body image and suicidal ideation in adolescents. Body Im 2007;4:207-12. Burgess G, Grogan S, Burwitz L. Effects of 6-weeks aerobic dance intervention on body image and physical self-perceptions in adolescent girls. Body Im 2006;3:57-66. Cash TF, Morrow JA, Hrabosky JI, Perry AA. How Has Body Image Changed? A Cross-Sectional Investigation of College Women and Men From 1983 to 2001. J Cons Clin Psychol 2004;72(6): 10819. Clark L, Tiggemann M. Sociocultural and Individual Psychological Predictors of Body Image in Young Girls. Dev Psychol 2008;44(4):1124-34. Conteva Z, Mojanchevska K. Young people, nutrition and their body image - published paper on the national HBSC 2002 Survey, results. Skopje: Centre for Psychosocial and Crisis Action Malinska 2005. Currie C, NicGabhainn, Godeau E, Roberts C, Smith R, Currie D, Picket W, Richter M, Morgan A, Barnekow V. (eds) Inequalties in Young Peoples Health. Health Behaviour in School-aged Children. International report from the 2005/2006 survey. CAHRU-WHO, Edinburgh, 2008;79-82. Daniels J. Wight and Weight Concerns: Are They Associated with Reported Depressive Symptoms? J Ped Health Care. 2005;19:33-41. Downs DS, DiNallo JM, Savage JS, Davison KK. Determinants of eating attitudes among overweight and non-overweight adolescents. J Adol Health 2007;41(2):138-45. Eisenberg ME, Neumark-Sztainer D, Paxton SJ. Five-year change in body satisfaction among adolescents. J Psychosom Res 2006;61:521-7. Fonseca H, Gaspar de Matos M, Perception of overweight and obesity among Portuguese adolescents: An overview of associated factors. Eur J Pub Health 2005;15(3):323-8. Grabe S, Ward LM, Hyde JS. The Role of the Media in Body Image Concerns Among Women:A MetaAnalysis of Experimental and Correlational Studies. Psych Bull 2008;134(3):460-76. Holt KE, Ricciardelli LA. Weight concerns among elementary school children: A review of prevention programs. Body Im 2008;5:233-43. Humphreys P, Paxton SJ. Impact of exposure to idealised male images on adolescent boys body image. Body Im 2004;1:253-66. Johnson F, Wardle J. Dietary Restraint, Body Dissatisfaction, and Psychological Distress: A Prospective Analysis. J Abnorm Psychol 2005;114(1):119-25. Jones DC. Body image among adolescent girls and boys: a longitudinal study. Dev Psychol 2004;40:82335. Jones DC, Thorbjorg HV, Lee Y. Body Image and the Appearance Culture Among Adolescent Girls and Boys: An Examination of Friend Conversation, Peer Criticism, Appearance Magazines, and the Internalization of Appearance Ideals. J Adol Health 2004;19(3):323-39. Kaufman AR, Augustson EM. Predictors of regular cigarette smoking among adolescent females: Does body image matter? Nicot Tob Res 2008;10(8):1301-9. Keerya H, Eisenberg ME, Kerri B, Neumark-Sztainer D, Story M. Relationships between maternal and adolescent weight-related behaviours and concerns: the role of perception. J Psychosom Res 2006;61:105-11.

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Kelly AM, Wall M, Eisenberg ME, Story M, Neumark-Sztainer D. Adolescent girls with high body satisfaction: who are they and what can they teach us? J Adol Health 2005;37:391-6. Knowles AM, Niven AG, Fawkner SG, Henretty JM. A longitudinal examination of the influence of maturation on physical self-perceptions and relationship with physical activity in early adolescent girls. J Adol 2008; http://dx.doi.org/10.1016/j.adolescence.2008.06.001 Kostanski M, Gullone E. The impact of teasing on childrens body image. J Child Family Studies 2007;16(3):307-19. Kololo H, Woynarowska B. Unfounded dieting among adolescent girls and socio-economic status of their families. (In Polish with English summary) Med Wieku Rozwoj 2004a;8:611-22. Kololo H, Woynarowska B. Self - perception of body mass and dieting in adolescents. (In Polish with English summary.) Przegld Pediatr. 2004b;34:196-201. Lien L, Dalgard F, Heyerdahl S, Thorensen M, Bjertness E. The relationship between age of menarche and mental distress in Norwegian adolescent girls from different immigrant groups in Norway: results from an urban city cross-sectional survey. Soc Sci Med 2006;63:285-95. Lindberg SM, Grabe, S, Hyde JS. Gender, Pubertal development, and peer sexual harassment predict objectified body consciousness in early adolescence. J Res Adol 2007;17(4):723-42. McCabe MP, Ricciardelli LA. A prospective study of pressures from parents, peers, and the media on extreme weight change behaviours among adolescent boys and girls. Behav Res Therapy. 2005;43:653-68. McCabe MP, Ricciardelli LA, Finemore J. The role of puberty, media and popularity with peers on strategies to increase weight, decrease weight and increase muscle tone among adolescent boys and girls. J Psychosom Res 2002;52:145-53. McCabe MP, Ricciardelli LA, Holt K. A longitudinal study to explain strategies to change weight and muscles among normal weight and overweight children. Appetite 2005;45:225-34. McCreary DR, Sasse DK. An exploration of the drive for muscularity in adolescent boys and girls. J Am College Health 2000;48:297-304. Meland E, Haugland S, Breidablik HJ Body image and perceived health in adolescence. Health Ed Res 2007;22(3):342-50. Michaud PA, Suris J-C, Deppen A. Gender-related psychological and behavioural correlates of pubertal timing in a national sample of Swiss adolescents. Mol Cell Endocrin 2006;254-55:172-8. Mulvihill C, Nmeth . Vereecken C. Body image, weight control and body weight. In: Currie C., Roberts C, Morgan A, Smith R, Settertobulte W, Samdal O, Rasmussen VB. (eds.) Young peoples health in context. Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Health Policy for Children and Adolescents 2004; WHO, Copenhagen:196-204. Muris P, Meesters C, van de Blom W, Mayer B. Biological, psychological, and sociocultural correlates of body change strategies and eating problems in adolescent boys and girls. Eat Behav 2005;6:11-22. Nmeth . Eating habits, body image and subjective well-being among adolescents (in Hungarian). j dita (New diet) 2007;16(3-4): 2-4. Nmeth, . Puberty: associations of biological maturation, health and health behaviour (in Hungarian). Briefing paper. 2009, National Institute of Child Health, Budapest. Nmeth , Bodzsr B, Aszmann, A. Maturation status and psychosocial characteristics of Hungarian adolescents (in English). Anthrop Kzlemnyek 2002;43:85-94. Nmeth , Kknyei Gy, Zakaris I. Mental health in adolescence: Relationship with pubertal development, body image, and parental monitoring. Anthrop Kzlemnyek 2007;48:105-49. Neumark-Sztainer D, Paxton SJ, Hannan PJ, Haines J, Story M. Does Body Satisfaction Matter? Five-year Longitudinal Associations between Body Satisfaction and Health Behaviors in Adolescent Females and Males. J Adol Health 2006;39:244-51. Nic Gabhainn S, Nolan G, Kelleher C, Friel S (2002). Dieting patterns and related lifestyle of school-aged children in the Republic of Ireland. Pub Health Nutr 5(3) 457-62. Nieri T, Stephen K, Keith VM, Hurdle D. Body image, acculturation, and substance abuse among boys and girls in the southwest. Am J Drug Alc Abuse 2005;31(4):617-39.

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ODea JA. School-based health education strategies for the improvement of body image and prevention of eating problems: an overview of safe and effective interventions. Health Ed 2005;1:11-33. Ojala K, Vlimaa R. Bodies and sport. Physically active, moderate and passive adolescents perceptions of their body weight. (In Finnish) Liikunta ja tiede 2001;38:3-10. Ojala K, Vlimaa R, Villberg J, Tynjla, J, Kannas, L. Weight reduction, weight management practices and physical activity among adolescent females. (In Finnish with English summary). Liikunta & Tiede 2003;40: 66-73. Ojala K, Vereecken C, Vlimaa R, Currie C, Villber J, Tynjala J, Kannas L. Attempts to lose weight among overweight and non-overweight adolescents: a cross-national survey. Int J Behav Nutr Physical Activity. 2007;4: 50, 40 ref. Piran N. A participatory approach to the prevention of eating disorders in a school. In: Vandereycken W, Noordenbos G. (eds) The prevention of eating disorders. Athlone, London 1998;173-86. Shroff H, Thompson JK. The tripartiate influence model of body image and eating disturbance. A replication with adolescent girls. Body Im 2007;3:17-23. Siegel JM. Body image change and adolescent depressive symptoms. J Adol Res 2002;17:27-41. Smith GT, Simmons JR, Flory K, Annus AM, Hill KK. Thinness and Eating Expectancies Predict Subsequent Binge-Eating and Purging Behavior Among Adolescent Girls. J Abnorm Psychol 2007;116(1):18897. Smolak L, Stein JA The relationship of drive for muscularity to sociocultural factors, self-esteem, physical attributes gender role, and social comparison in middle school boys. Body Im 2006;3:121-29. Stanford JN, McCabe MP. Sociocultural influences on adolescent boys body image and body change strategies. Body Im 2005;2:105-13. Storvoll EE, Strandbu , Wichstrm L. A cross-sectional study of changes in Norwegian adolescents body image from 1992-2002. Body Image 2005;2:5-18. Thompson JK, Coovert MD, Stormer S. Body image, social comparison and eating disturbance: a covariance structure modeling investigation. International J Eat Disord 1999;26(1):4353. Tiggemann M. Body dissatisfaction and adolescent self-esteem: prospective findings. Body Im 2005;2:129-35. Vlimaa R. Is my size the right? Young people's worries about their weight. (In Finnish) In: Kannas, L. (ed.) Koululaisten kokema terveys, hyvinvointi ja koluviihtyvyys. Opetushallitus, Hakapaino Oy, Helsinki 1995;65-74. Vlimaa R, Ojala K. Body weight status, self-perceived body weight, dieting and weight control behaviour among school-aged children in 1984-2002. (In Finnish). In Kannas L (ed.) School childrens health and health behaviour in change. HBSC Study 20 yrs. University of Jyvskyl, Research Center for Health Promotion, 2004; Publication 2.:55-78. Vlimaa R, Ojala K, Tynjl J, Villberg J, Kannas L. HBSC study: Overweight, self-perceived body weight and dieting in 15-year-old adolescents in Europe, Israel and North-America. (In Finnish with English summary). Suomen Lkrilehti . 2005 60(47):4843-4849. Verplanken B, Velsvik R. Habitual negative body image thinking as psychological risk factor in adolescents. Body Im 2008;5:133-140. Vieno A, Martini MC, Santinello M, Dallago L e Mirandola M. Body perception and psychosocial wellbeing in early adolescent development (in Italian). Psicoterapia Cognitiva e Comportamentale 2006;12(3):317-42. Wang Z, Byrne NM, Kenardy JA, Hills AP. Influences of ethnicity and socioeconomic status on the body dissatisfaction and eating behaviour of Australian children and adolescents. Eat Behav 2005;6:2333. Williams JM, Currie C. Self-esteem and physical development in early adolescence: pubertal timing and body image. J Early Adol 2000;20:129-149. Woynarowska B, Mazur J. Reported health and body image in school-aged children in Poland. (In Polish with English summary) Pediatria Polska 2000;75 (1):25-34.

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II.5 Health related behaviours


II.5.1 Eating habits
Vereecken, C, Kelly, C, Ahluwalia, N, Niclasen, B

1. Scope and purpose


Healthy eating habits in childhood and adolescence promote optimal childhood health, growth, and intellectual development; prevent immediate health problems, such as iron deficiency anaemia, obesity, eating disorders, and dental caries; and may prevent long-term health problems, such as coronary heart disease, cancer, and stroke (Centers for Disease Control, Prevention 1997). Additionally eating habits acquired during childhood and adolescence might track into adulthood (Kelder et al. 1994, Lien et al. 2001) where the association between diet and disease morbidity and mortality is well recognized (Willett 1994). Furthermore, psychosocial changes encountered during adolescence, that is, growing independence, the need to explore, to take risks and to seek self-identity, the need for peer acceptance, increased eating away from home, and busy schedules, may all have an effect on eating patterns and food choices (Sigman-Grant 2002, Story et al. 2002) and might put young people at increased risk for unhealthy eating habits and/or weight related eating disorders resulting in poor nutritional health. Finally, food habits are still developing during adolescence (Lien et al. 2001, Post et al. 2001, Post-Skagegard et al. 2002), therefore, it is important to help young people to adopt healthy eating habits. Although almost all Member States in the European Region have government-approved policies on nutrition, the burden of disease associated with poor nutrition continues to grow in the European Region, particularly as a result of the obesity epidemic (World Health Organization Regional Office of Europe 2008). The need has never been greater to support healthy eating and physical activity in children and youth; poor eating habits, including inadequate intake of vegetables, fruit, and milk, and eating too many energy-dense snacks, play a role in childhood obesity (Roblin 2007). Incorporating questions on food habits in the WHO Cross-National study on Health Behaviour in School-Aged Children (HBSC), a broad health and lifestyle survey, repeated every four years,

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with a standardized questionnaire and methodology in all participating countries offers the unique opportunity to allow between-country comparisons, to study trend analyses, and to move beyond examining isolated risk behaviours so that broader, tailored, more effective interventions and strategies can be developed.

2. Objectives
To investigate a selection of dietary indicators of adolescents food habits, recognizing the wide cultural variation in consumption and frequency of different food items within and between HBSC countries.

3. Theoretical framework
3.1 The Food frequency questionnaire (FFQ)
A healthy diet is a well balanced diet which contains a lot of fruit, vegetables and dairy products, a good portion of starchy foods like bread, potatoes and pasta, a moderate portion of meat or fish, and not too much fat and sugar. Also the intake of a large amount of fluid is very important in a healthy diet. The energy content of a healthy diet is in accordance with the needs of the human body (Vereecken et al. 2009a). The difficulties of assessing dietary habits among children and adolescents are numerous (Rockett / Colditz 1997). The challenge becomes even greater when attempting to asses dietary patterns of young people across countries. In order to fully investigate whether the respondent has a healthy diet or not, expensive and time consuming instruments such as food diaries and repeated 24-hour recalls are needed. However, in view of the overall structure and context of the HBSC survey, detailed dietary data and nutritional analyses remain out of the scope of the study, therefore it has been envisaged from the beginning that only a limited number of food frequency items, focusing on the intake of a few indicators of the adolescents diet would be employed. The indicators that have been used since the 2001-2002 survey are: fruit, vegetables, non-diet soft drinks and sweets. Fruit and vegetables are of high priority for most countries: continued attention to increasing fruit and vegetable consumption is an important way to optimize diet/nutritional status, to reduce disease risk and maximize good health (Van Duyn, Pivonka 2000) (World Health Organization Regional Office of Europe 2008). Non-diet soft drinks and

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sweets (i.e. candy or chocolate) were selected in the context of the increasing prevalence of obesity, although the data remains equivocal in this regard. A systematic review of the literature (to 2005) supports a link between the consumption of sugar-sweetened beverages and the risk of overweight and obesity (Malik et al. 2006), although more recent cross-sectional studies do not report an association between soft drink consumption and overweight (Gibson / Neate 2007, Haug et al. 2009, Janssen et al. 2005). In the HBSC 2001/02 survey, Jansen and co-workers (2005) found, in the majority of countries examined, that the frequency of sweets intake was lower in overweight than normal weight youth, whereas others found associations in the predicted direction (Amin et al. 2008, Nicklas et al. 2003). Moreover, sugars, with an increasing contribution coming from soft drinks, are the main aetiological factor for dental caries (Moynihan 2005). These food items are also generally considered empty calories, hampering intakes of more nutritious foods and hence a serious impediment for compliance with current dietary guidelines (Guenther 1986; Harnack et al. 1999). As these items are known to be popular among adolescents (Kerr et al. 2008), it was considered appropriate to include them in the study. Additional (optional) items for the 2005-2006 survey, were selected as important sources of dietary fibre (white bread, brown bread, cereals) and calcium (low fat/semi skimmed milk, whole fat milk, cheese, other milk products (such as yoghurt, chocolate milk, pudding, quark etc.) or because of their part in the youth food culture (diet soft drinks, crisps and chips) (Roblin 2007). A fibre rich diet is lower in energy density, often has a lower fat content, is larger in volume and is richer in micronutrients, all of which have beneficial health effects. Many of the diseases of public health significance obesity, cardiovascular disease, type 2 diabetes, as well as colonic diverticulosis and constipation, can be prevented or treated by increasing the amounts and varieties of fibre-containing foods (Marlett et al. 2002). Calcium intake during growth can influence peak bone mass/density, and may be instrumental in preventing subsequent postmenopausal and senile osteoporosis and fracture incidence in adulthood (Barr / McKay 1998, Bronner 1994, Key / Key 1994, Matkovic / Ilich 1993). The increased incidence of osteoporosis demands effective prevention strategies to promote bone growth and the accrual of adult peak bone mass during the adolescent years (Schettler / Gustafson 2004).

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Fish was added to the optional package of the survey because of its significance for health (Steingrimsdottir et al. 2002). Fish is an important nutrient source and although recommendations differ between countries, many include a need to increase fish intake among children. Many other nutrients, such as fat and sugar and food commodities such as salt are also important factors in the evaluation of diet adequacy. However a detailed and lengthy list of food items would need to be included in order to comprehensively assess intake of these nutrients which is not feasible within the overall scope of the HBSC study.

3.2 Breakfast consumption


Several studies have consistently shown that regular breakfast consumption is associated with higher intakes of micronutrients, and a better diet quality in school-aged children (Affenito 2007, Matthys et al. 2007, Rampersaud et al. 2005, Timlin et al. 2008). In addition, many crosssectional studies across the world suggest an inverse relationship between breakfast consumption and BMI or overweight (Affenito 2007, Keski-Rahkonen et al. 2003, Rampersaud et al. 2005, Timlin et al. 2008, Utter et al. 2007, Yang et al. 2006). This finding has also been noted in the cross-sectional analysis of data from 41 countries participating in the HBSC study (Haug et al. 2009). Prospective studies have confirmed this association in adolescents (Niemeier et al. 2006, Timlin et al. 2008). Despite recommendations encouraging regular breakfast consumption, breakfast skipping is highly prevalent in Europe and United States, ranging from 10 to 30% (Rampersaud et al. 2005). Data from HBSC 2005/06 confirm this pattern across all regions in Europe (Vereecken et al. 2009b); however, in 4 countries (Netherlands, Portugal, Denmark, and Sweden) ~ 70% children reported eating breakfast daily. Breakfast skipping has been shown to be associated with several health compromising behaviours such as smoking (Keski-Rahkonen et al. 2003, Timlin et al. 2008), alcohol consumption (Keski-Rahkonen et al. 2003, Timlin et al. 2008), drug use (Isralowitz / Trostler 1996) and inactive lifestyles (Timlin et al. 2008, Yang et al. 2006) and sedentary behaviours such as television viewing (Vereecken et al. 2009b).

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3.3 Food related lifestyle aspects


Adolescents food habits are influenced by a myriad of individual and environmental factors (Figure 1). In order to develop interventions to improve adolescents food habits these factors need to be better understood. Optional package 2 includes a selection of these factors that have changed considerably during the last decades and which may contribute to the marked increase in obesity. The specific items on the following topics can be found on the optional package webpage.

MACROSYSTEM (Societal)
Agriculture economic policies & Media

PHYSICAL ENVIRONMENT SOCIAL ENVIRONMENT (Interpersonal) INDIVIDUAL (Intrapersonal)


Psychosocial Lifestyle food preferences time taste, sensory convenience perceptions cost health beliefs meal patterns food meanings dieting self-efficacy Biologic knowledge age gender hunger growth status
Fast food outlets Schools Media role models

Neighborhoods Food production Worksites and distriPeers bution systems Restaurants

Advertising

Food Shopping access & malls availability

Friends

Vending machines Government & public policy

Convenience stores Relatives

Grocery

Culture

Social norms

Figure 1: Individual and Environmental Influences on Adolescent Eating Behaviors: An Ecological Model (Story et al. 2002)

Family meals, away from home meals and school meals In many societies, with busy schedules of parents and their children, it might become a real challenge for many adolescents and their parents to eat together as a family (Neumark-

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Sztainer et al. 2003). Nonetheless, findings from several studies indicate that a regular family meal is associated with healthier dietary intake of children and adolescents (Gillman et al. 2000, Haapalahti et al. 2003, Neumark-Sztainer et al. 2003, Videon / Manning 2003). Family meals may be an opportunity for parents to provide healthy choices, to be an example of healthy eating (Kelsey et al. 1998, Neumark-Sztainer et al. 1999) or have a family conversation about healthy eating practices (Gillman et al. 2000). In addition, family meals may contribute to the development of regular eating patterns, they may help the positive psychosocial development of young people (Neumark-Sztainer et al. 2003) and they may help parents to notice whether or not their child is eating an adequate diet (Neumark-Sztainer et al. 2004). Moreover, family meals during adolescence may have a positive influence on dietary quality and meal patterns in young adulthood (Larson et al. 2007). On the other hand, when children do not eat family dinners, they are more likely to eat ready-made dinners that are likely to have lower nutritional quality (Gillman et al. 2000). However, little is known about family meals in most European countries. A factor that might decrease family interactions during dinner (Taras et al. 1990) and is associated with poor eating habits (Coon et al. 2001) is television use during meal times. Again, very little research is published on television use during meal times (Boutelle et al. 2001) and data collected via the HBSC survey can contribute to this dearth. In many societies a higher proportion of meals are eaten away from home (Nicklas et al. 2001) with, for US adolescents, fast-food outlets providing almost one third of away-from home meals (Guthrie et al. 2002). Food consumed by adolescents from fast-food restaurants is however, higher in fat, saturated fat and sodium and lower in fibre, iron and calcium, than food prepared/consumed at home (Lin et al. 1999). Little is known about the frequency and/or amounts of fast food consumption in other countries. Many adolescents also obtain and consume a large proportion of their total daily food/energy intake at school, and hence the school environment can also have an important impact on adolescents food choices and dietary quality. An example is found in the School Nutrition Dietary Assessment Study, in which young people who participate in the National School Lunch Program had greater nutrient intakes compared with those who did not participate (Burghardt et al. 1993).

Snacking An increase in snacking has been reported in all age groups including adolescents (Anderson et al. 1993). There is debate around whether snacking leads to poorer diets or is beneficial for
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meeting nutrient needs (Bigler-Doughten / Jenkins, 1987, Gatenby 1997, Ovaskainen et al. 2006), with recent work illustrating that snacking can enhance the intake of fruit and vitamin C (Sebastian et al. 2008). However, less beneficial is that the most commonly selected snack foods are nutrient-poor foods, high in sugar (Dwyer et al. 2001, Matthys et al. 2003, Summerbell et al. 1995) contributing to discretionary calories and added sugar (Sebastian et al. 2008). Indeed, more recent work shows that sugar-sweetened beverages remain a popular choice of snack for adolescents (Kerr et al. 2008) and that there has been an increase in both the energy density (Zizza et al. 2001) and portion size of snack foods (Kerr et al. 2008). A direct link between the rise in snacking and the rise in obesity prevalence has been hypothesized but remains unproven in children or adults. How well frequent eaters can compensate for numerous snacks by reducing the size of subsequent meals may be an important factor in this debate (Drummond et al. 1996).

Family food rules The degree to which parents attempt to exert control over their childrens eating has been highlighted recently as an important influence on childrens food choice (Wardle et al. 2005). Restriction of intake and pressure to eat have been identified as two important aspects of parental control (Birch et al. 2001). Restriction refers to the extent to which parents restrict their childs access to unhealthy foods, particularly the type and amount of energy-dense snack foods. Pressure to eat refers to parents attempts to increase their childs intake of healthy foods by pressuring the child to eat more healthy food, typically at mealtimes (Francis et al. 2001). Parental control can be regarded as protective (i.e. parents restrict food to control the childs weight), but there has also been a view that parental control could prevent the child from learning to respond to internal cues that signal hunger and satiety and thus to self-regulate their own consumption (Birch / Fisher 1998, Wardle et al. 2002).

4. Summary of previous work


The international 2001-2002 data has been used in several publications, primarily to describe adolescents food habits of all participating countries. Wide variation between countries was found in consumption of all food items. However, despite the standardised methodology and measures used in all countries to collect the data, caution in comparing between countries is still necessary due to, for example, differences in food culture, classification of the food items

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and timing of the field work. Nevertheless, results from the HBSC survey indicate a need for national and international health promotion programs to improve adolescents food habits (Vereecken et al. 2005b). Associations between being overweight and the mandatory food items were investigated in Janssen et al (Janssen et al. 2005). The results showed that, in general, no significant relationships were found with fruit, vegetables and soft drink consumption and unexpectedly in almost all countries a significant inverse relationship for sweets was noted (lower consumption for those being overweight, even after controlling for being on a diet). Associations of daily fruit and soft drink consumption with parental occupation and family affluence investigated in 28 European countries and/or regions highlight the importance of socio-economic factors in relation to the food habits of young adolescents (Vereecken et al. 2005c). Associations of TV viewing with the consumption of sweets, soft drinks, fruit and vegetables were investigated in Vereecken et al. (Vereecken et al. 2006). Positive associations were found for sweets and soft drinks, negative associations for fruit and vegetables, although the latter were not so apparent among Central and Eastern European countries. A multilevel analyses including school-level variables in the Belgain Flemish sample indicated that school food policy can have an impact on adolescents food habits (Vereecken et al. 2005a). A study of food poverty in Ireland (Molcho et al. 2007), found that schoolchildren reporting food poverty were less likely to eat fruits, vegetables and brown bread and more likely to miss breakfast on weekdays and to eat crisps, fried potatoes and hamburgers. Interestingly, food poverty was similarly distributed across social classes. A trend analysis in Greenland from 1994 to 2002 indicates that the intake of vegetables has increased significantly since 1994, and the intake of fruits, sweets and soft drink has decreased significantly while an unchanged high proportion of schoolchildren report to be on a diet or consider themselves obese (Schnohr et al. 2004). Findings from Greece suggest that the eating habits of Greek school-aged adolescents are in the process of changing from more traditional to more Westernized ones (Yannakoulia et al. 2004). A study of meal patterns in Finland indicates that family meals and parental monitoring appear to be more important factors than the familys socio-economic status: in particular

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daily family meals and maternal monitoring were essential in achieving a consistent pattern of three main meals daily (Ojala et al. 2006). In a Hungarian national paper it was found that perceived good or excellent health was associated with daily fruit and vegetable consumption as well as regular breakfast consumption (Nmeth 2007a). Weight reduction behaviour was connected with rare sweet consumption and breakfast consumption, but not with fruit, vegetables or soft drink consumption. Another national paper reported a typical lifestyle-pattern among adolescents: daily consumption of breakfast and fibre rich foods were associated with physical activity, while television viewing was associated with the consumption of energy dense foods (Nmeth 2007b). Analyses of the international 2005-2006 survey, indicates that skipping breakfast is common among adolescents, especially girls, older adolescents and those from disadvantaged families. Additionally the results indicate that breakfast skipping can serve as an indicator to identify children at risk for unhealthy lifestyle behaviours (Vereecken et al. 2009b). Trend analyses of data from the Danish HBSC study found a decrease in intake of fruits and vegetables from 1988 to 2002 and an increase to 2006 (Rasmussen et al. 2008). It was suggested that the increase might be attributed to a nation-vide initiative to promote fruit and vegetable uptake, which was initiated in 2001. Still, the results imply that a substantial proportion of Danish schoolchildren do not meet the nationally recommended daily intake of fruit. In another Danish study, the role of socio-economic position (defined as parental occupation) in associations between skipping breakfast and overweight were investigated. The results indicated that frequent consumption of breakfast was most protective against overweight among children from high socio-economic backgrounds. Analyses in Polish adolescents (data from 2002-2006) indicated a decreasing trend in the frequency of fruit and vegetables consumption (Dzielska et al. 2008).

5. Research questions
1. Trends in the consumption of fruits, vegetables, soft drinks 2. Does the frequency of consumption of fruits, vegetables, sweets vary with family composition, family socio-economic status, and/or family relations?

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3. Does the consumption of fruits, vegetables, sweets, vary with BMI, body image and eating patterns? 4. Is there an association between overweight and dairy food items? 5. How are the food frequency items related to other lifestyle patterns? 6. To describe childrens eating patterns with regard to the most important sources of fibre and calcium. 7. To describe childrens eating patterns with regard to the four important Cs in childrens diet: chips, crisps, chocolate and coke. 8. What is the relation between consumption, availability, and affordability within regions? 9. Are there country differences in the food related lifestyle aspects and do these differences help explain diversity in food consumption between countries?

6. Instruments
This section contains a description of each item included in the Eating Habits section of the survey, including the origin, history of use, changes incurred and validation studies conducted.

Validation work In 2004-2005 a validation study, incorporating the questions on breakfast consumption, the FFQ and food related lifestyle aspects was conducted in Flanders, Italy, and Finland. In Flanders 112 pupils (52% boys; mean age 11.7 (SD=0.6)) from 4 primary schools (6 classes) completed the questionnaire - including questions on breakfast, the food frequency and food related lifestyle aspects - twice and filled in a 7-day diary record; data from 18 diaries were excluded for analyses because the pupils followed the Ramadan or did not complete the diaries accurately. In Italy 114 pupils (36% boys; mean age 11.6 (SD=0.3) from 3 primary schools (6 classes) completed the questionnaire twice and filled in a 7-day diary record (Vereecken et al. 2008). In Finland 252 young people of 11 (n=58; 50 % of boys; mean age 11.7, SD=0.3), 13 (n=94; 54 % of boys; mean age 13.7, SD=0.4), and 15 (n=100; 41% of boys; mean age 15.6, SD=0.3) years of

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age completed the questionnaires twice with a test retest interval of two weeks. The survey took place in 7 schools and 14 classes (Ojala et al., unpublished results). In a recent study in Belgian Flanders on the Role of Interpersonal Influences in Childrens Eating Behaviour (Coesens et al., unpublished results), parents and children of 70 two-parent families with at least two children between 10 and 18 years of age were each asked to fill in a questionnaire, including the HBSC FFQ (excluding milk cheese and milk products) and the optional package on food related lifestyle behaviours, during a home visit. Separate analyses were conducted for the youngest (26 boys, 44 girls; mean age 11; range 10-15) and oldest children (41 boys and 29 girls; mean age 14; range 11-18). The results presented below are limited to the comparison of the mothers responses with their children. For each of the studies, the relevant findings will be cited under the respective subheadings.

6.1 Mandatory items 6.1.1 Breakfast consumption


The item was introduced for the first time in the 2001-2002 survey. Item box 1
MQ5 How often do you usually have breakfast (more than a glass of milk or fruit juice)? Please tick one box for weekdays and one box for weekend Weekdays
1

Weekend
1

I never have breakfast during the week One day Two days Three days Four days Five days

I never have breakfast during the weekend I usually have breakfast on only one day of the weekend (Saturday OR Sunday) I usually have breakfast on both weekend days (Saturday AND Sunday)

Source: HBSC survey 2001/02, 2005/06

Test-retest kappa statistics of daily consumers versus less than daily consumers were strong (Flanders: week 0.71; weekend 0.60; Italy: week 0.71; Finland: week 0.78; weekend 0.58). Kappa statistics comparing the daily consumption of breakfast according to the diaries in the Flemish population were fair for the weekend (0.34) and moderate for the weekdays (0.47).

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6.1.2 Food Frequency Questions


In 1986, 11 food items were included in the HBSC FFQ: tea, coffee, fruits, coke or other fizzy drinks, sweets, vegetables, peanuts, potato crisps, chips/fried potatoes, hamburgers or hot dogs and dark bread. In the next survey, 1989-1990, tea was omitted, containing sugar was added to coke or other fizzy drinks, vegetables was replaced with raw vegetables, dark bread was replaced with whole wheat or rye bread and low fat milk and whole fat milk were added, resulting in a 12 item FFQ. In 1993-1994 the same items were repeated. In 1997-1998, cooked vegetables were added and peanuts were replaced with cake/pastry. The revision of the HBSC questionnaire for the 2001-2002 survey resulted in substantial changes: only four items were kept mandatory (fruits, vegetables, sweets (candy or chocolate) and regular soft drinks): these items were selected because of their high priority for most participating countries. Furthermore an optional package was proposed, with additional items focusing on important sources of fibre and calcium and the youth food culture (see item bank on the HBSC website). Item box 2
MQ6 How many times a week do you usually eat or drink .... ? Never Less than once a week Once a week 2-4 days a week 5-6 days a week Once a day, every day Every day, more than once
7

Fruits Vegetables Sweets (candy or chocolate) Coke or other soft drinks that contain sugar

Source: HBSC surveys 1985/06, 1989/90, 1993/94, 1997/98, 2001/02 (revised: response categories expanded; raw and cooked vegetables combined into one item vegetables), 2005/06.

The answer categories in the 1986 survey were (more than once a day, once a day, once a week, rarely and never). The only change that occurred was the replacement of once a week with at least once a week but not daily since the 1989-1990 survey. However, in 20012002 the latter was further subdivided into once a week, 2-4 days a week and 5-6 days a

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week as the gap between once a day and at least once a week but not daily was considered to be too wide. Meanwhile the response order was reversed. The revised format of answer categories was tested in the Flemish HBSC survey in 2000. Comparing the frequency distributions of the existing answer categories (data from the Flemish HBSC surveys in 1994 and 1996) with the frequency distributions of the new answer categories (data from the Flemish HBSC survey 2000) suggested that a lot of pupils who reported to consume the food items 5-6 days a week did indeed classify themselves as daily rather than weekly consumers in the earlier grouping. These significant changes in the answer categories do mean, however, that comparison of the 2001-2002 and subsequent surveys with the 1997-1998 and previous surveys are not possible. Validation studies in Belgian and Italian school children indicate that (Vereecken et al. 2008; Vereecken / Maes 2003) overestimation must be considered when the FFQ tool is used for estimating consumption frequencies. The ability to rank individuals varies considerably between food items. Based on the FFQ-items, several indices were created and compared with indices and nutrients based on 7-day dietary records. The results indicated that the Calcium index in particular can be useful in situations requiring brief dietary instruments, while the value of the other indices (excess, variety, fiber) was lower although still associations in the expected directions were found (Vereecken et al. 2008). Weighted kappas comparing FFQ responses of mothers and their youngest child participating in the study of Coesens et al. varied between 0.25 for vegetables and 0.6 for fish, with an average of 0.47; weighted kappas for the oldest child varied between 0.35 for chips and 0.63 for white bread, with an average of 0.52.

6.2 Optional items


The optional packages/items listed below can be found on the item bank on the HBSC website. Food frequency questionnaire Food related lifestyle aspects

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7. References
Affenito,S.G. (2007). Breakfast: A missed opportunity. Journal of the American Dietetic Association, 107(4), 565-569. Amin,T.T., Al-Sultan,A.I., & Ali,A. (2008). Overweight and obesity and their relation to dietary habits and socio-demographic characteristics among male primary school children in Al-Hassa, Kingdom of Saudi Arabia. European Journal of Nutrition, 47(6), 310-318. Anderson,A.S., Macintyre,S., & West,P. (1993). Adolescent meal patterns: grazing habits in the west of Scotland. Health Bulletin (Edinburgh), 51(3), 158-165. Barr,S.I., & McKay,H.A. (1998). Nutrition, exercise, and bone status in youth. International Journal of Sport Nutrition, 8(2), 124-142. Bigler-Doughten,S., & Jenkins,R.M. (1987). Adolescent snacks: nutrient density and nutritional contribution to total intake. Journal of the American Dietetic Association, 87(12), 1678-1679. Birch,L.L., & Fisher,J.O. (1998). Development of eating behaviors among children and adolescents. Pediatrics, 101(3 Pt 2), 539-549. Birch,L.L., Fisher,J.O., Grimm-Thomas,K. et al. (2001). Confirmatory factor analysis of the Child Feeding Questionnaire: a measure of parental attitudes, beliefs and practices about child feeding and obesity proneness. Appetite, 36(3), 201-210. Boutelle,K.N., Lytle,L.A., Murray,D.M. et al. (2001). Perceptions of the family mealtime environment and adolescent mealtime behavior: do adults and adolescents agree? Journal of Nutrition Education, 33(3), 128-133. Bronner,F. (1994). Calcium and osteoporosis. American Journal of Clinical Nutrition, 60(6), 831-836. Burghardt,J., Gordon,A., Chapman,N. et al. (1993). The School Nutrition Dietary Assessment Study: School Food Service, Meals Offered, and Dietary Intakes.: Princeton, NJ: Mathematica Policy Research, Inc. Centers for Disease Control and Prevention (1997). Guidelines for school health programs to promote lifelong healthy eating. Journal of School Health, 67(1), 9-26. Coon,K.A., Goldberg,J., Rogers,B.L. et al. (2001). Relationships between use of television during meals and children's food consumption patterns. Pediatrics, 107(1), e7. Drummond,S., Crombie,N., & Kirk,T. (1996). A critique of the effects of snacking on body weight status. European Journal of Clinical Nutrition, 50(12), 779-783. Dwyer,J.T., Evans,M., Stone,E.J. et al. (2001). Adolescents' eating patterns influence their nutrient intakes. Journal of the American Dietetic Association, 101(7), 798-802. Francis,L.A., Hofer,S.M., & Birch,L.L. (2001). Predictors of maternal child-feeding style: maternal and child characteristics. Appetite, 37(3), 231-243. Gatenby,S.J. (1997). Eating frequency: methodological and dietary aspects. British Journal of Nutrition, 77 Suppl 1 S7-20. Gibson,S., & Neate,D. (2007). Sugar intake, soft drink consumption and body weight among British children: further analysis of National Diet and Nutrition Survey data with adjustment for underreporting and physical activity. International Journal of Food Sciences and Nutrition, 58(6), 445460. Gillman,M.W., Rifas-Shiman,S.L., Frazier,A.L. et al. (2000). Family dinner and diet quality among older children and adolescents. Archives of Family Medicine, 9(3), 235-240. Guenther,P.M. (1986). Beverages in the diets of American teenagers. Journal of the American Dietetic Association, 86(4), 493-499. Guthrie,J.F., Lin,B.H., & Frazao,E. (2002). Role of food prepared away from home in the American diet, 1977-78 versus 1994-96: changes and consequences. Journal of Nutrition Education and Behavior, 34(3), 140-150. Haapalahti,M., Mykkanen,H., Tikkanen,S. et al. (2003). Meal patterns and food use in 10- to 11-year-old Finnish children. Public Health Nutrition, 6(4), 365-370.

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Harnack,L., Stang,J., & Story,M. (1999). Soft drink consumption among US children and adolescents: nutritional consequences. Journal of the American Dietetic Association, 99(4), 436-441. Haug,E., Rasmussen,M., Samdal,O. et al. (2009). Overweight in school-aged children and its relationship with demographic and lifestyle factors: Results from the WHO-Collaborative Health Behaviour in School-aged Children (HBSC) Study. submitted for publication. Isralowitz,R.E., & Trostler,N. (1996). Substance use: toward an understanding of its relation to nutritionrelated attitudes and behavior among Israeli high school youth. Journal of Adolescent Health, 19(3), 184-189. Janssen,I., Katzmarzyk,P.T., Boyce et al. (2005). Comparison of overweight and obesity prevalences in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity Reviews, 6 123-132. Kelder,S.H., Perry,C.L., Klepp,K.I. et al. (1994). Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors. American Journal of Public Health, 84(7), 1121-1126. Kelsey,K.S., Campbell,M.K., & Vanata,D.F. (1998). Parent and adolescent girls' preferences for parental involvement in adolescent health promotion programs. Journal of the American Dietetic Association, 98(8), 906-907. Kerr,M.A., Rennie,K.L., McCaffrey,T.A. et al. (2008). Snacking patterns among adolescents: a comparison of type, frequency and portion size between Britain in 1997 and Northern Ireland in 2005. British Journal of Nutrition 1-10. Keski-Rahkonen,A., Kaprio,J., Rissanen,A. et al. (2003). Breakfast skipping and health-compromising behaviors in adolescents and adults. European Journal of Clinical Nutrition, 57(7), 842-853. Key,J.D., & Key-LL,J. (1994). Calcium needs of adolescents. Current opinion in pediatrics, 6(4), 379-382. Lien,N., Lytle,L.A., & Klepp,K.I. (2001). Stability in consumption of fruit, vegetables, and sugary foods in a cohort from age 14 to age 21. Preventive Medicine, 33(3), 217-226. Lin,B.H., Guthrie,J.F., & Frazao,E. (1999). Nutrient contribution of food away from home. America's eating habits: Changes and Consequences. (pp.213-242). Washington, DC: US Department of Agriculture, Economic Research Service. Malik,V.S., Schulze,M.B., & Hu,F.B. (2006). Intake of sugar-sweetened beverages and weight gain: a systematic review. American Journal of Clinical Nutrition, 84(2), 274-288. Marlett,J.A., McBurney,M.I., & Slavin,J.L. (2002). Position of the American Dietetic Association: health implications of dietary fiber. Journal of the American Dietetic Association, 102(7), 993-1000. Matkovic,V., & Ilich,J.Z. (1993). Calcium requirements for growth: are current recommendations adequate? Nutrition Reviews, 51(6), 171-180. Matthys,C., De Henauw,S., Bellernans,M. et al. (2007). Breakfast habits affect overall nutrient profiles in adolescents. Public Health Nutrition, 10(4), 413-421. Matthys,C., De Henauw,S., Devos,C. et al. (2003). Estimated energy intake, macronutrient intake and meal pattern of Flemish adolescents. European Journal of Clinical Nutrition, 57(2), 366-375. Molcho,M., Gabhainn,S.N., Kelly,C. et al. (2007). Food poverty and health among schoolchildren in Ireland: findings from the Health Behaviour in School-aged Children (HBSC) study. Public Health Nutrition, 10(4), 364-370. Moynihan,P. (2005). The interrelationship between diet and oral health. Proceedings of the Nutrition Society, 64(4), 571-580. Nmeth,A. (2007a). Eating habits, body image and subjective well-being among adolescents. ne, 16(3-4), 2-4. Nmeth,A. (2007b). Physical activity and eating habits of adolescents. New Diet [j Dita], 16(6), 10-11. Neumark-Sztainer,D., Hannan,P.J., Story,M. et al. (2003). Family meal patterns: associations with sociodemographic characteristics and improved dietary intake among adolescents. Journal of the American Dietetic Association, 103(3), 317-322. Neumark-Sztainer,D., Story,M., Perry,C. et al. (1999). Factors influencing food choices of adolescents: findings from focus-group discussions with adolescents. Journal of the American Dietetic Association, 99(8), 929-937.

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Neumark-Sztainer,D., Wall,M., Story,M. et al. (2004). Are family meal patterns associated with disordered eating behaviors among adolescents? Journal of Adolescent Health, 35(5), 350-359. Nicklas,T.A., Baranowski,T., Cullen,K.W. et al. (2001). Eating patterns, dietary quality and obesity. Journal of the American College of Nutrition, 20(6), 599-608. Nicklas,T.A., Yang,S.J., Baranowski,T. et al. (2003). Eating patterns and obesity in children. The Bogalusa Heart Study. American Journal of Preventive Medicine, 25(1), 9-16. Niemeier,H.M., Raynor,H.A., Lloyd-Richardson,E.E. et al. (2006). Fast food consumption and breakfast skipping: Predictors of weight gain from adolescence to adulthood in a nationally representative sample. Journal of Adolescent Health, 39(6), 842-849. Ojala,K., Vlimaa,R., Villberg,J. et al. (2006). Adolescents' meal patterns: Who eats regularly on schooldays? Journal of Social Medicine (Sosiaalilketieteellinen aikakauslehti), 43 60-71. Ovaskainen,M.L., Reinivuo,H., Tapanainen,H. et al. (2006). Snacks as an element of energy intake and food consumption. European Journal of Clinical Nutrition, 60(4), 494-501. Post,B., de Vente,W., Kemper,H.C. et al. (2001). Longitudinal trends in and tracking of energy and nutrient intake over 20 years in a Dutch cohort of men and women between 13 and 33 years of age: The Amsterdam growth and health longitudinal study. British Journal of Nutrition, 85(3), 375385. Post-Skagegard,M., Samuelson,G., Karlstrom,B. et al. (2002). Changes in food habits in healthy Swedish adolescents during the transition from adolescence to adulthood. European Journal of Clinical Nutrition, 56(6), 532-538. Rampersaud,G.C., Pereira,M.A., Girard,B.L. et al. (2005). Review - Breakfast habits, nutritional status, body weight, and academic performance in children and adolescents. Journal of the American Dietetic Association, 105(5), 743-760. Rasmussen,M., Krolner,R., Svastisalee,C.M. et al. (2008). Secular trends in fruit intake among Danish schoolchildren, 1988 to 2006: Changing habits or methodological artefacts? International Journal of Behavioral Nutrition and Physical Activity, 5 6. Roblin,L. (2007). Childhood obesity: food, nutrient, and eating-habit trends and influences. Applied Physiology, Nutrition, and Metabolism, 32(4), 635-645. Rockett,H.R., & Colditz,G.A. (1997). Assessing diets of children and adolescents. American Journal of Clinical Nutrition, 65(4 Suppl), 1116S-1122S. Schettler,A.E., & Gustafson,E.M. (2004). Osteoporosis prevention starts in adolescence. Journal of the American Academy of Nurse Practitioners, 16(7), 274-282. Schnohr,C., Pedersen,J.M., Alcon,M.C. et al. (2004). Trends in the dietary patterns and prevalence of obesity among Greenlandic school children. International Journal of Circumpolar Health, 63 Suppl 2 261-264. Sebastian,R.S., Cleveland,L.E., & Goldman,J.D. (2008). Effect of snacking frequency on adolescents' dietary intakes and meeting national recommendations. Journal of Adolescent Health, 42(5), 503511. Sigman-Grant,M. (2002). Strategies for counseling adolescents. Journal of the American Dietetic Association, 102(3 Suppl), S32-S39. Steingrimsdottir,L., Ovesen,L., Moreiras,O. et al. (2002). Selection of relevant dietary indicators for health. European Journal of Clinical Nutrition, 56 Suppl 2 S8-11. Story,M., Neumark-Sztainer,D., & French,S.A. (2002). Individual and environmental influences on adolescent eating behaviors. Journal of the American Dietetic Association, 102(3), s40-s51. Summerbell,C.D., Moody,R.C., Shanks,J. et al. (1995). Sources of energy from meals versus snacks in 220 people in four age groups. European Journal of Clinical Nutrition, 49(1), 33-41. Taras,H.L., Sallis,J.F., Nader,P.R. et al. (1990). Children's television-viewing habits and the family environment. Am.J Dis.Child, 144(3), 357-359. Timlin,M.T., Pereira,M.A., Story,M. et al. (2008). Breakfast eating and weight change in a 5-year prospective analysis of adolescents: Project EAT (eating among teens). Pediatrics, 121(3), E638E645.

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Utter,J., Scragg,R., Mhurchu,C.N. et al. (2007). At-home breakfast consumption among New Zealand children: Associations with body mass index and related nutrition behaviors. Journal of the American Dietetic Association, 107(4), 570-576. Van Duyn,M.A., & Pivonka,E. (2000). Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: selected literature. Journal of the American Dietetic Association, 100(12), 1511-1521. Vereecken,C., Rossi,S., Giacchi,M. et al. (2008). Comparison of a short food frequency questionnaire and derived indices with a seven-day diet record in Belgian and Italian children. International Journal of Public Health, 53(6), 297-305. Vereecken,C., De,H.S., Maes,L. et al. (2009a). Reliability and validity of a healthy diet determinants questionnaire for adolescents. Public Health Nutrition 1-9. Vereecken,C., Dupuy,M., Mette,R. et al. (2009b). Breakfast consumption and its socio-demographic and lifestyle correlates in schoolchildren in 41 countries participating in the HBSC study. submitted for publication. Vereecken,C.A., Bobelijn,K., & Maes,L. (2005a). School food policy at primary and secondary schools in Belgium-Flanders: does it influence young people's food habits? European Journal of Clinical Nutrition, 59(2), 271-277. Vereecken,C.A., De Henauw,S., & Maes,L. (2005b). Adolescents' food habits: results of the Health Behaviour in School-aged Children survey. British Journal of Nutrition, 94(3), 423-431. Vereecken,C.A., Inchley,J., Subramanian,S.V. et al. (2005c). The relative influence of individual and contextual socio-economic status on consumption of fruit and soft drinks among adolescents in Europe. European Journal of Public Health, 15(3), 224-232. Vereecken,C.A., Todd,J., Roberts,C. et al. (2006). Television viewing behaviour and associations with food habits in different countries. Public Health Nutrition, 9(2), 244-250. Vereecken,C., & Maes,L. (2003). A Belgian study on the reliability and relative validity of the Health Behaviour in School-Aged Children food frequency questionnaire. Public Health Nutrition, 6(6), 581-588. Videon,T.M., & Manning,C.K. (2003). Influences on adolescent eating patterns: the importance of family meals. Journal of Adolescent Health, 32(5), 365-373. Wardle,J., Carnell,S., & Cooke,L. (2005). Parental control over feeding and children's fruit and vegetable intake: how are they related? Journal of the American Dietetic Association, 105(2), 227-232. Wardle,J., Sanderson,S., Guthrie,C.A. et al. (2002). Parental feeding style and the inter-generational transmission of obesity risk. Obesity Research, 10(6), 453-462. Willett,W.C. (1994). Diet and health: what should we eat? Science, 264(5158), 532-537. World Health Organization Regional Office of Europe (2008). European Action Plan for Food and Nutrition Policy 2007-2012. Copenhagen: World Health Organization Regional Office of Europe. Yang,R.J., Wang,E.K., Hsieh,Y.S. et al. (2006). Irregular breakfast eating and health status among adolescents in Taiwan. Bmc Public Health, 6. Yannakoulia,M., Karayiannis,D., Terzidou,M. et al. (2004). Nutrition-related habits of Greek adolescents. European Journal of Clinical Nutrition, 58(4), 580-586. Zizza,C., Siega-Riz,A.M., & Popkin,B.M. (2001). Significant increase in young adults' snacking between 1977-1978 and 1994-1996 represents a cause for concern! Preventive Medicine, 32(4), 303-310.

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II.5.2 Weight reduction behaviour


Ojala, K, Nmeth,

1. Scope and purpose


Being thin is greatly valued within Western societies in spite of increased rate of childhood and adolescent obesity. In fact, the stigmatization of obesity by children appears to have increased (Latner / Stunkard 2003). Weight control behaviour has become a well-known feature of adolescent behaviour, as a means of achieving the perfect body. Both the prevalence and frequency of weight control behaviour multiplies as the body mass index increases (Barker et al. 2000, Shisslak et al. 2006, Strauss 1999), but adolescents often find it difficult to classify themselves appropriately in terms of weight, and a perception of overweight rather than actual weight, appears to be a potent force behind attempts to lose weight (Mulvihill et al. 2004, Ojala et al. 2007). Concern has arisen about adolescents weight reduction behaviour, as it might be associated with negative physical and psychological outcomes. Dieters are more susceptible to nutritional deficiency, growth retardation, menstrual irregularities and delayed sexual maturation, irritability, sleep disturbances and concentration problems (Pesa 1999). Extreme dieting has been connected with low self-esteem and other negative psychological states, such as a strong relationship with depression, anxiety and suicidal thoughts and eating disorders (NeumarkSztainer / Hannan 2000, Patton et al. 1999, Pesa 1999). The majority of adolescents who are trying to lose weight adopt what would be considered healthy eating and exercise behaviour, but also fasting, diet pills or laxatives, vomiting and smoking are used (Caroll et al. 2006, Honjo / Siegel 2003, Lowry et al. 2002, Paxton et al. 2004, Tomeo et al. 1999). Repeated attempts to lose weight may lead to weight gain via the longterm adoption of binge eating, fasting followed by overeating or decreased breakfast consumption that are counterproductive to weight management (Field et al. 2003, NeumarkSztainer et al. 2007a). In addition, dietary restrain has been proved to predict binge eating especially among obese children (Allen et al. 2008). Neumark-Sztainer et al. (2006) stated in their longitudinal study that unhealthy weight-control behaviours predict outcomes related to obesity and eating disorders 5 years later in adolescents. Therefore, the identification of shared risk and protective factors for overweight

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and disordered eating can guide the development of relevant interventions to a broad spectrum of weight-related problems (Neumark-Sztainer et al. 2007b).

2. Objectives
The HBSC study offers the possibility to investigate the contexts of weight control behaviour in a wide range of industrialised countries. The main objectives of these study items are to identify those 11-, 13- and 15-year-old adolescents who are currently engaged in weight reduction behaviour or have need of weight reduction or weight gain (mandatory item). The optional items enable us to study the prevalence and duration of weight controlling and use of specific weight control practices in adolescents. In addition, items can be used to identify highrisk groups and to explore associations between weight control behaviour and other health related behaviour (e.g. physical activity, eating habits, smoking) psychological well-being (e.g. body image and life satisfaction), as well as social factors (e.g. family relationships) and to study trends in weight control behaviour especially in respect of obesity.

3. Theoretical framework
Gender differences are apparent in the ways in which male and female adolescents evaluate their body shape and weight. Males are most likely to report dissatisfaction with their muscle size and shape whereas females are more often dissatisfied with their weight and want to become thinner (Hargreaves / Tiggemann 2006, Lappalainen et al. 1999, Muris et al. 2005, Murnen et al. 2003, Shisslak et al. 2006, Strauss 1999). Self-perception of overweight due to the more intense cultural pressure to be thin among females partly explains relatively high percentages of non-overweight girls trying to lose weight. The 13- and 15-year-old girls may see the increase in weight caused by physical development as an obstacle for reaching the ideal thin female body (Hargreaves / Tiggemann 2006). In boys physical development is rather associated with muscle-building activities (McCabe et al. 2002, Ricciardelli / McCabe 2003) than weight reduction. Evidence in this topic, however, is not unambiguous. For instance, a relationship between pubertal status and drive for muscularity was not found by Smolak/Stein (2006). Results are also mixed regarding pubertal timing: early but not late maturation was found to be related to engagement in muscle increasing behaviour in a longitudinal study (McCabe / Ricciardelli 2004). However, in another longitudinal study Ricciardelli and McCabe (2003) did not find a relationship between these variables.

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Pubertal development, which is a key process in adolescence, is highly associated with BMI, body image and body weight satisfaction changes (see sections on body mass and body image, Abraham / ODea 2001). More advanced pubertal status is connected with higher bodyconsciousness and stronger desire to lose weight in girls (Gralen et al. 1990, McCabe / Ricciardelli, 2004, ODea / Abraham 1999), though results are far from conclusive regarding the mechanism among puberty, body weight, body dissatisfaction and weight management behaviour. Some studies stress the key impact of BMI on body dissatisfaction and attempts to lose weight and a marginal role of puberty itself (McCabe et al. 2001, Muris et al. 2005), others stated that pubertal development causes increased body dissatisfaction regardless of nutritional status changes which leads to weight managing behaviours (Cotrufo et al. 2007). On one hand, most of the studies found early puberty to be risky for weight reduction behaviour and eating disorders (Currie / Nmeth 2004, Kaltiala-Heino et al. 2001, Williams / Currie 2000). On the other hand, a similar relationship with late maturation has been reported (McCabe / Ricciardelli 2004). Moreover, Kaltiala-Heino et al. (2001) found an elevated risk for disordered eating among very early and late maturing boys. This U-shaped curve regarding body image disturbance and dysfunctional eating patterns was observed by Michaud et al. (2006), too. The physical changes occurring during adolescence include accumulation of body weight. In some cases the accumulation can be excessive and may lead to obesity. It has been stated that overweight adolescents may adopt extreme weight reduction practices because they are further from their ideal weight or have failed to lose weight by means of modest eating or exercise changes (Boutelle et al. 2002, Field et al. 2003, Malinauskas et al. 2006, McCabe et al. 2005, Neumark-Sztainer et al. 2002). It may also be that the increased bias against obesity drives obese young people to turn to rapid or unhealthy ways to lose weight (Latner / Stunkard 2003). Young people who value their body and health are less likely to engage in rapid or extreme weight reduction practices, regardless of their body weight (Strauss 1999). It is essential to promote self-esteem for all health-related behaviours and particularly, for weight control.

4. Summary of previous work


The mandatory question At present are you on a diet or doing something else to lose weight? with answer options 1) No, my weight is fine, 2) No, but I should lose some weight, 3) No, because I need to put on weight and 4) Yes, was used in 2001/2002 survey and repeated in 2005/2006 survey. More concise Are you on a diet to lose weight? with three answers

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options was used in the 1997/98 survey and corresponding item has been presented in some countries in the earlier surveys. The national data has been used in several publications (Al Sabbah et al. 2009a, Due et al. 1991a, 1991b, Kololo / Woynarowska 2004, Nmeth 2007, Nmeth et al. 2002, Ojala et al. 2003, Ojala et al. 2006, Roberts et al. 1993, Ter Bogt et al. 2006, Vlimaa / Ojala 2004, Woynarowska / Mazur 2000). According to the international reports from the HBSC 2001/02 (Mulvihill et al. 2004) and 2005/06 (Nmeth / Ojala 2008) surveys, weight reduction behaviour has shown clear gender differences: girls are about three times as likely as boys to report engaging in weight control behaviour. The difference increases with age. No clear relation with family affluence has been found. In the international cross-sectional study of Al Sabbah et al. (2009b) body weight dissatisfaction was highly prevalent and more common among girls than boys, among overweight than non-overweight, and among older adolescents than younger adolescents. In addition, difficulties in talking to father were associated with weight dissatisfaction among both boys and girls in most countries. Difficulties in talking to mother were rarely associated with body weight dissatisfaction among boys while among girls this association was found in most countries (Al Sabbah et al. 2009b). Weight dissatisfaction (i.e. feeling too fat or too thin) was positively associated with most of the outcome variables (body image, health complaints, risk behaviours, and television viewing) regardless of weight status, whereas weight status was associated with only a few of the outcome variables among Palestinian adolescents (Al Sabbah et al. 2009a). The optional items of weight control activities and methods were used first in the 2001/02 survey. The optional question Have you gone on a diet, changed your eating habits or done something else to control your weight, during the last 12 months? assesses the occurrence and duration of weight control practices. The period of 12 months were chosen to cover seasonal variations. Six affirmative answer options for this question are from Yes, for a few days to Yes, for 6 months or more. Those respondents who answer yes to this item indicate which of the listed methods they used to control their weight during the previous 12 months. Listed methods are based on the Flanders HBSC 2000 survey in which the responders filled in an open-ended question concerning their weight control methods. The top frequencies for the healthier as well as the less healthy methods were selected to be presented in the 2001/02 survey.

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Overweight adolescents odd ratios for weight controlling during the past 12 months were higher than those for non-overweight adolescents in both boys and girls in all surveyed countries with exception of Estonian girls (Ojala et al. 2007). The difference in used weight control practices between overweight and non-overweight weight controllers was significant in most of the countries with regard to eating fewer sweets, drinking fewer soft drinks and dieting under the supervision of a health care professional as a means to control weight in the 2001/02 survey. The international data demonstrated also that adolescents attempts to lose weight are not only strongly defined by weight status but also by gender, age, self-perception of overweight and the country of residence. However, no clear geographical pattern across Europe and North America was found. The importance of promoting a healthy body image for all adolescents was highlighted by the fact that self-perception of overweight was found to be the most important factor leading to attempts to lose weight. Physical activity seemed to have a relationship with the used weight control methods. In the 2001/02 data, the physically active Finnish girls were more likely to control their weight by exercising, eating less sweets and fat, drinking less soft drinks and eating more fruit and/or vegetables than the physically passive girls who, instead, appeared to smoke more in order to control their weight (Ojala et al. 2003).

5. Research questions
1. Are there changes over time in weight concerns; body dissatisfaction and weight reduction behaviour? (Mandatory question) 2. Is weight reduction associated with physical activity, diet and/or smoking? (Mandatory question) 3. What are the specific factors within countries that bring about country-level contribution in current attempts to lose weight? (Mandatory question) 4. What kind of association is there between body dissatisfaction and risky weight control behaviour? (Mandatory and optional questions) 5. What kind of risk and protective factors can be identified for body dissatisfaction and health compromising weight control behaviour? (Mandatory and optional questions)

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6. Instruments
6.1 Mandatory items
The item of weight reduction identifies those young people who are currently trying to lose weight or feel the need for it. Item box 1
MQ7
1 2 3 4

At present are you on a diet or doing something else to lose weight? No, my weight is fine No, but I should lose some weight No, because I need to put on weight Yes

Source: HBSC 1993/94, 1997/98, 2001/02 (revised: question of dieting expanded to include other methods to lose weight, response category no because I need to put on weight added) & 2005/2006

Vakidation work Original testing of this item M9 took place in Flanders, Belgium 2000 (n=560 school pupils: Kappa = .77, 88% agreement). Test-retest reliability was investigated again in Finland in 2005 (n=194 13 and 15-year-old school children, Kappa = .69, 83% agreement, ICC .64 with the confidence interval of 0.55-0.71) and found to be acceptable.

Item placement Appearance and body image items should not be placed together with items of weight reduction. Its also advisable to place BMI variables (weight and height), and food related questions (food frequency and breakfast consumption) apart from.

6.2 Optional items


Optional items can be found in the item bank on the HBSC website.

7. References
Abraham S, ODea, JA. Body mass index, menarche, and perception of dieting among peripubertal adolescent females. International Journal of Eating Disorders 2001, 29(1):23-8. Allen KL, Byrne SM, La Puma M, McLean N, Davis EA. The onset and course of binge eating in 8- to 13year-old healthy weight, overweight and obese children. Eating Behaviors 2008, doi:10.1016/j.eatbeh.2008.07.008.

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Al Sabbah H, Vereecken C, Abdeen Z, Coats E, Maes L. Associations of overweight and of weight dissatisfaction among Palestinian adolescents: findings from the national study of Palestinian schoolchildren (HBSC-WBG2004). Journal of Human Nutrition and Dietetics 2009a, 22(1):40-49. Al Sabbah H, Vereecken C, Elgar FJ, Nansel T, Aasvee K, Abdeen Z, Ojala K, Ahluwalia N, Maes L. Body weight dissatisfaction and communication with parents among adolescents in 24 countries: International cross-sectional survey. BMC Public Health 2009b, 9:52 DOI:10.1186/1471-2458-952. Barker M, Robinson S, Wilman C, Barker DJP. Behaviour, body composition and diet in adolescent girls. Appetite 2000, 35:161170. Boutelle K, Neumark-Sztainer D, Story M, Resnick M. Weight control behaviours among obese, overweight, and nonoverweight adolescents. Journal of Pediatric Psychology 2002, 27:531540. Caroll SL, Lee RE, Kaur H, Harris KJ, Strother ML, Huang TT-K. Smoking, weight loss intention and obesitypromoting behaviors in college students. Journal of American College of Nutr ition 2006, 25:348 353. Cotrufo P, Cella S, Cremato F, Labella AG. Eating disorder attitude and abnormal eating behaviours in a sample of 11-13 year-old school children: The role of pubertal body transformation. Eating and Weight Disorders 2007, 12(4):154160. Currie C, Nmeth . Puberty and health. In: Candace Currie et al (eds.) Young peoples health in context, Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Health Policy for Children and Adolescents 2004, No. 4:196204. Due P, Holstein BE, Groth MV. Diet and health behaviour in Danish children aged 11-15 years (in Danish). Tandlgernes nye tidsskrift 1991a, 6:232237. Due P, Holstein BE, Groth MV. Diet and health behaviour in Danish children aged 11-15 years (in Danish). Ugeskr lger 1991b, 153: 984988. Field AE, Austin SB, Taylor CB, Malspeis SM, Rosner B, Rockett HR, Gillman MW, Colditz GA. Relation between dieting and weight change among preadolescents and adolescents. Pediatrics 2003, 112:900906. Gralen SJ, Levine MP, Smolak LM, Sarah K. Dieting and disordered eating during early and middle adolescence: Do the influences remain the same? International Journal of Eating Disorders 1990, 9(5):501512. Hargreaves DA, Tiggemann M. Body image is for girls. A qualitative study of boys body image. Journal of Health Psychology 2006, 11:567576. Honjo K, Siegel M: Perceived importance of being thin and smoking initiation among young girls. Tobacco Control 2003, 12:289295. Kaltiala-Heino R, Rimpel M, Rissanen A, Rantanen P. Early puberty and early sexual activity are associated with bulimic-type eating pathology in middle adolescence. Journal of Adolescent Health 2001, 28:346352. Kololo H, Woynarowska B. Self-reported body weight status and weight control practices in adolescents. Przeglad Pediatryczny (Pediatric Review) 2004, 34(3/4):196-201. Latner JD, Stunkard AJ. Getting worse: the stigmatization of obese children. Obesity Research 2003, 11:452456. Lowry R, Galuska DA, Fulton JE, Wechsler H, Kann L. Weight management goals and practices among U.S high school students: associations with physical activity, diet, and smoking. Journal of Adolescent Health 2002, 31:133144. Malinauskas BM, Raedeke TD, Aeby VG, Smith JL, Dallas MB. Dieting practices, weight perceptions, and body composition: A comparison of normal weight, overweight, and obese college females. Nutrition Journal 2006, 5:1118. McCabe MP, Ricciardelli LA. A longitudinal study of pubertal timing and extreme body change behaviors among adolescent boys and girls. Adolescence 2004, 39:14566. McCabe MP, Ricciardelli LA, Banfield S. Body image, strategies to change muscles and weight, and puberty. Do they impact on positive and negative affect among adolescent boys and girls? Eating Behaviors 2001, 2:129149.

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McCabe MP, Ricciardelli LA, Finemore J. The role of puberty, media and popularity with peers on strategies to increase weight, decrease weight and increase muscle tone among adolescent boys and girls. Journal of Psychosomatic Research 2002, 52:145153. McCabe MP, Ricciardelli LA, Holt K: A longitudinal study to explain strategies to change weight and muscles among normal and overweight children. Appetite 2005, 45:225234. Michaud PA, Suris JC, Deppen A. Gender-related psychological and behavioural correlates of pubertal timing in a national sample of Swiss adolescents. Molecular and Cellular Endocrinology 2006, 25455:1728. Mulvihill C, Nmeth , Vereecken C. Body image, weight control and body weight. In Currie C et al (eds.) Young peoples health in context, Health Behaviour in School-aged Children (HBSC) study: international report from the 2001/2002 survey. Copenhagen, WHO Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4), 120-129. Muris P, Meesters C, van der Blom W, Mayer B. Biological, psychological, and sociocultural correlates of body change strategies and eating problems in adolescent boys and girls. Eating Behaviour 2005, 6:1122. Murnen SK, Smolak L, Mills JA, Good L. Thin, sexy women and strong, muscular men: Grade-school childrens responses to objectified images of women and men. Sex Roles 2003, 49:427437. Nmeth . Eating habits, body image, and subjective well-being among adolescents. (In Hungarian), j dita (New diet) 2007, 16(34):234. Nmeth , Bodzsr B, Aszmann, A. Maturation status and psychosocial characteristics of Hungarian adolescents. (In English) Anthropolgiai kzlemnyek (Anthropological Bulletins9 2002, 43:8594. Nmeth , Ojala K. Weight reduction behaviour. In Currie C et al (eds.) Inequalities in young peoples health: Health Behaviour in School-aged Children international report from the 2005/2006 survey. Copenhagen, WHO Regional Office for Europe, 2008 (Health Policy for Children and Adolescents No. 5), 101104. Neumark-Sztainer D, Hannan PJ. Weight-Related behaviors among adolescent girls and boys results from a national survey. Archives of Pediatrics & Adolescent Medicine 2000, 154:569577. Neumark-Sztainer D, Story M, Hannan PJ, Perry CL, Irving LM. Weight-related concerns and behaviors among overweight and nonoverweight adolescents. Implications for preventing weight-related disorders. Archives of Pediatrics & Adolescent Medicine 2002, 156:171178. Neumark-Sztainer D, Wall M, Guo J, Story M, Haines J, Eisenberg M: Obesity, Disordered Eating, and Eating Disorders in a Longitudinal Study of Adolescents: How Do Dieters Fare 5 Years Later? Journal of the American Dietetic Association 2006, 106:559568. Neumark-sztainer D, Wall M, Haines J, Story M, Eisenberg ME. Why does dieting predict weight gain in adolescents? Findings from Project EAT-II:A 5-year longitudinal study. Journal of the American Dietetic Association 2007a, 107:448455. Neumark-Sztainer D, Wall MM, Haines JI, Story MT, Sherwood NE, van den Berg PA. Shared Risk and Protective Factors for Overweight and Disordered Eating in Adolescents. American Journal of Preventive Medicine 2007b, 33(5):359369. ODea JA, Abraham S. Onset of disordered eating attitudes and behaviors in early adolescence: interplay of pubertal status, gender, weight and age. Adolescence 1999, 34(136):671679. Ojala K, Vereecken C, Vlimaa R, Currie C, Villberg J, Tynjl J, Kannas L. Attemps to lose weight among overweight and non-overweight adolescents: a cross-national survey. International Journal of Behavioural Nutrition and Physical Activity 2007, 4:50 DOI:10.1186/1479-5868-4-50. Ojala K, Vuori M, Vlimaa R, Villberg J, Tynjl, J, Kannas, L. Boys increasing the weight while girls are dropping it results from the WHO Health Behaviour in School-aged Children study. (In Finnish with English summary) In: Sakari Karvonen (ed.) Onko sukupuolella vli? Hyvinvointi, terveys, pojat, tytt. Nuorten elinolot vuosikirja 2006. Stakes & Nuorisotutkimusverkosto/Nuorisotutkimusseura publications 71:7282. Ojala K, Vlimaa R, Villberg J, Tynjl, J, Kannas, L. Weight reduction, weight management practices and physical activity among adolescent females. (In Finnish with English summary) Liikunta & Tiede (Sport & Science) 2003, 40: 6673.

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Patton GC, Selzer R, Coffey C, Carlin JB, Wolfe R. Onset of adolescent eating disorders: population based cohort study over 3 years. British Medical Journal 1999, 318:76576. Paxton RJ, Valois RF, Drane JW. Correlates of body mass index, weight goals, and weight management practices among adolescents. Journal of School Health 2004, 74:136143. Pesa J. Psychosocial factors associated with dieting behaviours among female adolescents. Journal of School Health 1999, 69:196201. Ricciardelli LA, McCabe MP. A longitudinal analysis of the role of biopsychosocial factors in predicting body change strategies among adolescent boys. Sex Roles 2003, 48(78):34959. Roberts C, Smith C, Moore L, Catford, J. Diet and young people in Wales, 1986-1992. Health Promotion Wales Technical Report No. 3. 1993. Shisslak CM, Mays MZ, Crago M, Jirsak JK, Taitano K, Cagno C. Eating and weight control behaviors among middle school girls in relationship to body weight and ethnicity. Journal of Adolescent Health 2006, 38:631633. Smolak L, Stein JA. The relationship of drive for muscularity to sociocultural factors, self-esteem, physical attributes gender role, and social comparison in middle school boys. Body Image 2006, 3:121 129. Strauss R. Self-reported weight status and dieting in a cross-sectional sample of young adolescents. National Health and Nutrition Examination Survey III. Archives of Pediatric & Adolescent Medicine 1999, 153:741747. Ter Bogt T, van Dorsselaer S, Monshouwer K, Verdurmen J, Engels R, Vollebergh W. Body mass index and body weight perception as risk factors for internalizing and externalizing problem behaviour among adolescents. Journal of Adolescent Health 2006, 39(1):2734. Tomeo CA, Field AE, Berkey CS, Colditz GA, Frazier AL. Weight concerns, weight control behaviors, and smoking initiation. Pediatrics 1999, 104:918924. Vlimaa R, Ojala K. Body weight status, self-perceived body weight, dieting and weight control behaviour among school-aged children in 19842002. (In Finnish with English summary). In Lasse Kannas (ed.) Schoolchildrens health and health behaviour in change. University of Jyvskyl, Research Center for Health Promotion, Publications 2, 2004:5578. Vlimaa R, Ojala K, Tynjl J, Villberg J, Kannas L. HBSC study: Overweight, self-perceived body weight and dieting in 15-year-old adolescents in Europe, Israel and North-America. (In Finnish with English summary). Suomen Lkrilehti (Finnish Medical Journal) 2005, 47:48434849. Williams JM, Currie C. Self-esteem and physical development in early adolescence: pubertal timing and body image. Journal of Early Adolescence 2000, 20:129149. Woynarowska B, Mazur J. Reported health and body image in school-aged children in Poland. (In Polish with English summary) Pediatria Polska 2000, 75 (1): 2534.

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II.5.3 Physical Activity


Iannotti, RJ, Roberts, C, Tynjl, J, Henriksen, PE and the Physical Activity Focus Group

1. Scope and purpose


The benefits of physical activity to the health of adults are well documented; regular physical activity can make an important contribution to improving the quality of life, both physical and psychological (Penedo / Dayn 2005). The relationship is complex, however, in that the type and amount of physical activity play a part. Regular physical activity can reduce the risk of cardiovascular diseases, cancer of the colon, obesity, non-insulin-dependent diabetes mellitus, and osteoporosis. It can also benefit people with arthritis, sexual dysfunction, mental problems (such as anxiety and depression) and cognitive impairment. An increase in physical activity is also often associated with a corresponding increase in fitness, which in turn can influence the quality of sleep (Driver / Taylor 2000). Sleep is essential to good health and the quality of life in general and can have long-term effects for adult health (Landhuis et al. 2008). Extensive reviews of the literature on children and adolescents (ages 6 through 18) indicate that moderate to vigorous activity is related to decreased adiposity, improvement in Metabolic Syndrome (abdominal obesity, elevated blood pressure, elevated fasting glucose, and reduced HDL), decreased triglyceride level, increased HDL, bone density, muscular strength and endurance, and aerobic fitness, and improved mental health (anxiety, depression, selfconcept) (Hallal et al. 2006, Strong et al. 2005). National surveys confirm the negative relationship between physical activity and obesity (Fleming-Moran / Thiagarajah 2005). Physical activity appears to improve both short- and long-term physical and mental health status; general health, bone health, health-related quality of life, and positive mood states have all been associated with higher levels of daily physical activity (Annesi 2005, Hallal et al. 2006, Iannotti et al., in press, Penedo / Dahn 2005). In early and mid adolescence, physical activity is related to self-image and quality of family and peer relationships and negatively related to health complaints and smoking (Iannotti et al., in press). In addition, there is evidence that increased physical activity improves academic and cognitive performance (Strong et al. 2005, Tomporowsky et al. 2008). The benefits of an active childhood can carry over into adulthood. Establishment of healthy patterns of physical activity during childhood and adolescence is important because physical activity tracks during adolescence and from adolescence to adulthood (Hallal et al. 2006).
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Furthermore, adolescent physical activity predicts obesity and abdominal obesity in adulthood (Menschik et al. 2008, Pietilinen et al. 2008). Unfortunately, both secular and age trends indicate a decrease in physical activity in childhood and adolescence and a corresponding increase in childhood obesity (Nader et al. 2008, Nelson et al. 2006). However, HBSC surveys suggest that VPA (vigorous physical activity during leisure time) has not decreased in adolescence from 1985 to 2002 (Samdal et al. 2007). Much work has gone into identifying the determinants of physical activity, in order to address potential barriers and promote more opportunities to participate. For example, previous international HBSC research has demonstrated that physical activity rates are higher for boys, decline with age, particularly among girls (Borraccino et al., in press; Hickman et al. 2000, Roberts et al. 2004, Samdal et al. 2007) and increase with socio-economic status (Borraccino et al., in press, Holstein et al. 2004, Inchley et al. 2005). Furthermore, those countries where socio-economic status is important are more likely to display the decrease in physical activity with age (Borraccino et al., in press). Other HBSC research has shown that involvement in sport and exercise increases with the number of family members and best friends that participate in sports (Wold / Anderssen 1992) and that motivation for sport participation becomes increasingly fun oriented and decreasingly achievement oriented with age (Wold / Kannas 1993). In addition, it has been shown that young people who meet up with their friends on more than two evenings a week are more likely to be physically active than their peers who socialise less frequently (Settertobulte et al. 2004). Finally, active travel to school can play a role daily physical activity (Boarnett et al. 2005). Numerous studies have documented factors associated with young peoples physical activity. Sallis et al. (1999) and Biddle et al. (2004) provide useful reviews of work in this area, suggesting that the key determinants include demographic factors (younger age, male), psychological factors (such as perceived barriers, competence and enjoyment), social factors (such as encouragement from parents, siblings and peers) and the physical environment (such as the availability of facilities and programmes). Appropriate guidelines for physical activity at population level, for example in terms of intensity and duration, have been widely debated in recent years. Based on their extensive review of the literature, Strong et al. (2005) developed the recommendation that children participate in at least 60 min of moderate to vigorous physical activity daily. Moderate intensity was defined as being equivalent to brisk walking, which might leave the participant feeling warm and slightly out of breath. These recommendations are consistent with

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recommendations of governmental and professional organizations (CDC 2000, Chief Medical Officer 2004). Others suggest an even longer duration of daily moderate intensity physical activity is necessary to affect the pattern of cardiovascular risk factors (Andersen et al. 2006). A secondary recommendation suggests that activities improving muscular strength, flexibility and bone health should be undertaken on two or more days a week.

2. Objectives
The purpose of assessing physical activity in the HBSC population is to determine:
-

the duration of students physical activity on weekdays and weekends and correlates of physical activity;

the proportion of students who meet the current guidelines for daily physical activity and potential determinants of meeting and not meeting the guidelines;

the duration and frequency of students vigorous physical activity and correlates of vigorous physical activity;

secular trends in students physical activity.

3. Theoretical framework
Physical activity is linked with a number of positive physical health outcomes including decreased adiposity, improvement in Metabolic Syndrome (abdominal obesity, elevated blood pressure, elevated fasting glucose, and reduced HDL), decreased triglyceride level, decreased insulin resistance, increased HDL, bone health, muscular strength and endurance, aerobic fitness, and health-related quality of life as well as a number of psychological health outcomes including short- and long-term physical and mental health status, positive mood states, selfimage and quality of family and peer relationships (Annesi 2005, Biddle et al. 2004, Hallal et al. 2006, Iannotti et al., in press, Penedo / Dahn 2005, Strong et al. 2005). Physical activity has been negatively related to health complaints and smoking (Iannotti et al., in press). One mechanism for the effect of physical activity on health is the benefits of normal weight status. A primary cause of overweight and obesity is energy imbalance; that is, when daily energy intake regularly exceeds energy expenditure. Regular physical activity increases energy expenditure and improves muscular strength, physical endurance, and aerobic fitness.

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Overweight, obesity, and cardiovascular fitness are strongly related to risk for a variety of chronic illnesses. Physical activity is also linked to improvements in lipid fractions (e.g. HDL) which reduce risk for cardiovascular disease (Strong et al. 2005). Potential mechanisms for the effects of physical activity on mental health are biochemical and attitudinal changes (Annesi 2005). Biochemical changes in brain chemistry, including changes in endorphin, serotonin, and norepinephrine as a result of physical activity, may contribute to positive changes in mood. Others suggest that changes in perceived competence and selfefficacy as a result of participation in competitive and non-competitive physical activity may affect mood, self-concept, and perceived of quality of life. Because of cognitive and social developmental changes during adolescence, increasingly complex influences on physical activity can and have been studied. More sophisticated theories, similar to those applied to a variety of theoretical approaches to explain adult behavior, are applicable to adolescent physical activity. These approaches include Social Cognitive Theory (Bandura 1991), Theory of Planned Behaviour (Ajzen / Madden 1986), and Self-Determination Theory (Ryan / Deci 2000). These theories assume complex cognitive processes including self-evaluation, goal setting, and planning. The key constructs include selfefficacy, outcomes expectations, perceived social norms, behavioral attitudes, perceived behavioral control, perceived competence and autonomy. Environmental issues have also been addressed as key facilitators of physical activity (Sallis et al. 1998). Ecological approaches to health and health behaviours have been recognised in, for example, the fields of sociology, psychology, education and public health (Sallis et al. 1998). Within the field of physical activity research, physical environment has been identified as a crucial element of the ecological model. The thinking behind the approach is that the physical environment can promote or constrain health behaviours, although the interplay between social and physical environment and individual characteristics is fully recognised. For example, McLeroy et al. (1988) identify five key levels of behavioural determinants: intrapersonal factors, including psychological and biological variables, as well as developmental history; interpersonal processes and primary social groups, including family, friends, and co-workers; institutional factors, organisations such as companies, school, health agencies, or health care facilities; community factors, which includes relationships among organisations, institutions, and social networks in a defined area; and public policy, which consists of laws and policies at the local, state, national, and supranational levels. The physical environment can be located among the institutional factors and can clearly be influenced by public policy. Similarly, in their review of environmental interventions to promote physical activity, Sallis et al. (1998) identify

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individual factors, individual behaviours, social environment factors, physical environment and public regulatory factors. It should also be noted that other environmental factors are hugely important and work on the school as a setting to promote physical activity is ongoing. First, links can be made between the items presented below and the proposed school-level questionnaire, particurlarly as the school-level questionnaire is likely to include a module on school physical activity. The study of physical activity in the school setting could be considered to be important for a variety of reasons. For example, the total amount of physical activity that students undertake at school might in some cases form a significant part of their overall physical activity. In addition, there is likely to be an interest in monitoring and evaluating national and local programs aimed at increasing the amount of physical activity during the school day.

4. Summary of previous work


Previous HBSC research has examined age, gender, and socio-economic differences in physical activity as well as potential mediating relationships between these influences on physical activity (Borraccino et al., in press, Hickman et al. 2000, Holstein et al. 2004, Inchley et al. 2005, Roberts et al. 2004, Samdal et al. 2007). The VPA items have also been used in assessing sleep quality (Tynjl et al. 1999), the influence of school policies on health behaviours (Maes / Lievens 2003), sedentary behaviour and weight problems (Elgar et al. 2005) and in assessing the influence of socio-economic status on health behaviours (Inchley et al. 2005). The MVPA items, introduced to the study in 2001/02, have been used in examining patterns of overweight and obesity (Janssen et al. 2004, Janssen et al. 2005) and health complaints (Janssen et al. 2004). Social correlates of physical activity and relationships between physical activity and other health behaviours and health risks have also been examined (Iannotti et al., in press, Settertobulte et al. 2004). More recently, secular trends and the relationship between physical activity and sedentary behaviour has attracted the attention of HBSC researchers (Borraccino et al., in press, Iannotti et al., in press, Janssen et al. 2005, Samdal et al. 2007). Other HBSC research has examined influences on participation in sport and exercise and social reproduction of physical activity (Wold / Anderssen 1992, Wold / Kannas 1993).

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5. Research questions
5.1 Mandatory items
A number of potential research questions have been identified by those in the physical activity focus group and colleagues in other groups. Some of these are ongoing (i.e. based on 2001/02 data and 2005/06) while others will make use of 2009/10 data. 1. What is the relationship between physical activity, sedentary behaviors, and obesity? Are there country differences in these relationships? Secular trends? Age and gender differences? 2. What is the association between physical activity and self reported health and how does this vary by country? 3. What is the association between physical activity and risk behaviours and how does this vary by country? 4. Does perception of local area influence physical activity patterns and in particular, active transport? 5. What is the association between clustering of food habits and physical inactivity? 6. What is the association between physical activity and psychosocial environment (selfefficacy, relations with peers and family?) It is anticipated that further consultation with focus groups will result in additional papers being proposed.

5.2 Optional items


A number of potential research questions have been identified by those in the physical activity focus group and colleagues in other groups. Some of these are ongoing (i.e. based on 2001/02 data and 2005/06) while others will make use of 2009/10 data. 1. How many children are walking or cycling as a means of travel to school, and how does this vary by country? What are the secular trends for school transport? 2. What are school childrens views as to potential facilitators for promoting walking or cycling to school i.e. active transport?

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3. How do activity patterns differ by school environment, measured using the proposed school level questionnaire and which school environmental aspects are most strongly associated?

6. Instruments
6.1 Mandatory items
Measuring physical activity In deciding on choice of items for a study, it is important to recognise that moderate to vigorous physical activity (MVPA) and vigorous physical activity (VPA) are two distinct measures. MVPA provides a picture of total activity, with a focus on the physical aspect of physical activity. In contrast, VPA explicitly encompasses a dimension of physical activity as a recreational pursuit or hobby. Not surprisingly, a confirmatory factor analysis among adolescent girls indicated that the latent variables representing VPA and MVPA were uncorrelated and that the two measures express different behavioural patterns and may even have different outcomes (Motl et al. 2004). Three items measuring physical activity are included as mandatory in the 2009/10 survey, measuring both MVPA and VPA. Given the limited space available and high correlation between activity in the past 7 days and a typical week, only the first of the MVPA items used in 2001/02 will be used (MQ12). A similar approach has been taken in the Youth Risk Behaviour Study in the United States. Trend analysis will still be possible on MVPA using the single item from 2001/02. The two different types of physical activity (VPA and MVPA) already take account of intensity and an additional item measuring this is not necessary. Younger adolescents are likely to find it difficult to distinguish between different intensity levels of physical activity. The VPA items which were mandatory until 1997/98 were reinstated for the 2005/06 survey and appear in the 2009/10 survey (MQ12 and MQ13).

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Moderate-to-vigorous physical activity (MVPA) Item box 1


MQ12 Physical activity is any activity that increases your heart rate and makes you get out of breath some of the time. Physical activity can be done in sports, school activities, playing with friends, or walking to school. Some examples of physical activity are running, brisk walking, rollerblading, biking, dancing, skateboarding, swimming, soccer, basketball, football, & surfing. [COUNTRY SPECIFIC EXAMPLES CAN BE GIVEN] For this next question, add up all the time you spent in physical activity each day. Over the past 7 days, on how many days were you physically active for a total of at least 60 minutes per day? 0 1 2 3 4 5 6 7

Source: Prochaska JJ, Sallis JF, Long B. (2001). A physical activity screening measure for use with adolescents in primary care. Archives of Paediatrics & Adolescent Medicine. 155: 554-559. Adapted for use in HBSC survey 2001/02, 2005/2006.

Reliability and validity Evidence for the validity of self-reported physical activity can be seen in the range of studies using this methodology (e.g., Booth et al. 2002, Treuth et al. 2005). Prochaska et al. (2001) developed the MVPA measure to produce a reliable and valid physical activity screening measure for use with children and adolescents. Prochaska et al. (2001) found these items to be reliable (intraclass correlation=.77) and to correlate significantly (r=.40, p<.001) with accelerometer data from US adolescents. A recent test-retest study in Finland with approximately 250 young people of both sexes aged 11-15 demonstrated that the reliability of the MVPA and VPA items proposed was acceptable, with intraclass correlation coefficients in the order of 0.6 to 0.8, although there was some variation between age-groups (Vuori et al. 2005).

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Vigorous physical activity (VPA) Item box 2


MQ13 OUTSIDE SCHOOL HOURS: How often do you usually exercise in your free time so much that you get out of breath or sweat? Every day 4 to 6 times a week 2 to 3 times a week Once a week Once a month Less than once a month Never

1 2 3 4 5 6 7

Source: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02 (optional), 2005/06.

Item box 3
MQ14 OUTSIDE SCHOOL HOURS: How many hours a week do you usually exercise in your free time so much that you get out of breath or sweat? None About half an hour About 1 hour About 2 to 3 hours About 4 to 6 hours 7 hours or more

1 2 3 4 5 6

Source: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02 (optional), 2005/06.

Reliability and Validity Booth et al. (2001) evaluate the reliability and validity of the HBSC vigorous physical activity items in a large sample of 13 and 15-year-old Australian students. Based on their responses, students were classified as active or inactive. Boys and girls classified as active had higher fitness levels than those classified as inactive. Reliability of the measure was good (67% to 85%). The measurement of strenuous physical activity showed good validity and reliability in a community-based study of physical activity, lifestyle and self-esteem among Swedish school children (Rasmussen et al. 2004). Rangul et al. (2008) examined the reliability of the HBSC items assessing vigorous PA and the International Physical Activity Questionnaire (IPAC, short version) items. The HBSC items were reliable (intraclass correlation = .71 for frequency and .73 for duration) and validity was fair when correlated with peak VO2 (.33 to .39). The IPAQ items were less reliable (.10 to .62) and had fair validity for assessing vigorous activity (.26 to .32). Similar results have been found in a validation study by the Scottish HBSC team, which suggests that the validity of the VPA and MVPA self-reports were similar, confirms that MVPA

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levels are likely to be underestimated and shows that VPA levels are likely to be overestimated.

6.2 Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. OP1: Reasons for Physical Activity OP2: Active Transport OP3: Facilitators of active transport

7. References
Ajzen I & Madden TJ. Prediction of goal-directed behavior: Attitudes, intentions, and perceived behavioral control. Journal of Experimental Social Psychology 1986;22:453-474. Andersen LB, Harro M, Sandinha LB, Froberg K, Ekelund U, Brage S & Anderssen SA. Physical activity and clustered cardiovascular risk in children: a cross-sectional study (The European Youth Heart Study). Lancet 2006;368:299-304. Annesi JJ. Correlations of depression and total mood disturbance with physical activity and self-concept in preadolescents enrolled in an after-school exercise program. Psychological Reports 2005;96:891-898. Bandura, A. Self-regulation of motivation through anticipatory and self-reactive mechanisms. In R Dienstbier (Ed.) Nebraska symposium on motivation 1990: Perspectives on motivation (pp 69164). Lincoln, NE: University of Nebraska Press, 1991 Biddle SJH, Gorely T & Stensel DJ. Health-enhancing physical activity and sedentary behaviour in children and adolescents. Journal of Sports Sciences 2004;22:679-701. Boarnet M.G., Anderson C.L., Day K., McMillan T., Alfonzo M. Evaluation of the Californian Safe Routes to School Legislation Urban Form Changes and Childrens Active Transport to school. American Journal of Preventive Medicine 2005;28:134-140. Booth ML, Okely AC, Chey T & Bauman A. The reliability and validity of the physical activity questions in the WHO health behaviour in schoolchildren (HBSC) survey: a population study. British Journal of Sports Medicine 2001;35:263-267. Borraccino A, Lemma P, Iannotti R, Zambon A, Dalmasso P, Lazzeri G, Giacchi M & Cavallo F. Socioeconomic effects on meeting PA guidelines: comparisons among 32 countries. Medicine & Science in Sports & Exercise, in press. Center for Disease Control and Health Promotion (CDC). Promoting better health for young people through physical activity and sports: a report to the President. U.S. Government Printing Office: Washington, DC, 2000. Chief Medical Officer. At least five a week: Evidence on the impact of physical activity and its relationship to health. Crown Press: United Kingdom, 2004. Driver HS & Taylor SR. Exercise and sleep. Sleep Medicine Reviews 2000:4:387-402. Elgar FJ, Roberts C, Moore L & Tudor-Smith C. Sedentary behaviour, physical activity and weight problems in adolescents. Public Health 2005;119:518-524.

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Fleming-Moran, M. & Thiagarajah, K. (2005) Behavioral interventions and the role of television in the growing epidemic of adolescent obesity. Methods of Information in Medicine 2005;44:303-309. Hallal PC, Victora CG, Azevedo RM & Wells JCK. Adolescent physical activity and health. A systematic review. Sports Medicine 2006:36:1019-1030. Hickman M., Roberts C., Gaspar de Matos M. Exercise and leisure time activities. In: Currie C., Hurrelmann K., Settertobulte W., Smith R., Todd J. (Eds.) Health and health behaviour among young people. Health Policy for Children and Adolescents, No. 1. Copenhagen, WHO Regional Office for Europe, 2000. Holstein B, Parry-Langdon N, Xambon A, Currie C & Roberts C. Socioeconomic inequality and health. In Currie C., Roberts C., Morgan A., Smith R., Settertobulte W., Samdal O., Barnekow Rasmussen V. (Eds.) Young People's Health in Context: international report from the HBSC 2001/02 survey. WHO Policy Series: Health policy for children and adolescents Issue 4. Copenhagen: WHO Regional Office for Europe, 2004. Iannotti RJ, Kogan MD, Janssen I & Boyce WF. Patterns of Adolescent Physical Activity, Screen-Based Media Use and Positive and Negative Health Indicators in the U.S. and Canada. Journal of Adolescent Health, in press. Inchley JC, Currie DB, Todd JM, Akhtar P & Currie CE. Persistent socio-demographic differences in physical activity among Scottish schoolchildren 1990-2002. European Journal of Public Health 2005;15:386-388. Jago R., Baranowski T. Non-curricular approaches for increasing physical activity in youth: a review. Preventive Medicine 2004;39:157-163. Janssen I, Katzmarzk PT, Boyce WF, King MA, Pickett W. Overweight and obesity in Canadian adolescents and their associations with dietary habits and physical activity patterns. Journal of Adolescent Health 2004;35:360-367. Janssen I., Katzmarzyk P.T., Boyce W., Pickett W. The independent influence of physical inactivity and obesity on health complaints in 6th to 10th grade Canadian youth. Journal of Physical Activity and Health 2004;1:331-343. Janssen I, Katzmarzk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, Currie C, Pickett W & The Health Behaviour in School-aged Children Obesity Working Group. Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity Reviews 2005;123-132. Landhuis CE, Poulton R, Welch D & Hancox RJ. Childhood sleep time and long-term risk for obesity: a 32year prospective birth cohort study. Pediatrics 2008;122;955-960. Maes L & Lievens J. Can the school make a difference? A multilevel analysis of adolescent risk and health behaviour. Social Science and Medicine 2003;56:517-529. McLeroy KR, Bibeau D, Steckler A & Glanz K. An ecological perspective on health promoting programs. Health Education Quarterly 1988;15:351-77. Menschik D, Ahmed S, Alexander MH & Blum RW. Adolescent physical activities as predictors of young adult weight. Archives of Pediatric and Adolescent Medicine 2008;162:29-33. Motl RW, Dishman RK, Dowda M & Pate R. Factorial Validity and Invariance of a Self-Report Measure of Physical Activity Among Adolescent Girls. Research Quarterly for Exercise and Sport. 2004;75:259271. Nader PR, Bradley RH, Houts RM, McRitchie LS & OBrien M. Moderate-to-vigorous physical activity from ages 9 to 15 years. Journal of the American Medical Association 2008;300:295-305. Nelson MD & Gordon-Larsen P. Physical activity and sedentary behavior patterns are associated with selected adolescent health risk behaviors. Pediatrics 2006;117:1281-1290. Ommundsen Y., Heggeb L.K., Anderssen S.A. Psycho-social and environmental correlates of selfreported physical activity among 9- and 15-year-old Norwegian boys and girls. Paper submitted to European Journal of Sports Science, December 2004. Penedo FJ & Dahn JR. Exercise and well-being: a review of mental and physical health benefits associated with physical activity. Current Opinion in Psychiatry 2005;18:189-193.

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Pietilinen KH, Kaprio J, Borg P, Plasqui G, Yki-Jevinen H, Kujala UM, Rose RJ, Westerterp KR & Rissanen A. Physical inactivity and obesity: a vicious circle. Obesity 2008;16:409-414. Prochaska JJ, Sallis JF & Long B. A physical activity screening measure for use with adolescents in primary care. Archives of Pediatrics & Adolescent Medicine [Arch Pediatr Adolesc Med] 2001;155:554559. Rangul V, Holmen TL, Kurtze N, Cuypers K & Midthjell K. Reliability and validity of two frequently used self-administered physical activity questionnaires in adolescents. BMC Medical Research Methodology 2008;8:47. Rasmussen F, Eriksson M, Bokedal C, Schfer Elinder L. Fysisk aktivitet, matvanor, vervikt och sjlvknsla bland ungdomar. COMPASS en studie i sydvstra Storstockholm. Rapport 2004:1. Stockholm: Samhllsmedicin, Stockholms lns landsting och Statens folkhlsoinstitut, 2004. Riddoch C., Edwards D., Page A., Froberg K., Anderssen S.A., Wedderkopp N., Brage S., Cooper A., Sardinha L.B., Harro M., Klasson Heggeb L., van Mechelen W., Boreham C., Ekelund U., Bo Andersen L., European Youth Heart Study team. The European Youth Heart Study-Cardiovascular Disease Factors in Children: Rationale, Aims, Study Design, and Validation of Methods. Journal of Physical Activity and Health 2005;2:115-129. Roberts C, Tynjl J, Komkov A. Physical activity. In Currie C., Roberts C., Morgan A., Smith R., Settertobulte W., Samdal O., Barnekow Rasmussen V. (Eds.) Young People's Health in Context: international report from the HBSC 2001/02 survey. WHO Policy Series: Health policy for children and adolescents Issue 4. Copenhagen: WHO Regional Office for Europe, 2004. Ryan MR & Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. American Psychologist 2000;55:68-78. Sallis JF, Bauman A, Pratt M. Environmental and policy interventions to promote physical activity. American Journal of Preventive Medicine 1998;15:379-97. Sallis JF, Prochaska JJ, Taylor WC, Hill JO & Geraci JC. Correlates of physical activity in a national sample of girls and boys in grades 4 through 12. Health Psychology 1999;18:410-415. Samdal O, Tynjl J, Roberts C, Sallis JF, Villberg J & Wold B. Trends in vigorous physical activity and TV watching of adolescents from 1986 to 2002 in seven European Countries. The European Journal of Public Health 2007;17:242-248. School Travel Advisory Group. School Travel Advisory Group report 1998-1999. UK: School Travel Advisory Group, 1999. Settertobulte W., Gaspar de Matos M. Peers and health. In Currie C., Roberts C., Morgan A., Smith R., Settertobulte W., Samdal O., Barnekow Rasmussen V. (Eds.) Young People's Health in Context: international report from the HBSC 2001/02 survey. WHO Policy Series: Health policy for children and adolescents Issue 4. Copenhagen: WHO Regional Office for Europe, 2004. Strong WB, Malina RM, Bumke CJ, Daniels SR, Dishman RK, Gutin B, Hergenroeder AC, Must A, Nixon PA, Pivarnik JM, Rowland T, Trost S & Trudeau F. Evidence based physical activity for school-age children. Journal of Pediatrics 2005;146:732-737. Tomporowski PD, Davis CL, Miller PH & Naglieri JA. Exercise and childrens intelligence, cognition, and academic achievement. Educational Psychology Review 2008;20:111-131. Treuth MS, Hou N, Young DR, Maynard LM. Validity and reliability of the Fels Physical Activity Questionnaire for children. Med Sci Sports Exerc 2005;37:488-95. Tynjl J., Kannas L., Levlahti E., Vlimaa R. Perceived sleep quality and its precursors in adolescents. Health Promotion International 1999;14:155-166. Vuori M, Ojala K, Tynjl J, Villberg J, Vlimaa R, Kannas L. The stability of physical activity survey items in the HBSC study. Liikunta & Tiede (Finnish Sport Journal) 2005;42(6), 3946. (In Finnish with an English abstract) Wold B & Anderssen N. Health promotion aspects of family and peer influences on sport participation. International Journal of Sport Psychology 1992;23:343-359. Wold B & Kannas L. Sport motivation among young adolescents in Finland, Norway and Sweden. Scandinavian Journal of Medicine and Science in Sports 1993;3:283-291.

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II.5.4 Sedentary behaviour


Iannotti, RJ, Kuntsche, E, Tynjl, J and the Physical Activity Focus Group

1. Scope and purpose


Investigators usually measure sedentary behaviour (SB) as time spent in screen-based sedentary activities, such as television watching, computer game playing, and video/DVD viewing, chatting on the internet, etc., and may exclude time spent doing homework or reading. One of the reasons for recent interest in sedentary behaviours is the relationship between SB and risk for being overweight or obese. Worldwide, among the leading causes of death are coronary heart disease, cerebrovascular diseases, and chronic obstructive pulmonary disease (Ezzati et al. 2004). Obesity is a risk factor for many of these chronic conditions and there is an increasing prevalence in obesity and type 2 diabetes in adolescents and adults with resulting morbidity and mortality (Smyth / Heron 2006). The primary mechanism for overweight and obesity is an imbalance of energy intake versus energy expenditure and one reason for the interest in SB is due to its association with reduced energy expenditure relative to other activities. Daily SB are associated with risk for overweight in adolescents ages 11 through 15 (Mikolajczyk / Richter 2008) and older adolescent girls were also vulnerable to gain weight in a longitudinal study if they spent a lot of time on the Internet (Berkey et al. 2008). The relationship between sedentary behaviour and obesity may depend on the specific activity (watching television, playing computer/video games, or using computers for homework and email), gender, and age (Burke et al. 2006). There is evidence for a dose-response relationship between SB and prevalence of overweight (Crespo et al. 2001) and a causal relationship between SB and obesity is suggested by interventions demonstrating reduction in SB leads to improvements in weight status (DeMattia et al. 2007). In addition, there is evidence that the cumulative effect of SB over the course of childhood is significant (Hancox / Poulton 2006). Adolescent SB has been related to other health problems including neck, shoulder, and lower back pain, psychological and somatic symptoms, physical and verbal aggression, hostility, cigarette smoking, alcohol use, and illicit drug use (American Academy of Pediatrics 2001, Berkey et al. 2008, Hakala et al. 2006, Iannotti et al., in press-a, Iannotti et al., in press-b, Kuntsche 2004, Kuntsche et al. 2006, Kuntsche et al. 2008, Nelson / Gordon-Larsen 2006). However, at least one study has found a negative relationship between SB and tobacco use
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(Leatherdale / Wong 2008). Adolescent SB has also been shown to be negatively related to a number of health assets: physical health status, nutrition, quality of life, body image, self image, school performance, and quality of family communication (American Academy of Pediatrics 2001, Iannotti et al., in press-a, Iannotti et al., in press-b, Nelson / Gordon-Larson 2006, Punamki et al. 2007). However, SB can also have positive effects in adolescence. For example, across countries and age groups, a positive relationship between SB and the number of friends, the time spent with friends, and the quality of peer relationships was found (Iannotti, in press, Kuntsche et al., in press). Although there have been inconsistent findings on whether SB and physical activity are related (Biddle et al. 2004, Borraccino et al., in press, Ekelund et al. 2006, Iannotti et al., in press-a, Iannotti et al., in press-b, Tammelin et al. 2007), it appears that SB contributes to weight status independent of the level of physical activity (Crespo et al. 2001, Ekelund et al. 2006). Secular trends for SB parallel those for physical activity; just as physical activity is decreasing, SB is increasing (Holstein et al. 2007). Developmental patterns are also parallel; leisure-time SB increases from childhood through adolescence as physical activity is decreasing; unfortunately, these developmental and secular trends are accompanied by a corresponding increase in childhood obesity (Hardy et al. 2007, Nelson et al. 2006). Newer active video games may not affect the risk of SB for overweight and obesity. Although adolescents expend significantly more energy playing the new generation of active computer games (such as Dance Dance Revolution in which children physically dance as part of the game) than in traditional sedentary computer games (in which controls can be operated from a sitting position), the level of energy expenditure does not meet the criteria for moderate intensity physical activity (Graves et al. 2008). There is some evidence that a proportion of the high-level users of electronic media are more physically active than low-level users (Ho / Lee 2001); this may be because males are more likely to be in both groups. Furthermore, some studies have found a positive association between heavy use of computers and academic success, self-confidence and social physical activity (Ho / Lee 2001). Generally, adolescent males spend more time in SB (excluding homework and reading) than adolescent females (Leatherdale / Wong 2008). However, overweight females accumulate more screen time than normal weight females (Leatherdale / Wong 2008). Girls spent more time daily using mobile phone than boys (Punamki wt al. 2007).

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2. Objectives
The American Academy of Pediatrics (2001) recommendation is that children be exposed to no more than 2 hours of quality television programming per day (this recommendation is sometimes stated as screen time so that it refers to video/computer games as well). Others suggest a threshold of four hours per day before the negative effects of SB are evident (Mark / Janssen 2008). The objectives of the HBSC sedentary behaviour items are to assess time spent in the three primary components of adolescent sedentary behaviours: playing computer/video games; using a computer for activities other than games (online interactions, internet, emailing, homework, etc.); and watching television. Each of the items assesses weekday and weekend use separately and provides both a measure of time spend in these activities and the ability to calculate whether adolescents exceed the 2hr/day and 4hr/day guidelines.

3. Theoretical framework
The most prevalent adolescent SB appears to be television watching (Hardy et al., 2006) and it may be that the negative effects of SB on health are more evident for television watching than for computer use or video games (Rey-Lpez et al. 2008). There is evidence that adolescents who spend more time watching television are less likely to engage in preventive behaviours such as seat belt use, adequate sleep, and activities outside of school and more likely to engage in health risk behaviours such as sex, delinquency, smoking, alcohol, drugs, and truancy (Chandra et al. 2008, Nelson / Gordon-Larsen 2006). However, at least one study suggests that internet use may have a greater negative impact on sleep than TV (Suganuma et al. 2007). Authors argue that the higher impact of television viewing compared to computer game playing on a variety of health-compromising behaviours and outcomes might be related to the fact that television viewing is passive whereas adolescents interact actively when using a computer, even when playing violent computer games (Kuntsche et al. 2008). One explanation for the effect of SB on health status is that higher rates of exposure to the content of television programs foster risk taking, affecting the willingness to engage in health-risk behaviours (Chandra et al. 2008). Other explanations for the effect of television viewing on adiposity are the effect of television advertising on diet and increased caloric intake when families watch television during mealtimes (Dietz 1991). However, Mark and Janssen (2008) report a dose-response relationship between adolescent screen time (television, computer and video game combined)

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and indices of the metabolic syndrome (tryglycerides, fasting glucose, waist circumference, blood pressure, and HDL cholesterol) even when controlling for fat and carbohydrate intake. They used a threshold of 4hrs of SB per day, suggesting that guidelines for SB may be increased from 2 to 4 hrs/day without noticeable health effects. In contrast, assessing PA, television, videogame, and computer usage, homework and school transportation in 13- to 18-yr-old Spanish youths, Vicente-Rodriquez et al. (2009) found that risk of being overweight increased by 15.8% per hour of TV watching and 9.4% per hour of weekend videogame usage. Another explanation for the negative effects of SB is that SB competes with or displaces physical activity; that is, youth who spend more time engaging in SB have less time to reap the benefits of physical activity. However, most studies do not support this hypothesis (Biddle et al. 2004, Rey-Lpez et al. 2008). And finally, there is some evidence for a biological mechanism for the relationship between SB and obesity and type 2 diabetes. Just as physical activity reduces insulin resistance, SB has been related to higher fasting insulin levels (Ekelund et al. 2006). Although it would be difficult to make a the case that SB is strongly related to physical activity (Biddle et al. 2004, Borraccino et al., in press, Ekelund et al. 2006, Iannotti et al., in press-a, Iannotti et al., in press-b, Tammelin et al. 2007), negative correlates of sedentary behaviours which suggest potential intervention strategies include parent encouragement of physical activity, parent support of physical activity, and the level of physical activity of friends (Leatherdale / Wong, 2008). Interventions to reduce SB have been family-based, school-based, or individual and usually involve a system for daily monitoring SB and linking SB with rewords or alternative activities (DiMattia et al. 2007).

4. Summary of previous work


The HBSC leisure use items have been related to a variety of health behaviours. Much of the previous work has examined relations between SB and physical activity and has shown weak or no relationship (Borraccino et al., in press, Iannotti et al., in press-a, Iannotti et al., in press-b, Janssen et al. 2005). SB has been shown to be positively related to diet (Vereecken et al. in press), alcohol and tobacco use (Iannotti et al., in press-a, Iannotti et al., in press-b), hostility among classmates (Kuntsche et al. 2008), bullying (Kuntsche et al. 2006), and physical violence (Iannotti et al., in press-a, Iannotti et al., in press-b, Kuntsche 2004). The implications of computer use for health education have also been explored, with a focus on health complaints

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such as headache, neck/shoulder pain and backache (Alexander / Currie 2004). Iannotti et al. (in press) report SB was negatively related to positive health indicators including self image, physical health status, quality of life, and quality of family relationships; however, SB was positively related to quality of peer relationships and negative health indices such as health complaints, physical aggression, cigarette smoking, and alcohol use.

5. Research questions
Because the sedentary behaviour items have not been changed since the modifications made in the 2001/02 survey, the 2009/10 survey will provide an opportunity to examine trends over time. In addition, plans will include examining relations between sedentary behaviours and variables such as weight status, physical activity, substance use, diet, health complaints, body image, self image, and family and peer communication. A number of potential research questions have been identified by those in the physical activity focus group and colleagues in other groups. Some of these are ongoing (i.e., based on 2001/02 and 2005/06 data) while others will make use of 2009/10 data. 1. What is the association between sedentary behaviour and physical activity? 2. What is the association between sedentary behaviour and self reported health and how does this vary by country? 3. What is the association between sedentary behaviour and indicators of positive health and how does this vary by country, age, and gender? 4. What is the association between sedentary behaviour and risk behaviours and how does this vary by country, age and gender? 5. Does social inequality affect patterns in sedentary behaviours? 6. What is the association between clustering of food habits and sedentary behaviours, particularly television watching? 7. What are the trends in sedentary behaviours from 2001/02 through 2009/10 and how do these parallel trends in obesity, physical activity, and diet? Are the trends different across age, gender, and country?

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6. Instruments
6.1 Mandatory items
Items on leisure-time sedentary activities have been included in all HBSC surveys from 1985/86; however, they have been amended slightly through time, largely due to technological change. For example, televisions are now used for viewing videos, DVDs and games; computer ownership is widespread internationally, being used for working, gaming and more recently, for electronic communication. The potential for a variety of sedentary ways to spend ones leisure time is perhaps greater than ever before. In 1997/98, two items were included in the survey, covering hours a day watching television and hours a week playing computer games. In 2001/02, items on hours a day watching television (and videos), using a computer (for playing games, emailing, chatting or surfing the internet) and doing homework were included. The items in 2001/02 were split by weekday and weekend as this was thought to be important in gaining a more accurate picture of the time spent participating in them. A broader range of response categories was also introduced in 2001/02 following piloting, ranging from no time at all, about half an hour a day, about an hour a day and hourly intervals until about 7 or more hours a day. In previous work with a similar age group, similar items have been shown to have good testretest reliability (rs ranging from .55 to .80) and validity (rs ranging from .37 to .47) (Utter et al. 2003, Schmitz et al. 2004).

Sedentary behaviours Six mandatory items are proposed to capture three typical sedentary leisure activities, based on those included in the 2001/02 HBSC study. Question MQ15 measures time spent watching television and is almost identical to the items included in 2001/02, when the weekday/weekend split was introduced. Subsequent pilot work in Scotland suggests that 11year-olds found it easier to allocate their time watching television for weekdays and weekends separately. A minor amendment to note is that respondents are asked to include DVDs as well as videos in their calculations. Given the increase in computer ownership and the various uses of computers, from gaming to chatting, the item included in the 2001/02 survey was split, capturing (i) gaming and (ii) chatting on-line, internet, emailing, homework etc. It should be noted that splitting the 2001/02 item has only been piloted in Scotland but this new format appeared to work well

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(MQ15 and M16). Given that these items are unlikely to be the subject of trends analysis and that in certain instances items must keep up to date with wider societal developments, such a change can be justified in this instance. These mandatory items should be placed following the two vigorous physical activity measurement items (MQ15 and MQ16) or the optional items on participation in physical activity (PA1.1) if this is included. Item box 1
MQ15 About how many hours a day do you usually watch television (including DVDs and videos) in your free time? (Please tick one box for weekdays and one box for weekend) Weekdays
1 2 3 4 5 6 7 8 9

Weekend
1 2 3 4 5 6 7 8 9

None at all Half an hour a day 1 hour a day 2 hours a day 3 hours a day 4 hours a day 5 hours a day 6 hours a day 7 or more hours a day

None at all Half an hour a day 1 hour a day 2 hours a day 3 hours a day 4 hours a day 5 hours a day 6 hours a day 7 or more hours a day

Source: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02 (Revised: weekday/weekend split introduced; response categories expanded; videos included), 2005/06 (revised: DVDs added), 2005/06.

Item box 2
MQ16 About how many hours a day do you usually play games on a computer or games console (Playstation, Xbox, GameCube etc.) in your free time? (Please tick one box for weekdays and one box for weekend) Weekdays
1 2 3 4 5 6 7 8 9

Weekend
1 2 3 4 5 6 7 8 9

None at all About half an hour a day About 1 hour a day About 2 hours a day About 3 hours a day About 4 hours a day About 5 hours a day About 6 hours a day About 7 or more hours a day

None at all About half an hour a day About 1 hour a day About 2 hours a day About 3 hours a day About 4 hours a day About 5 hours a day About 6 hours a day About 7 or more hours a day

Source: HBSC surveys1989/90, 1993/94, 1997/98, 2001/02 (revised: weekly activity changed to daily; weekday/weekend split introduced; definition in brackets added), 2005/06.

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Item box 3
MQ17 About how many hours a day do you usually use a computer for chatting on-line, internet, emailing, homework etc. in your free time? (Please tick one box for weekdays and one box for weekend) Weekdays
1 2 3 4 5 6 7 8 9

Weekend
1 2 3 4 5 6 7 8 9

None at all About half an hour a day About 1 hour a day About 2 hours a day About 3 hours a day About 4 hours a day About 5 hours a day About 6 hours a day About 7 or more hours a day

None at all About half an hour a day About 1 hour a day About 2 hours a day About 3 hours a day About 4 hours a day About 5 hours a day About 6 hours a day About 7 or more hours a day

Source: HBSC surveys1989/90, 1993/94, 1997/98, 2001/02 (revised: weekly activity changed to daily; weekday/weekend split introduced; definition in brackets added), 2005/06.

Item placement It is suggested that the measurement items are placed in separate sections, with an appropriate headings such as Leisure time or Things that you do in your free time.

7. References
Alexander L.M., Currie C. Young peoples computer use: implications for health education. Health Education 2004;104(4), 254-261. American Academy of Pediatrics. Children, adolescents and television. Pediatrics 2001;107:423-426. Berkey CS, Rockett HRH & Colditz GA. Weight gain in older adolescent females: the internet, sleep, coffee and alcohol. The Journal of Pediatrics 2008;153:635-645. Biddle SJH, Gorely T & Stensel DJ. Health-enhancing physical activity and sedentary behaviour in children and adolescents. Journal of Sports Sciences 2004;22:679-701. Borraccino A, Lemma P, Iannotti R, Zambon A, Dalmasso P, Lazzeri G, Giacchi M & Cavallo F. Socioeconomic effects on meeting PA guidelines: comparisons among 32 countries. Medicine & Science in Sports & Exercise, in press. Burke V, Beilin LJ, Durkin K, Stritzke WGK, Houghton S & Cameron CA. Television, computer use, physical activity, diet and fatness in Australian adolescents. International Journal of Pediatric Obesity 2006;1:248-255. Chandra A, Martino SC, Collins RL, Elliott MN, Berry SH, Kanouse DE & Miu A. Does watching sex on television predict teen pregnancy? Findings from a national longitudinal survey of youth. Pediatrics 2008122:1047-1054. Crespo CJ, Smit E, Troiana RP, Bartlett SJ, Macera CA & Andersen RE. Television watching, energy intake, and obesity in US children. Archives of Pediatric and Adolescent Medicine 2001;155:360-365. DeMattia L, Lemont L & Meurer L. Do interventions to limit sedentary behaviours change behaviour and reduce childhood obesity? A critical review of the literature. Obesity Reviews 2007;8:69-81. Dietz W. Factors Associated with Childhood Obesity. Nutrition 1991;7:290-291.

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Ekelund U, Brage S, Froberg K, Harro M, Anderssen SA, Sardinha LB, Riddoch C & Andersen LB. TV viewing and physical activity are independently associated with metabolic risk in children: The European Youth Heart Study. PloS Medicine 2006;3:2449-2457. Ezzati, M., A. D. Lopez, et al. Comparative Quantification of Health Risks. Global and Regional Burden of Disease Attributable to Selected Major Risk Factors. Geneva, World Health Organization (WHO), 2004. Graves L, Stratton G, Ridgers ND & Cable NT. Energy expenditure in adolescents playing new generation computer games. British Journal of Sports Medicine 2008;42:592-594. Hakala PT, Rimpel AH, Saarni LA & Salminen JJ. Frequent computer-related activities increase the risk of neck-shoulder and low back pain in adolescents. European Journal of Public Health 2006;16:536541. Hancox RJ & Poulton R. Watching television is associated with childhood obesity: but is it clinically important? International Journal of Obesity 2006;30:171-175. Hardy LL, Bass SL & Booth ML. Changes in sedentary behavior among adolescent girls: a 2.5-year prospective cohort study. Journal of Adolescent Health 2007;40:158-165. Ho S.M., Lee T.M. Computer Usage and its relationship With Adolescent Lifestyle in Hong Kong. Journal of Adolescent Health 2001;29:259-266. Holstein BE, Henriksen PE, Krlner R, Rasmussen M & Due P. Udviklingen i energisk fysisk aktivitet og fysisk inaktivitet blandt 11-15-rige 1988-2002 [Trends in vigorous physical activity versus physical inactivity among 11-15 year olds from 1988 to 2002]. Ugeskrift for Laeger 2007;169: 37-42. Iannotti RJ, Janssen I, Haug E, Kololo H, Annaheim B, Borraccino A & the HBSC Physical Activity Focus Group. Interrelationships of adolescent physical activity, sedentary behaviour, and positive and negative social and psychological health. International Journal of Public Health, in press-a. Iannotti RJ, Kogan MD, Janssen I & Boyce WF. Patterns of Adolescent Physical Activity, Screen-Based Media Use and Positive and Negative Health Indicators in the U.S. and Canada. Journal of Adolescent Health, in press-b. Janssen I, Katzmarzk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, Currie C, Pickett W & The Health Behaviour in School-aged Children Obesity Working Group. Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obesity Reviews 2005;123-132. Kuntsche E.N. Hostility among adolescents in Switzerland? Multivariate relations between excessive media use and forms of violence. Journal of Adolescent Health 2004:34(3): 230-236. Kuntsche, E., Pickett, W., Overpeck, M., Craig, W., Boyce, W. & Matos, M. (2006). Television viewing and forms of bullying among adolescents from 8 countries. Journal of Adolescent Health, 39(6), 908915. Kuntsche, E., Overpeck, M., & Dallago, L. (2008). Television viewing, computer use and hostile perception of classmates among adolescents from 34 countries. Swiss Journal of Psychology, 67(2), 97-106. Kuntsche, E., Simons-Morton, B., Ter Bogt, T., Snchez Queija, I., Muoz Tinoco, V., Gaspar de Matos, M., Santinello, M., Lenzi, M., and the HBSC Peer Culture Focus Group. Electronic media communication with friends from 2002 to 2006 and links to face-to-face contacts in adolescence. An HBSC study in 31 European and North American countries and regions. International Journal of Public Health, in press. Leatherdale ST & Wong SL. Modifiable characteristics associated with sedentary behaviours among youth. International Journal of Pediatric Obesity 2008;3:93-101. Mark AE & Janssen I. Relationship between screen time and metabolic syndrome in adolescents. Journal of Public Health 2008;30:153-160. Mikolajczyk RT & Richter M. Associations of behavioural, psychosocial and socioeconomic factors with over- and underweight among German adolescents. International Journal of Public Health 2008;53:214-220. Nelson MD & Gordon-Larsen P. Physical activity and sedentary behavior patterns are associated with selected adolescent health risk behaviors. Pediatrics 2006;117:1281-1290.

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Nelson MC, Neumark-Stzainer D, Hannan PJ, Sirard JR & Story M. Longitudinal and secular trends in physical activity and sedentary behavior during adolescence. Pediatrics 2006;118:e1627-e1634. Punamki R-L, Wallenius M, Nygrd C-H, Saarni L & Rimpel A. Use of information and communication technology (ICT) and perceived health in adolescence. the role of sleeping habits and waking-time tiredness. Journal of Adolescence 2007;30:569-585. Rey-Lpez JP, Vicente-Rodrquez G, Biosca M & Moreno LA. Sedentary behaviour and obesity development in children and adolescents. Nutrition, Metabolism & Cardiovascular Diseases 2008;18:242-251. Schmitz KH, Harnack L, Fulton JE, Jacobs DR, Gao SJ, Lytle LA & Van Coevering P. Reliability and validity of a brief questionnaire to assess television viewing and computer use by middle school children. Journal of School Health 2004;74:370-377. Smyth S & Heron A. Diabetes and obesity: the twin epidemics. Nature Medicine. 2006;12:75-80. Suganuma N, Kikuchi T, Yanagi K, Yamamua S, Morishima H, Adachi H, Kumano-Go T, Mukami A, Sugita Y & Takeda M. Using electronic media before sleep can curtail sleep time and result in selfperceived insufficient sleep. Sleep and Biological Rhythms 2007; 5: 204214. Tammelin T, Ekelund U, Remes J & Nyh S. Physical activity and sedentary behaviors among Finnish youth. Medicine & Science in Sports & Exercise 2007;39:1067-1074. Utter J, Neumark-Sztainer D, Jeffery R & Story M.Couch potatoes or French fries: Are sedentary behaviors associated with body mass index, physical activity, and dietary behaviors among adolescents? Journal of the American Dietetic Association 2003;103:1298-1305. Vereecken C.A., Todd J., Roberts C., Mulvihill C., Maes L. TV viewing behaviour and associations with food habits in different countries. Public Health Nutrition 2006;9:244-250. Vicente-Rodrquez G, Rey-Lpez J, Martin-Matillas J, Moreno LA, Wrnberg J, Redondo C, Tercedor P, Delgado M, Marcos A, Castillo M & Bueno M. Television watching, videogames, and excess of body fat in Spanish adolescents: The AVENA study. Nutrition 2008;24:654-662.

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II.5.5 Tobacco use


Hublet, A, Fotiou, A, Godeau, E

1. Scope and purpose


Despite the many reports on the negative health consequences of smoking, tobacco is still the leading cause of preventable death in the world (WHO 2007). In 2000, worldwide, 4.83 million premature deaths could be attributed to smoking (Ezzati / Lopez 2003). If the current smoking patterns continue, the total tobacco-attributable deaths will rise to 8.3 millions in 2030 (Mathers / Loncar, 2006). Main causes of death were cardio-vascular diseases, chronic obstructive pulmonary diseases and lung cancer (Centers for Disease Control and Prevention, 2005). Smoking also has short-term health effects on youth, including decreased lung function, decreased physical fitness, increased asthmatic problems, and increased coughing, wheezing and shortness of breath (US Department of Health and Human Services 2004). In addition, there is evidence to support a positive relation between cigarette use and the subsequent use of alcohol and cannabis (Duncan et al. 1998). The financial burden of a country associated with smoking-related illnesses is overwhelming, if the cost of treatment for tobacco-related illness and the loss of productivity from premature death are taken into account. In high-income countries, the World Bank reports that smokingrelated healthcare accounts for between 6 and 15 percent of all annual healthcare costs (The World Bank 1999). Also within a country, tobacco and poverty are inextricably linked. Smoking can be seen as the largest single cause of socio-economical inequalities in morbidity and mortality (Kunst et al. 2004), a fact that invites for active interventions. Smoking behaviour is undeniably established in adolescence. Most adult smokers lit their first cigarette or were already addicted to nicotine before the age of 18 (Jarvis 2004). As smoking related health problems are a function of the duration (years of smoking) and the intensity of use (amount of cigarettes smoked) (US Department of Health and Human Services 1994), smoking prevention in adolescents is very important. Thereby, in adolescents the duration of smoking and the number of cigarettes required to establish nicotine addiction is lower than in adults (Prokhorov et al. 2006). Once addiction occurs, however, nicotine dependence is

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extremely difficult to break. Less than half of all smokers successfully quit before the age of 60 (WHO 1996). In spite of all those negative consequences of smoking, adolescents may see positive aspects in smoking. The most prevalent functions of smoking are to control negative moods and depression (to relax, to concentrate, to reduce stress, to reduce boredom); to belong to a group or to have contact with a group (smoking as a vehicle for entering a desired friendship group, to have contact with the other sex); to control weight (especially in girls); to be identified with a certain image of maturity and self-reliance (Lambert et al. 2002).

2. Objectives
Many countries in the HBSC network use the tobacco questions as surveillance tools to monitor tobacco use across time. The monitoring of tobacco use can be used for policy evaluations and for drafting new action plans and policy initiatives. The objectives of the mandatory questions addressing tobacco have three significant purposes. The first mandatory question helps to define the scope of the tobacco use by measuring the prevalence of tobacco use among participating students. The second mandatory question addresses the depth of the tobacco problem by measuring the frequency with which student smoke. The distinction between prevalence and frequency is important as it identifies the population that has moved from trial, to experimental, to regular use of tobacco. These students will be most highly at risk for adult smoking and future health problems. The third mandatory question aims at capturing the age of initiation of tobacco use, as the literature shows there are strong links between the age of onset of smoking and current smoking both in adolescence and in adulthood, and the use of other substances.

3. Theoretical framework
The risk and protective factors related to youth smoking extend over a broad range of aspects and over different levels of adolescents life. These risk and protective factors can be placed in an ecological model which suggests interconnections among factors from different levels. Five levels of influence are proposed to explain individual behaviour such as smoking: the intrapersonal level (which are the individual characteristics such as knowledge, attitudes, beliefs and personality traits), the interpersonal level (which are the interactions between

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family, peers and friends), the institutional level (which are the rules and regulations within institutions such as the school and workplace), the community level (which are the influences from social networks and norms within the community) and public policy (which are the regulations and laws at national or regional level). At intrapersonal level, demographic factors such as age (Riala et al. 2004), gender (Turner et al, 2004), educational level (Kunst et al, 2004), family structure (Griesbach et al. 2003, Granado Alcon / Pederson 2001, Kuntsche / Silbereisen 2004) and socio-economical status of the parents (Hanson / Chen 2007) influence smoking behaviour. According to the Theory of Planned Behaviour, the best predictor of smoking behaviour is the intention to smoke. The intention is influenced by attitudes towards smoking, social norms and self-efficacy. For attitudes, for example, female regular smokers are more likely to believe that smoking controls weight (Cavallo et al. 2006), while on the other hand, non-smokers perceive more health-related and personal disadvantages of smoking (de Vries 1995). Concerning selfefficacy, all adolescents find it hard to refuse cigarettes from friends (de Vries 1995). Psychological factors are also important. Less smoking is observed in adolescents with an optimistic mood, strong engagement and perceived control (Kunst et al. 2004). Stress factors such as abuse, job loss of the parents, conflicts with the parents, and poor performance at school, are related to smoking initiation and continuation (Schepsis / Rao 2005, Prokhorov et al. 2006). At interpersonal level, the direct environment of the adolescent plays a very important role in smoking initiation, experimentation and regular smoking. Parental smoking has been found to be a predictor for smoking experimentation (Rasmussen et al. 2005), while peer smoking is more consistently related to regular smoking (Prokhorov et al. 2006). Not only the actual behaviour, but also parental expectations of good behaviour is protective against smoking (Schepsis / Rao 2005), while low family cohesion and connectedness are risk factors for smoking (Kowalewska et al. 2007, Zambon et al. 2006). Peers are particularly influential because they provide access to tobacco products, increase the perceived prevalence of smoking behaviour, and help to create norms with which the child identifies (Carvajal et al. 2000). Recent research shows that mechanisms of social influence as well as mechanisms of social selection can explain the relation between smoking behaviour of the adolescent and of smoking peers (Arett 2007).

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At institutional level: In adolescents, the school is an important environment. Schools are social and learning environments that are relatively stable. This is especially important in adolescence, a period of change in relationships with family and peers. Important characteristics of the school that are related to smoking are school size, school culture, type of school, sex ratio of the students and of the staff, curriculum, school ethos and school policy (Aveyard et al. 2004). A smoking ban at school enforced by punishment reduces tobacco use in, especially younger, adolescents (Piontek et al. 2007). For older students, increased risk of smoking was related to exposure to teachers smoking outdoor the school grounds. At community level, smoking behaviour is influenced by values, social norms and behaviour of those in the wider environment. But also other elements of the neighbourhood of the adolescent become more and more important in research. Low neighbourhood attachment, community disorganisation, community norms favouring drug use and the lack of community opportunities for pro-social involvement, are associated with regular smoking in adolescents (Beyers et al. 2004). At policy level, a tobacco control policy will have an influence on the individual smoking behaviour. The World Bank distinguish 6 cost effective tobacco control initiatives (World Bank 1999): increasing tobacco price and taxes, bans or restrictions of smoking in public places, giving consumer information by campaigns, bans on smoking advertisements, putting health warnings on packages, and investing in treatment for smoking cessation. It is still unclear what is effective in youth protection. Several of these variables at intrapersonal and interpersonal level (peer relations, parental support and school environment) are included in the HBSC questionnaire and therefore, instead of only looking at smoking prevalence rates, smoking can be studied in a broader context and as part of an adolescents lifestyle.

4. Summary of previous work


The first two mandatory items have been present, and remained unchanged, in the HBSC questionnaire since the 1983/84 survey. These items allow for monitoring trends across countries and across survey cycles. Hublet et al. (2006) examined gender differences in daily smoking among 1415 year olds in a 12 year period (1990-2002) using the data from ten European countries and Canada. Analyses identified three daily smoking trend groups that

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showed a geographical pattern. Macedo and Precioso (2006) compared 1998 and 2002 HBSC data on smoking prevalence in Portuguese adolescents as an indicator for the evaluation of smoking prevention campaigns in the country. Kuntsche (2004) used Swiss data from 1986, 1994 and 1998 on - inter alia - smoking in 15 year olds and found that the prevalence has significantly increased over the 12-year period. Trends of lifetime and current tobacco use have been examined in other regions, such as the Flemish Belgium (1990, 1994) (De Backer et al. 1999) and Wales (1986, 1988, 1990, 1992) (Smith et al. 1994) all suggesting increases. Langness et al. (2005) compared the German 2002 HBSC data on inter alia tobacco use to those of other European and Northern American countries and found that adolescents in Germany report overall higher rates of at least weekly smoking. Analyses have been undertaken to explain smoking behaviour by focusing on various aspects of adolescent life (i.e. personality, school, family, peers etc) and by treating data at different levels of analysis. School related aspects in adolescent smoking have been key variables in numerous analyses using HBSC data. Nutbeam et al. (1993) used 1988-99 HBSC data from Australia and Wales in order to determine the relationship between student alienation (poor academic performance, negative attitudes towards school and towards the future) and health damaging behaviours, including regular smoking, in 15 year old students. Regular smoking was found to bear strong associations with all school variables. Employing multilevel analysis, a Flemish Belgian study on 1994 data assessed the relationship between individual characteristics and structural and (health) policy variables of the school on, inter alia, regular smoking of adolescents (Maes / Lievens 2003). At school level, the school characteristics that had an effect on the odds of being a regular smoker were the above the average teachers workload and the lenient rules for pupils. Poulsen et al. (2002) used 2002 Greenlandic data in order to examine associations between adolescent smoking and their perceived exposure to smoking at school. Having adjusted for sex, exposure to teachers smoking indoors at school and pupils smoking outdoors at school, as well as the smoking behaviour of parents and best friend, they found that adolescents' perceived exposure to teachers smoking outdoors on the school premises was significantly associated with daily smoking. Perceived unfair school environment (i.e. unfair treatment by teachers) was found to correlate to daily smoking in Italian adolescents (Zambon et al 2006), while also low school satisfaction and heavy smoking peers were correlated to regular smoking in Polish adolescents (Kowalewska et al. 2007). In Denmark, where the social networks formed by classmates are tight, Rasmussen et al. (2002) found that the risk of becoming a smoker is different for boys and girls. Smoking prevalence among boys did not

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correlate with the smoking prevalence of girls in the same class group. The inverse association between school connectedness (perceived level of school satisfaction and sense of belonging) and adolescent smoking had been found in Rasmussens study in Danish adolescents (1998 data) (Rasmussen et al. 2005). Schnohr et al. (2008), finally, used 2001/02 data from 27 HBSC countries in order to examine the association between three types of policies to control smoking (i.e. school restrictions, price and minimum age for buying tobacco) and daily smoking in adolescents. Smoking bans in schools were associated with lower odds ratios of daily smoking. The study found no association between cigarette prices and adolescent daily smoking, while also age limits for buying tobacco was associated with an increased risk of daily smoking. Family related aspects of adolescent life have also emerged as important factors in analyses on adolescent smoking. Griesbach et al. (2003) examined the relationship of family structure and smoking in seven HBSC countries and regions (1998 data). Among 15-year-olds in all countries, smoking prevalence was lowest among adolescents in intact families and highest among adolescents in stepfamilies. Restructured family was also a strong predictor for adolescent smoking in Greenland (1998 data) (Granado Alcon / Pedersen 2001) and in Switzerland (Kuntsche / Silbereisen 2004). Comparing ex- with current adolescent smokers in Poland, Kowalewska et al. (2007) concluded that abstinence from smoking is associated with good family relations. Zambon et al (2006) conducted an analysis on the 2002 Italian data in order to assess the effect of the quality of social relations (including those in the family) in adolescent habits (including smoking). They found that daily smoking is strongly associated with poor relationships with the mother. A strong association between parental smoking behaviour and smoking behaviour among girls was found in the study of Rasmussen et al. (2005) in Danish data. Interestingly, when used as predictors in HBSC analyses, the socio-economical status of the parents or the family was not associated with adolescent smoking when controlled for education level of the adolescent (Granado Alcon / Pedersen 2001, Vereecken et al. 2004). Individual health and risk behaviour elements of adolescent lifestyles have also been used in studying the aetiology of adolescent smoking. For example, Hublet et al. (2007) used the 2002 data from six HBSC countries to assess the correlates of regular tobacco use in two groups of 15 year old adolescents: those with diagnosed -and those without asthma. Smoking has been used in several other studies as determinant of health and risk behaviours such as: perceived health in Finland (Suominen et al. 2000) and in Poland (Mazur / Woynarowska 2004), perceived life satisfaction in Poland (Mazur / Woynarowska 2004), psychosomatic complaints in the US (Ghandour et al. 2004, Saluja et al. 2004), injuries in

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Canada (Pickett et al. 2002a, Koven et al. 2005), in Lithuania (Starkuviene / Zaborskis 2005) and in various other HBSC countries (Pickett et al. 2002b), unhealthy dieting patterns in Ireland (Nic Gabhainn et al. 2002), regular alcohol drinking in Turkey (Alikasifoglu et al. 2004) and in Poland (Mazur et al. 2003), bullying in Poland (Mazur / Malkowska. 2003) and in Greenland (Schnohr / Niclasen 2006), early sexual initiation in France (Godeau et al. 2008). The age of onset item was introduced for the first time as a mandatory item in the 2001/02 survey. A study examining the relationship of the early initiation of cannabis use with other high risk behaviours and with psychosocial and health-related correlates in 15-year-old adolescents in six European countries showed that the early initiation ( 13 years of age) of tobacco (and alcohol) use was associated with the early use of cannabis, and with frequent use of tobacco, alcohol and cannabis at age 15 (Kokkevi et al. 2006).

5. Research questions
Besides the monitoring of smoking behaviour in adolescents through time, several other questions on smoking can be studied within the HBSC study: 1. What gender-specific factors are associated with smoking at individual level (using HBSC data) and on other levels such as school level (using HBSC data) and policy level (using external databases)? 2. What is the influence of early smoking initiation on health and health outcomes at the age of 15 years? 3. To what extent do substance use cluster?

6. Instruments
Validity in general on self-reported smoking Self-reported smoking status is a simple and inexpensive method to study smoking prevalence. In general, self-reported smoking prevalence has been considered as a good indicator of the actual smoking status compared with biochemical validated smoking prevalence (Post 2005). Factors influencing self-reports are the level of demand (perceived pressure to answer socially desirable), age (adolescents have higher rates of misreporting), and gender (men tend to report their smoking status less accurately than women) (Bowlin et al 1993, Newell et al.

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1999). In the HBSC study, an observational study, the level of demand is low compared with, for example, an intervention study, and the questionnaires are completed anonymously. Cultural differences in choosing answers that are socially desirable cannot be avoided, especially as smoking can be regarded as either normal or deviant in different countries and periods for girls and/or boys (Pirkens et al. 2003). As age and gender play an important role in self-reports, the results could be an underestimation of the real smoking problem. It should be noted that validation studies have been carried out in Western countries only. It should also be noted that no question referring to smokeless tobacco or other tobacco products is included in the survey. This could lead to an underestimation of tobacco consumption in some countries (Prokhorov et al. 2006).

6.1 Mandatory items


6.1.1 Smoking prevalence Smoking prevalence is measured by three mandatory questions. A first question (MQ18) asks about ever smoking. A second question (MQ19) asks about current smoking. The two questions have been part of HBSC since 1985/86. A third mandatory question (MQ23) is included to assess the frequency of substance use more precisely within the last 30 days. The question was part of the optional package in the 2005/06 HBSC survey. The same format is used for cigarette use, alcohol drinking and drunkeness and cannabis use. No validity study has been done for these smoking questions within HBSC. Item box 1
MQ18
1 2

Have you ever smoked tobacco? (At least one cigarette, cigar or pipe) Yes No

Source: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/8, 2001/02, and 2005/06.

Item box 2
MQ19
1 2 3 4

How often do you smoke tobacco at present? Every day At least once a week, but not every day Less than once a week I do not smoke

Source: HBSC surveys 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, and 2005/06.

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Item box 3
MQ23 On how many occasions (if any) have you done the following things in the last 30 days? Please tick one box for each line.

1-2

3- 5

6 to 9

10-19

20-39

40 or more
7

Smoked cigarettes [Drunk alcohol] [Been drunk]

Source: Adapted from Monitoring the Future (1975 on) and the European School Survey Project on Alcohol and other Drugs, ESPAD (1995 on)

6.1.2 Smoking initiation A fourth mandatory item measures the age of initiation to tobacco. This question is comparable with the ESPAD question. In the ESPAD question, the specification more than a puff was not mentioned. No validation has been done for this question. Remark: Countries surveying children older than 16, can adapt the response category up to 17 years and older, or to 18 years or older as appropriate. Guidance on use in analyses: Caution should be exercised when using this variable as for some students initiation into smoking is still in process. Item box 4
MQ22 At what age did you first do the following things? If there is something you have not done, choose the never category. Never Smoke a cigarette (more than a puff) [Drink alcohol (more than a small amount)} [Get drunk] 11 years old or less
2

12 years old
3

13 years old
4

14 years old
5

15 years old
6

16 years or older
7

Source: Adapted from the European School Survey Project on Alcohol and other Drugs (ESPAD) 2007; HBSC survey 2001/02, 2005/06.

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Item placement within questionnaire: Smoking is part of the group of risk behaviour items. The questions about smoking should be included together with those other items. M1 and M2 should follow each other. M3 should be placed after the cannabis questions.

6.2. Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. Frequency of smoking Peer smoking

7. References
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Godeau E, Vignes C, Duclos M, Navarro F, Cayla F, Grandjean H. Factors associated with early sexual initiation in girls: French data from the international survey Health Behaviour in School-aged Children HBSC/WHO. Gynecol Obstet Fertil. 2008;36(2):176-82. Granado Alcn MC, Pedersen JM. Family as a child development context and smoking behaviour among schoolchildren in Greenland. Intern J Circ Health 2001; 60: 52-63. Griesbach D, Amos A, Currie C. Adolescent smoking and family structure in Europe. Soc Sci Med 2003; 56: 42-52. Griesbach D, Inchley J, Currie C. More than words? The status and impact of smoking policies in Scottish schools. Health Promotion International 2002; 17(1): 31-41. Hanson MD, Chen E. Socioeconomic status and health behaviors in adolescence: a review of the literature. J Behav Med 2007; 30: 263-285. Hublet A, De Bacquer D, Boyce W, Godeau E, Schmid H, Vereecken C, De Baets F, Maes L. Smoking in young people with asthma. J Public Health (Oxf). 2007;29(4):343-9. Hublet A, De Bacquer D, Valimaa R, Godeau E, Schmid H, Rahav G, Maes L. Smoking trends among adolescents from 1990 to 2002 in ten European countries and Canada. BMC Public Health 2006, 6:280 Jarvis MJ. Why people smoke? BMJ 2004; 328: 277-279. Kokkevi A, Nic Gabhainn S, Spyropoulou M. Early initiation of cannabis use: a cross-national European perspective J Adolesc Health 2006; 39(5): 712-9. Koven R, McColl MA, Ellis P, Pickett W. Multiple risk behaviour and its association with head and neck injuries: a national analysis of young Canadians. Preventive Medicine 2005; 41: 240-246. Kowalewska A, Mazur J, Woynarowska B. Selected psychosocial factors in 15-year-old current smokers and ex-smokers. Przegl Lek. 2007;64(10):747-51. Kunst A, Giskes K, Mackenbach J. Socio-economic inequalities in smoking in the European Union. Applying an equity lens to tobacco control policies. Report for the EU Network on Interventions to Reduce Socio-economic Inequalities in Health. ENSP-reports 2004. http://www.ensp.org/publications/enspreports. Kuntsche, E. N. & Silbereisen, R. K. Parental closeness and adolescent substance use in single and twoparent families in Switzerland. Swiss Journal of Psychology 2004; 63(2), 85-92. doi:10.1024/14210185.63.2.85 Kuntsche, E. N. Progression of a general substance use pattern among adolescents in Switzerland? Investigating the relationship between alcohol, tobacco, and cannabis use over a 12 year period. European Addiction Research 2004; 10, 118-125. Lambert M, Verduykt P, Van den Broucke S. Summary on the literature on young people, gender and smoking. In: Gender differences in smoking in young people. Lambert M, Hublet A, Verduykt P, Maes L, Van den Broucke S. 2002. Flemish Institute for Health Promotion, Brussels, Belgium. Langness A, Richter M, Hurrelmann K. Health Behaviour in school-aged children--results of the international study "Health Behavior in School-aged Children". Gesundheitswesen. 2005;67(6):422-31. Macedo M, Precioso J. Smoking trends in Portuguese school-aged children and approaches for a control-an analysis based on the Health Behaviour in School-Aged Children (HBSC) data. Rev Port Pneumol. 2006;12(5):525-38. Maes L, Lievens J. Can the school make a difference? A multilevel analysis of adolescent risk and health behaviour. Social Science and Medicine 2003; 56, Issue 3, pages 517-529. Mathers CD & Loncar D. Projections of Global Mortality and Burden of Disease from 2002 to 2030. PloSMed 2006, 3(11): e442. Mazur J, Kowalewska A, Woynarowska B. Alcohol drinking and other risk behaviors among adolescents aged 11-15 years. Med Wieku Rozwoj. 2003;7(1 Pt 2):75-89. Mazur J, Makowska A. Bullies and victims among Polish school-aged children. Med Wieku Rozwoj. 2003;7(1 Pt 2):121-34. Mazur J, Woynarowska B. Risk behaviors syndrome and subjective health and life satisfaction in youth aged 15 years. Med Wieku Rozwoj. 2004;8(3 Pt 1):567-83.

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Newell S, Girgis A, Sanson-Fisher R. The accuracy of self-reported health behaviors and risk factors relating to cancer and cardiovascular disease in the general population: a critical review. Am J Prev Med 1999; 17: 211-29. Nic Gabhainn S, Nolan G, Kelleher C, Friel S. Dieting patterns and related lifestyles of school aged children in the Republic of Ireland. Public Health Nutrition 2002; 5 (1): 1-7. Nutbeam D, Smith C, Moore L, Bauman A. Warning! Schools can damage your health: alienation from school and its impact on health behaviour. Journal of Paediatrics and Child Health 1993; 29, (S1): S25-S30. Pickett W, Garner M, King MA, King AJC, Boyce W. Gradients in risk for youth injury associated with multiple risk behaviours: a study of 11,329 Canadian children. Social Science and Medicine 2002; 55 (6):1055-68. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt P, Mazur J, Molcho M, Godeau E, Aszmann A, Overpeck M, Harel Y. Multiple risk behaviours and injury: an international study of youth in 12 countries. Archives of Pediatrics & Adolescent Medicine 2002; 156: 786-793. Piontek D, Buehler A, Rudolph U, Metz K, Kroeger C, Gradl S, Floeter S, Donath C. Social contexts in adolescent smoking: does school policy matter? Health Education Research 2007. Doi:10.1093/her/cym063. Pirkis JE, Irwin CE, Brindis C, Patton GC, Sawyer MG. Adolescent substance use: Beware of International Comparisons. J Adolesc Health 2003; 33:279-286. Post A, Gilljam H, Rosendahl I, Meurling L, Bremberg S, Galanti MR. Validity of self reports in a cohort of Swedish adolescent smokers and smokeless tobacco (snus) users. Tobacco Control 2005;14:114117. Poulsen LH, Roberts C, Osler M, Due P, Holstein BE. Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark. Tobacco Control 2002; 11: 246-51. Prokhorov AV, Winickoff JP, Ahluwalia JS, Ossip-Klein D, Tanski S, Lando HA, Moolchan ET, Muramoto M, Klein JD, Weitzman M, Ford KH and for the Tobacco Consortium, American Academy of Pediatrics Center for Child Health Research. Youth Tobacco Use: A global perspective for child health care clinicians. Pediatrics 2006; 118: e890-e903. Rasmussen M, Damsgaard MT, Due P, Holstein BE. Boys and girls smoking within the Danish elementary school classes: a group-level analysis. Scandinavian Journal of Public Health 2002; 30: 62-9. Rasmussen M, Damsgaard MT, Holstein BE, Poulsen LH, Due P. School connectedness and daily smoking among boys and girls: the influence of parental smoking norms. Eur J Public Health. 2005;15(6):607-12. Riala K, Hakko H, Isohanni M, Jarvelin M, Rasanen P. Teenage smoking and substance use as predictors of severe alcohol problems in late adolescence and in young adulthood. Journal of Adolescent Health 2004; 35: 245-254. Saluja G, Iachan R, Scheidt PC, Overpeck MD, Sun W, Giedd JN (2004) Prevalence of and Risk Factors for Depressive Symptoms Among Young Adolescents. Arch Pediatr Adolesc Med. ;158:760-765. Schepsis TS, Rao U. Epidemiology and etiology of adolescent smoking. Curr Opin Pediatr 2005; 17: 607612. Schnohr C, Niclasen BV. Bullying among Greenlandic schoolchildren: development since 1994 and relations to health and health behaviour. Int J Circumpolar Health. 2006; 65(4):305-12. Schnohr CW, Kreiner S, Rasmussen M, Due P, Currie C, Diderichsen F. The role of national policies intended to regulate adolescent smoking in explaining the prevalence of daily smoking: a study of adolescents from 27 European countries. Addiction. 2008; 103(5):824-31. Smet B, Maes L, De Clercq L, Haryanti K and Djati Winarno R. (1999). Determinants of smoking behaviour in Semarang, Indonesia. Tobacco Control, 8: 186-191. Smith C, Nutbeam D, Roberts C, Moore L, Catford J. (1994). Current changes in smoking attitudes and behaviours among adolescents in Wales, 1986-1992. Journal of Public Health Medicine, 16: 165 171.

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Starkuviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian schoolchildren. Medicina (Kaunas). 2005;41(1):73-80. Suominen SB, Vlimaa RS, Tynjl JA, Kannas LK. Minority status and perceived health: a comparative study of Finnish- and Swedish-speaking schoolchildren in Finland. Scand J Public Health. 2000;28(3):179-87. The World Bank. Development in Practice: Curbing the Epidemic. Governments and the Economics of Tobacco Control. A World Bank Publication. Washington D.C.: 1999. Turner L, Mermelstein R, Flay B. Individual and contextual influences on adolescent smoking. Ann N.Y. Acad. Sci 2004; 1021: 175-197. US Department of Health and Human Services. Preventing Tobacco Use Among Young People: A Report of the Surgeon General. US Department of Health and Human Services, Public Health Service, Centres for Disease Control, Centre for Health Promotion and Education, Office on Smoking and Health; Atlanta, Georgia: 1994. US Department of Health and Human Services. The health consequences of smoking: a report of the Surgeon General. US Department of Health and Human Services, Centre for Disease Control and Prevention, National Centre for Chronic Disease Prevention and Health promotion, Office on Smoking and Health; Washington, D.C: 2004. Vereecken C, Maes L, De Bacquer D. The influence of parental occupation and the pupils educational level on lifestyle behavior among adolescents in Belgium. J Adolesc Health 2004; 34(4): 330-8. WHO. The European tobacco control report 2007. Copenhagen: World Health Organization Regional Office for Europe; 2007 WHO. Tobacco , alcohol and illicit drugs in The evidence of Health promotion effectiveness, ECSC-ECEAEC, Brussels, 2000,: 69-79. Trends in Substance Use and Associated Health Problems. WHO Fact Sheet No. 127, August 1996. Zambon A, Lemma P, Borraccino A, Dalmasso P, Cavallo F. Socio-economic position and adolescents' health in Italy: the role of the quality of social relations. Eur J Public Health. 2006;16(6):627-32.

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II.5.6 Alcohol use


Simons-Morton, B, Ter Bogt, T, Godeau, E, Hublet, A, Kokkevi, A, Kuntsche, E for the Risk Behaviour Focus Group

1. Scope and Purpose


The study of alcohol consumption among adolescents is important because the initiation of alcohol use (e.g. Johnston et al. 2004, Kuntsche et al., in press) and excessive drinking (Tucker et al. 2005) frequently begin during this period, and drinking prevalence increases dramatically (Currie et al. 2008, Johnston et al. 2006, Nic Gabhainn / Franois 2000). Frequent and excessive drinking is associated with a range of negative outcomes to which some adolescents may be particularly susceptible (Brown et al. 2008, Rehm et al. 2004). Adolescent alcohol use is associated with a range of adverse consequences, including future drinking and drug use (Guo et al. 2000), academic problems (Grunbaum et al. 2004), unplanned and risky sex (Eaton et al. 2005, Cooper 2002, Johnston et al. 2008), motor vehicle crashes (NHTSA 2002), and various physical and emotional problems (Brown et al. 2008). Therefore, there is great interest in many countries in monitoring adolescent alcohol use, identifying associated factors, and establishing policies and programs to limit its use (Brand et al. 2007). Alcohol is the most commonly used substance among post-primary students internationally (Ahlstrom 2007, Hibell et al. 2004, Johnston et al. 2006). The use of alcohol remains high in many countries, although it has declined recently in some countries and increased in others (Simons-Morton et al. 2009). The range in prevalence across countries is substantial, with monthly use among 15-year olds lower than 30% in some countries and greater than 60% in others (Simons-Morton et al. in press). There is evidence that differences in drinking rates between adolescent boys and girls may have diminished in recent years in some countries of (Ahlstrom 2007, Keyes et al. 2008, Simons-Morton et al. 2009). Alcohol consumption among adolescent boys and girls is largely dominated by beer (Hibell et al. 2000, Kuntsche 2001, Kuntsche et al. 2006, Nic Gabhainn / Franois 2000). However, adolescent use of spirits appears to be particularly associated with negative effects (Schmid et al. 2003). In addition to a measure of 30-day frequency it is valuable to include a measure of drinking volume. Drinking volume is defined as the product of frequency and usual quantity and represents the total number of consumed drinks during a specified period of time such as the

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last 30 days. According to Rehm et al. (2004) volume and risky single occasion drinking are the two main dimensions of alcohol consumption. Over the last decade, drunkenness (i.e., drinking to intoxication or heavy episodic drinking often labelled as binge drinking) among young people has become a major public health concern in the United States (see, for example, the two special issues on this phenomenon; Journal of Studies on Alcohol Supplement, 14, 2002 and Psychology of Addictive Behaviors, 15(4), 2001) and many other countries world wide. Recent results demonstrate that drunkenness ranges considerably across countries, with lifetime prevalence rates of over 40% in some countries but less than 20% in other countries (Simons-Morton et al. 2009).

2. Objectives
The objectives of the HBSC assessment of alcohol are to identify patterns of use and factors associated with use in adolescents by age, sex, country, and time. Objectives are included regarding various aspects of prevalence: 1. Frequency of use over lifetime, past year, and past month. 2. Consumption of types of alcoholic beverages

3. Theoretical framework
Many theories have been applied to adolescent substance use (White 1996, Petraitis et al. 1995, Leonard / Blane 1999). Among these, developmental theories such as primary socialization theory (Oetting / Donnermeyer 1998), social bonding theory (Hirshi 1969), social identity theory (Terry / Hogg 2000) are prominent. Developmental theories emphasize the importance of family and other social influences on adolescent experimentation with alcohol. Other prominent psychosocial theories also emphasize social influences, for example, problem behaviour theory (Jessor / Jessor 1977), social exchange theory (Kelley / Thibaut 1985); social cognitive theory (Bandura, 1996); and reasoned action (Fishbein / Ajzen 1975). A range of social influences have been emphasized, for example, peers, parents, normative perceptions, and social context (Simons-Morton / Farhat 2008). Moreover, based on the empirical literature, peer influence is the factor most closely associated with adolescent substance use, with parent factors, school and neighbourhood, and cognitions also important (Andrews et al. 2002, Hawkins et al. 1992, Simons-Morton / Farhat 2008). Expectancy theory, which derives

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from social cognitive theory, has perhaps the next strongest empirical base with respect to a theoretical relationship to adolescent alcohol use (Jones et al. 2001). The basic idea is that behaviour is the product of expectations. When people expect positive outcomes from behaviour there is a tendency to engage in the behaviour. However, expectations do not need to be realistic to be influential. Expectations can be based on experience, but even experience can be subject to cognitive interpretation. For example, an adolescents initial experience with alcohol may appear to produce negative outcomes, for example, if the adolescent finds the taste and after affects objectionable, but if the adolescent also believes that drinking produced positive social effects in the form of shared experience with friends or the like, then overall subjective expectations may favour drinking in the future. In this manner drinking expectancies are often social mediated. While there is evidence that personality, genetic, and neurobiological explanations may be important with respect to the development of alcohol problems, the evidence of their link to experimental use is weak (Leanard / Blane 1999).

4. Summary of previous work


The module on alcohol use has been included in the HBSC study since its inception. A number of publications based on the HBSC alcohol use survey items have resulted. For example, several papers have been published on the relationship between alcohol use and family factors (Kuendic / Kuntsche 2006a, Kuntsche / Kuendig 2006b) and peer and school factors (Kuntsche / Delgrande 2006). Kuntsche and Kuendig (2005) reported on the relationship between alcohol outlet density and adolescent alcohol use. Kuntsche et al. (2006) reported on reasons adolescents drink and use cannabis. Kuntsche and Gmel (2006) reported on the relationship between emotional well-being and solitary risky single occasion adolescent drinkers (2004). Schmid and Nic Gabhainn (2004) reported on alcohol use in HBSC countries. Schmid et al. (2003) reported a cross-national comparison of drunkenness and Simons-Morton, Farhat, Ter Bogt et al. (2009) reported trends in alcohol use and drunkenness. Previously, Zaborskis et al. (2006) reported trends in drinking in Baltic countries. Simons-Morton et al. (2009) evaluated alcohol and cannabis use in the US, Canada, and the Netherlands. A number of national reports on alcohol use have been published, including one on mental health and alcohol use among Dutch adolescents (Verdurmen et al. 2005), progression among Swiss adolescents (Kuntsche 2004), and drinking among Turkish high school students (Alikasifoglu et al. 2004).

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With respect to the measurement of alcohol use, a compromise has been sought between keeping the original questions for monitoring purposes and improving them to reflect contemporary measurement standards, capture emerging changes, and enable comparisons with other surveys. Questions on the types of alcoholic beverages consumed were introduced into the mandatory survey in 1998. Several sets of questions were introduced into the optional package of alcohol in the 2006 survey, as indicated below under instruments. A small subset of the optional items was proposed as mandatory in 2007, but no decision was reached. The RBFG again proposes the inclusion of these items in the mandatory survey. The inclusion of these few items would greatly enhance the surveys credibility and utility.

5. Research questions
The questions on alcohol use are designed to enable the analyses of the following types of research questions: Research questions relating to mandatory items: 1. What is the prevalence of drinking and drunkenness among study participants by age, gender, geographic location within countries, cross nationally, etc? 2. What types of alcoholic beverages are consumed and how frequently? Are the traditional beverages of beer, wine, and spirits replaced by newly designed drinks like alcopops or are alcopops added to traditional beverages? Is the frequency of drinking specific beverages linked to the frequency of drunkenness? 3. To what extent are drinking and drunkenness associated with social outcomes, such as spending time with friends, family relations, and getting along at school? 4. What health and behaviour outcomes (e.g. injuries, fighting, bullying, mental health, well-being) are associated with drinking and drunkenness? 5. What is the relation between drinking and drunkenness? 6. What is the role of early onset of drinking and drunkenness in the development of health problems and in the use of other illicit drugs? 7. To what extent do health risk behaviours cluster, including smoking, elicit substance use, drinking, drunkenness, and early onset of drinking?

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Research questions relating to optional items: 1. What is the frequency of drinking alcohol in the past 30 days and past 12 months? 2. What is the frequency of getting drunk in the past 12 months? 3. What is the relationship between adolescent and peer drinking?

6. Instruments
6.1 Mandatory items
6.1.1 Frequency of alcohol use The mandatory questions for the 2005/06 HBSC survey are designed to measure the frequency with which adolescents currently consume specific alcoholic beverages (MQ20). The question consists of a maximum of eight (8) items corresponding to specific types of alcoholic beverages. An estimation of total intake of alcohol can be calculated by collapsing the items. The question has changed slightly since the 2001/02 HBSC survey. First, an item on alcopops was added to the existing mandatory list of the types of alcohol. Second, responding to a broader need for a better measurement of frequency of intake, a maximum of three (instead of an unlimited number) examples of country/region specific alcoholic beverages can be specified. Restricting the number of country options is designed to improve reliability (Weng 2004). Third, an item on any other drink that contains alcohol has been added to the list to capture all possible responses from students whose alcoholic preferences are not covered by the preceding items.

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The mandatory question [MQ20] for the 2005/06 HBSC survey now reads as follows: Item box 1
MQ20 At present, how often do you drink anything alcoholic, such as beer, wine or spirits like.[Add appropriate examples]? Try to include even those times when you only drink a small amount. Please tick one box for each line Every day Beer Wine Spirits / Liquor
1 1 1

Every week
2 2 2

Every month
3 3 3

Rarely
4 4 4

Never
5 5 5

Alcopops [eg. Smirnoff Ice, Bacardi Breezer, 1 Mikes Hard Lemonade] National drinks categories 1 (maximum of three) Any other drink that 1 contains alcohol Source: HBSC 1986, 1990, 1994, 1998, 2002

Validation work The frequency of alcohol use in young people is correlated to their frequency of drunkenness (Kuntsche 2001, Schmid et al. 2003). The correlation between drunkenness and a preference for spirits was positive in 21 countries and strong (Pearsons r > .40) in some eastern countries. International comparisons show large variation in the frequency of drinking in general (Simons-Morton et al., in press) and in the preference for specific beverages. It is possible to identify clusters of countries according to their tradition of alcohol use (Schmid / Nic Gabhainn 2004). A recent review of existing empirical literature indicates that the validity of adolescent self-report of alcohol use is better when the language is simple and clear (Brener et al. 2003). Complex recall tasks are less reliable than simple recall tasks and the recall of recent events is more reliable than the recall of distant events (Bailey et al. 1992). Notably, questions assessing age of initiation of alcohol use tend to elicit a large proportion of inaccurate responses (Engels et al. 1997, Johnson / Mott 2001). Therefore, the question on initiation is restricted to 15 year olds. In general, self reported substance use is considered to be highly reliable and accurate when the questions are self-administered, anonymous, and carefully administered in the school setting (Campanelli et al. 1987).

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Instructions on use and item placement 1. Question: The question includes the sub-text Try to include even those times when you only drink a small amount. In this case, small amount' means an amount less than a glass, but more than a single sip. Counting these small amounts of alcohol means it will be possible to detect the current prevalence of alcohol drinking. 2. Alcopops item (no4): a. Alcopops include all pre-mixed sweet flavored alcoholic beverages which are based on distilled alcohol. Brands, size, design and volumes vary substantially across countries. Alcopops are bottled or canned drinks containing spirits premixed with sugar and various (mostly fruity) flavors or beverages (often lemonade). Alcopops are characterized by their sweet taste and alcoholic content of up to 5.5% alcohol by volume (Wicki et al. 2006). b. Alcopops can be subdivided into 'premixed drinks' and designer drinks. Premixed drinks are established brands of e.g. vodka and rum mixed with softdrinks. Examples of premixed drinks type of alcopops are: Smirnoff Ice, Mikes Hard Lemonade, Jack Daniels Original Hard Cola, Bacardi Breezer, Sublime, Anheuser-Buschs DOC Otis Hard Lemon. Designer drinks are newlydesigned sweet, carbonated liquids with a certain percentage of pure alcohol. Types of designer drinks include: alcoholic ciders as Ice Dragon, TNT, White Lightening, Diamond White; but not fortified wines such as Mad Dog 20/20, Fruits Unlimited or Spectra Flavours for Ravers. Such fortified wines could be included as a national option in some countries. c. Countries should translate the term alcopops in a way that best assesses the use of these types of alcoholic beverages (as defined in a. above). Examples of country specific brand names of alcopops could also be added in brackets. 3. Country specific drinks (no5 to no7): A maximum of three country/region specific alcoholic drinks can be added after the first four items. Countries should ensure that the national drinks a) do not overlap with any of the previous types of alcohol (i.e. white ciders should be listed under the alcopops category while conventional ciders could be placed as a national option) and b) that the national drinks chosen for inclusion be popular among adolescents. The selection of national options should ideally be based on official sales data in each country. All additional national wording

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and/or items should be documented, translated and back-translated and thoroughly checked during the translation review process. An illustration of how the country specific items could be placed and presented is shown below:
-

Alcopops (i.e. Smirnoff Ice, Bacardi Breezer etc.) Cider with alcohol (e.g. Strongbow, Woodpecker etc.) Champagne, sparkling wine (e.g Prosecco etc.). Aperitif (e.g. Pernod, Martini etc.) Any other drink that contains alcohol.

6.1.2. Lifetime drunkenness This mandatory item (MQ21) is designed to measure lifetime drunkenness. This item has been included in all HBSC surveys since the beginning of the study and has been shown to be associated with other risk behaviour as well as poor adjustment to school. Drunkenness is an aspect of the pattern of drinking that may be specially important in young people and is correlated to the frequency of drinking as well as to the intake of different types of beverages, mainly spirits (Kuntsche 2001; Schmid et al. 2003). Because the term drunkenness requires a subjective evaluation, thereby increasing response variability, other major surveys assess drunkenness by asking about the frequency the respondent has had 5 or more drinks at one time or period (Hibell et al. 2004). Item box 2
MQ21
1 2 3 4 5

Have you ever had so much alcohol that you were really drunk? No, never Yes, once Yes, 2-3 times Yes, 4-10 times Yes, more than 10 times

Source: HBSC 1985/86, 1989/90, 1993/94, 1997/98, 2001/02, 2005/06.

Validation work The frequency of drunkenness in young people is correlated to the frequency of their alcohol use (Kuntsche 2001, Schmid et al. 2003). E.g. the correlation between drunkenness and a preference for spirits was positive in 21 countries and strong (Pearsons r > .40) in some eastern countries. A recent international comparison showed large variation across countries

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in the frequency of drunkenness (Simons-Morton et al., in press). It is possible to identify clusters of countries according to their tradition in alcohol use (Schmid / Nic Gabhainn 2004, Simons-Morton et al. 2009).

Instruction on use and item placement MQ 21 should follow MQ 20

6.1.3 Age of onset An item measuring the age of onset of alcohol use and drunkenness has been used in the previous HBSC surveys (Schmid / Nic Gabhainn 2004). Monitoring changes in the age of onset is useful because the earlier a person begins drinking alcohol and the earlier a person experiences drunkenness, the more likely this person is to establish a lifestyle pattern that includes drinking, and the higher is the risk of developing negative alcohol-related health outcomes (Hawkins et al. 1997, DeWit et al. 2000). Item box 3
MQ22 At what age did you first do the following things? If there is something you have not done, choose the never category. Never Drink alcohol (more than a small amount) Get drunk 11 years old or less
2

12 years old
3

13 years old
4

14 years old
5

15 years old
6

16 years or older
7

Smoke a cigarette (more 1 2 3 4 5 6 than a puff) Source: HBSC 2005/6, Adapted from HBSC 2001/2; Adapted from the European School Survey Project on Alcohol and other Drugs (ESPAD) 1995, 1999, 2003

Validation work The earlier a person begins drinking alcohol, the more likely he or she is to establish a lifestyle pattern that includes drinking, and the higher is his or her risk of negative health outcomes associated with alcohol drinking (Hawkins et al. 1997, DeWit et al. 2000).

Instructions on use and item placement The age of onset item (MQ22) for the 2005/06 HBSC survey should be asked only of 15-yearolds and uses a close-ended format, because the previous open-ended format yielded excessive missing data.

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Definition: A person can be drunk after a single drink and is always considered drunk when they have consumed five or more drinks on one occasion over a period of hours.

The numbers above the response options are for coding purposes only and should not be included on the actual questionnaire because they might confuse the respondents.

The item on onset should be placed after MQ20 and MQ21 items and (where applicable) their complementary optional items.

-Countries administering their questionnaires to an older student population can add to the response categories additional options (e.g. 17 years or older, etc).

6.1.4 Drinking and getting drunk in past 30 days These items (MQ23) aim to assess the frequency of substance use more precisely and are in line with other international surveys of youth substance use (e.g., Monitoring the Future, ESPAD). They were part of the optional package in the 2005/06 survey, but are now included in the mandatory items. Employing the same format for questions about various substances will allow direct comparison across substances and asking these questions within a 30-day framework will allow us to identify those who are frequent and thus high-risk consumers of these substances. Measures of the frequency of smoking, drinking alcohol, and drunkenness during the previous 30 days are the standard international measures of experimental substance use (MtF, ESPAD, YRBS). Item box 4
MQ23 On how many occasions (if any) have you done the following things in the last 30 days? Please tick one box for each line. 0 1-2 3- 5 6 to 9 10-19 20-39 40 or more
7

[Smoked cigarettes] Drunk alcohol Been drunk

Source: Adapted from Monitoring the Future (1975 on) and the European School Survey Project on Alcohol and other Drugs, ESPAD (1995 on)

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Validation work To determine the consistency of responses between the frequency of alcohol use and drunkenness (MQ20/MQ21) and the 30-day measure of alcohol use and drunkenness, the responses of US HBSC study participants in the 2005/6 survey were compared. In brief, the percent missing were low (2.1% for 15 year olds and <4% over all) for both the mandatory and the 30-day use items. The Pearson correlations between MQ20 and 30-day alcohol use were 0.67 for 15 year olds and.62 for all ages. The rank order correlations were 0.72 for 15 year olds and 0.68 for all ages. These correlations show substantial consistency considering the differences in the periods of time asked about and the variability in response options.
Missing No or Pearson Spearman ICC #/% Never/%a Correlation Correlation AR b 11, 13, and 15 year olds (n=3,892) Drinking With RB2 RB2: How many times have 130/3.3 2725/72.7 ___ ___ ___ you drunk alcohol in past 30 days? (never) Alcfreq (MQ20) 111/2.8 2213/59.6 .62 .68 .59 Drunk RB3 RB3: On how many occasions have you been drunk in past 135/3.5 3196/85.9 ___ ___ ___ 30 days? (never) MQ21: Have you ever had so 140/3.6 3107/83.5 .59 .68 .58 much alcohol that you were really drunk? (no, never) 15 year olds) (n=1,284) RB2: How many times have 27/2.1 884/54.8 ___ ___ ___ you drunk alcohol in past 30 days? (never) Alcfreq (MQ20) 26/2.0 502/39.9 .67 .72 .64 Table 1a Comparison of 2005 mandatory (M) and Optional Risk Behavior (RB) questions, 2005-06 US survey Item
a Denominator is n-missings b AR = auto regressive

Instructions on use and item placement This question should be placed in the questionnaire to immediately follow the mandatory question on types of alcoholic beverages consumed (MQ20). The numbers above the response options are for coding purposes only and should not be included on the actual questionnaire because they might confuse the respondents. Note that the question text specifies On how many occasions have you. Occasion should be defined as a brief period of time, such as over a period of several hours. The question should not be interpreted as asking about the actual number of drinks the respondent had.

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Smoking and marijuana use are included only to show how the question should be presented. The item on drunk in past 30 days should be included as shown above with 30 day use. Definition: A person can be drunk after a single drink and is always considered drunk when they have consumed five or more drinks on one occasion over a period of hours.

6.2 Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. Drinking and getting drunk in past 12 months Perceived alcohol use and drunkenness by friends Usual Quantity Drinking Motives

7. References
Ahlstrom S. Gender differences in youth drinking cultures. In: Jarvinen M, Room R, editors. Youth Drinking Cultures: European Experiences. England: Ashagate, 2007. Alikasifoglu M, Erginoz E, Ercan O, Uysal O, Albayrak-Kaymak D, Ilter O.(2004) Alcohol drinking behaviors among Turkish high school students. Turkish Journal of Pediatrics, 46(1):44-53. Andrews, J. A., Tildesley, E., Hops, H., & Li, F. (2002). The influence of peers on young adult substance use. Health Psychology, 21, 349-357. Bailey, S. L., Flewelling, R. L., & Rachal, J. V. (1992). The characterization of inconsistencies in self-reports of alcohol and marijuana use in a longitudinal study of adolescents. Journal of Studies on Alcohol, 53, 636-647. Bandura, A. (1996). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall. Brand DA, Saisana M, Rynn LA, Pennoni F, Lowenfels AB. Comparative analysis of alcohol control policies in 30 countries. PLoS Med 2007; 4:e151. Brener, N. D., Billy, J., O.G.,, & Grady William R. (2003). Assessment of factors affecting the validity of self-reported health-risk behavior among adolescents: evidence from the scientific literature. Journal of Adolescent Health, 33, 436-457. Brown SA, McGue M, Maggs J, Schulenberg J, Hingson R, Swartzwelder S et al. A developmental perspective on alcohol and youths 16 to 20 years of age. Pediatrics 2008; 121 Suppl:S290-S310. Campanelli, P. C., Dielman, T. E., & Shope, J. T. (1987). Validity of adolescents' self-reports of alcohol use and misuse using a bogus pipeline procedure. Adolescence, 22(85), 7-22. Cooper, M. L. (2002). Alcohol use and risky sexual behaviour among college students and youth: evaluating the evidence. J Stud Alcohol, 14 Suppl, 101-117. Currie C, Gabhainn SN, Godeau E, Roberts C, Smith R, Currie D et al. Inequalities in young people's health: HBSC international report from the 2005/2006 survey. 2008. Copenhagen, WHO Regional Office for Europe.

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De Wit, D. J., Adlaf, E. M., Offord, D. R., & Ogborne, A. C. (2000). Age at first alcohol use: a risk factor for the development of alcohol disorders. American Journal of Psychiatry, 157, 745-750. Engels, R. C., Knibbe, R. A., & Drop, M. J. (1997). Inconsistencies in adolescents' self-reports of initiation of alcohol and tobacco use. Addictive Behaviors, 22(5), 613-623. Fishbein, M. & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. Grunbaum JA, Kann L, Kinchen S, Ross J, Hawkins J, Lowry R et al. Youth risk behavior surveillance United States, 2003. Morbidity and Mortality Weekly Report 2004; 53:1-96. Guo J, Collins LM, Hill KG, Hawkins JD. Developmental pathways to alcohol abuse and dependence in young adulthood. J Stud Alcohol 2000; 61:799-808. Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris WA et al. Youth risk behavior surveillance - United States, 2005. MMWR Surveill Summ 2006; 55:1-108. Hawkins, J. D., Catalano, R. F., & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64-105 Hawkins, J. D., Graham, J. W., Maguin, E., Abbot, R., Hill, K. G., & Catalano, R. (1997). Exploring the effects of age of alcohol use initiation and psychosocial risk factors on subsequent alcohol misuse. Journal of Studies on Alcohol, 58(3), 280-290. Hibell B, Andersson B, Bjarnason T, Ahlstrom S, Balakireva O, Kokkevi A et al. The ESPAD Report 2003: Alcohol and other drug use among students in 35 European countries. 2004. Stockholm, The Swedish Council for Information on Alcohol and Other Drugs and the Pompidou Group at the Council of Europe. Hirschi, T. (1969). Causes of delinquency. Los Angeles, CA: University of California Press. Jessor, R., & Jessor, S.L. Problem Behaviour and Psychosocial Development: A Longetudinal Study. New York, NY: Academy Press, 1977. Johnston, T. P. & Bachman, J.G. Monitoring the Future: Questionnaire responses from the Nation's high school seniors, 1975. Ann Arbor, MI: Institute for Social Research. Johnson, T. P., & Mott, J. A. (2001). The reliability of self-reported age of onset of tobacco, alcohol and illicit drug use. Addiction, 96(8), 1187-1198. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future national survey results on drug use, 1975-2005. 2006. Bethesda, MD, National Institute on Drug abuse. Johnston LD, O'Malley PM, Bachman JG, Schulenberg JE. Monitoring the future national survey results on drug use, 1975-2005. 2008. Bethesda, MD, National Institute on Drug abuse. Jones, B.T, Corbin, W., & Fromme, K. (2001). A review of expectancy theory and alcohol consumptoin. Addiction 96, 57-72. Kelley, H. H. & Thibaut, J. W. (1985). Self-Interest, Science, and Cynicism. Journal of Social and Clinical Psychology, 3, 26-32. Keyes KM, Grant BF, Hasin DS. Evidence for a closing gender gap in alcohol use, abuse, and dependence in the United States population. Drug Alcohol Depend 2008; 93:21-29. Kuendig, H. & Kuntsche, E. (2006a). Family bonding and adolescent alcohol use: Moderating effect of living with excessive drinking parents. Alcohol and Alcoholism, 41(4), 464-471. Kuntsche, E. N. & Kuendig, H. (2006b). What is worse? A hierarchy of family-related risk factors predicting alcohol use in adolescence. Substance Use & Misuse, 41(1), 71-86. Kuntsche, E., Knibbe, R., Gmel, G., & Engels, R. (2006). I drink spirits to get drunk and block out my problems Beverage preference, drinking motives and alcohol use in adolescence. Alcohol and Alcoholism, 41(5), 566-573. Kuntsche, E. & Delgrande Jordan, M. (2006). Adolescent alcohol and cannabis use in relation to peer and school factors. Results of multilevel analyses. Drug and Alcohol Dependence, 84(2), 167-174. Kuntsche E, Kuendig H (2005) Does school surrounding matter? Alcohol outlet density, perception of adolescent drinking in public, and adolescent alcohol use. Addictive Behaviors, 30(1), 151-158.

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Kuntsche, E. N. & Gmel, G. (2004). Emotional well-being and violence among social and solitary risky single occasion drinkers in adolescence. Addiction, 99(3), 331-339. Kuntsche, E. N. (2004). Progression of a general substance use pattern among adolescents in Switzerland? Investigating the relationship between alcohol, tobacco, and cannabis use over a 12 year period. European Addiction Research, 10, 118-125. Kuntsche, E. N. & Silbereisen, R. K. (2004). Parental closeness and adolescent substance use in single and two-parent families in Switzerland. Swiss Journal of Psychology, 63(2), 85-92. Leonard, K.E. & Blane, H.T. (Eds) 1999. Psychological theories of drinking and alcoholism, 2 Ed. New York, NY: Guilford Press. National Highway Traffic Safety Administration. Traffic safety facts, 2002: Alcohol. 2003. Washington D. C., National Center for Statistics and Analysis. (Accessed July 30, 2008, at http://wwwnrd.nhtsa.dot.gov/Pubs/2002ALCFACTS.PDF) Nic Gabhainn, S., & Franois, Y. (2000). Substance use. In C. Currie, Hurrelmann K., Settertobulte W., Smith R. & J. Todd (Eds.), Health and health behaviour among young people (pp. 97-114). Copenhagen: World Health Organization, Regional Office for Europe. Oetting, E. R. & Donnermeyer, J. F. (1998). Primary socialization theory: The etiology of drug use and deviance. I. Substance Use & Misuse, 33, 995-1026. Petraitis, J., Flay, B. R., & Miller, T. Q. (1995). Reviewing theories of adolescent substance use: organizing pieces in the puzzle. Psychological Bulletin, 117(1), 67-86. Rehm, J., Room, R., Monteiro, M. G., Gmel, G., Graham, K., Rehn, N., et al. (2004). Alcohol use. In M. Ezzati, A. D. Lopez, A. Rodgers & C. J. L. Murray (Eds.), Comparative Quantification of Health Risks. Global and Regional Burden of Disease Attributable to Selected Major Risk Factors (Vol. 1, pp. 959-1108). Geneva: World Health Organization (WHO). Schmid, H., & Nic Gabhainn, S. (2004). Alcohol use. In C. Currie, C. Roberts, A. Morgan, R. Smith, W. Settertobulte, O. Samdal & V. B. Rasmussen (Eds.), Young people's health in context (Vol. 4, pp. 73-83). Copenhagen: WHO Health Policy for Children and Adolescents (HEPCA). Schmid, H., Ter Bogt, T., Godeau, E., Hublet, A., Dias, S. F., & Fotiou, A. (2003). Drunkenness among young people. A cross-national comparison. Journal of Studies on Alcohol, 64(5), 650-661. Simons-Morton, B.G. & Chen, R. Over Time Relationships Between Early Adolescent and Peer Substance Use. Addictive Behaviour, 31:1211-1223, 2006. Simons-Morton, B.G. Social influences on adolescent substance use. American Journal of Health Behaviour, 6:672-684, 2007. Simons-Morton, B.G., Farhat, T. Recent findings on peer group influences on adolescent substance use. Paper presented at the Duke University Trans-disciplinary Prevention Research Center Conference, Reducing Substance Use Initiation Among Adolescents: An Interdisciplinary Conversation. Durham, NH, October 13-14, 2008. Simons-Morton, B.G., Pickett, W. Boyce, W., Ter Bogt, TF.M, Vollegergh, W. Cross-national comparison of adolescent drinking and cannabis use in the United States, Canada, and the Neterlands. International Journal of Drug Policy, in press. Simons-Morton BG, Farhat, T., Ter Bogt, T.F.M., Hublet, A, Kuntsche, E., Gabhainn, SN, Godeau, E, Kokkevi, A, for the HBSC Risk Behavior Focus Group. Gender specific trends in alcohol use: Crosscultural comparisons from 1998 to 2006 in 24 countries and regions. IJPH, in press. Terry, D. J., Hogg, M. A., & White, K. M. (2000). Attitude-behavior relations: Social identity and group membership. In D.J.Terry & M. A. Hogg (Eds.), Attitudes, behavior and social context: The role of norms and group membership (pp. 47-66). Mahway, NJ: Erlbaum Associates. Tucker, J. S; Ellickson, P. L; Orlando, M.; Martino, St. C; Klein, D. J. (2005). Substance Use Trajectories From Early Adolescence to Emerging Adulthood: A Comparison of Smoking, Binge Drinking, and Marijuana Use. Journal of Drug Issues. 35(2), 307-332. Verdurmen J et al (2005). Alcohol use and mental health in adolescents: interactions with age and gender - findings from the Dutch 2001 HBSC survey. Journal of Studies on Alcohol 66: 605-609. Weng, L.-J. (2004). Impact of the Number of Response Categories and Anchor Labels on Coefficient Alpha and Test-Retest Reliability. Educational and Psychological Measurement, 64(6), 956-972.
nd

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White, H. R. (1996). Empirical validity of theories of drug abuse: Introductory comments. Journal of Drug Issues, 26(2), 279-288. Wicki, M., Gmel, G., Kuntsche, E., Rehm, J., & Grichting, E. (2006). Is alcopop consumption in Switzerland associated with riskier drinking patterns and more alcohol-related problems? Addiction, 101(4), 522-533. World Health Organization (WHO). (2001). Declaration on Young People and Alcohol, from http://www.euro.who.int/AboutWHO/Policy/20030204_1Zaborkis A, Sumskas L, Maser M, Pudule I. (2006) Trends in drinking habits among adolescents in the Baltic countries over the period of transition: HBSC survey results, 1993-2002. BMC Public Health, 6(1), 67

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II.5.7 Illicit drug use


Ter Bogt, T, Nic Gabhainn, S

1. Scope and purpose


Since the 1960s there has been an increasing number of young people experimenting with illicit drugs. In many industrialised countries occasional use of cannabis, the most widely used illicit drug among adolescents, has become normative among a substantial minority of high school age students (Costa e Silva 2002, EMCDDA 2003, Hibell et al. 2000, Johnston et al. 1999, Nic Gabhainn / Francois 2000, Ter Bogt et al. 2004). Cannabis use emerged as a central component of alternative lifestyle during the 1960s and 1970s, especially so among young people rebelling against the culture of their parents; this counterculture propagated use of cannabis and other psychotropic drugs as a way to free themselves from the bourgeois mindset that was considered typical of the older generation. Middle class youth first popularised the use of cannabis and in later years it spread to other sections of youth. Both in Europe and in the US, cannabis use rose further during the 1990s, decreasing thereafter in the US (Johnson et al. 2008), and stabilising or increasing further across Europe (Hibbel et al. 2004). Lifetime and last month prevalence still vary widely across countries that participate in the Health Behaviour in School-aged Children (HBSC) and European School Survey Project on Alcohol and Other Drugs (ESPAD) studies. The lifetime prevalence of cannabis use among the HBSC and ESPAD target group of 15-16 year-old students has in some countries increased to over 40%, while in others it remains substantially below 10% (Currie et al. 2008, Hibell et al. 2004, Ter Bogt et al. 2006). The late 1980s and 1990s saw the ascent of rave culture. The frantic dancing that is characteristic of this type of youth culture was sustained by widespread and heavy use of MDMA and other so-called party-drugs (Ter Bogt et al. 2002). Among younger adolescents use of easy accessed, cheap solvents has become popular. Amphetamines and MDMA (ecstasy) represent the second largest group of illicit substances consumed in the EU and North America, but are used much less than cannabis. However, in younger adolescents (under age 16) the use of solvents is more frequent than either Amphetamines or MDMA. In the ESPAD survey (Hibell et al. 2004), the highest lifetime prevalence of inhalant / solvent use is reported in Greenland (22%), other countries with high levels of inhalants use include Cyprus,

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Greece, Ireland, Malta and Slovenia (15-19%). In the United States, the use of MDMA among all adolescents rose sharply in the 1990s, but has declined since 2002 (Johnston et al. 2008). While many of the counterculture believed that drug use was a positive factor in life, at least with regard to cannabis, LSD and other mind-altering drugs, and ravers held that MDMA and other party drugs could really enhance their moods and get them through a night of dancing and partying, the negative consequences of drug use - health risks, psychosocial problems, dependence - became more apparent when youth started using these substances in larger numbers and greater frequency, and as the substances themselves became more potent (Ter Bogt 2000). Within HBSC, drug use is considered to be an integral part of youth culture, with young people using drugs for a variety of reasons. Drug use is also seen as a health risk behaviour. HBSC monitors illicit drug use cross-nationally and can link drug use to differences in social contexts, cross-national and cultural determinants of use and to health related outcomes (e.g., health risks, psychosocial problems).

2. Objectives
The HBSC illicit drug use items provide the surveillance tools to monitor substance use, and when used in sequential surveys, demonstrate trends in illicit drug use. As both lifetime use, last year use and last month use of cannabis use are assessed it is possible to discern between first time, recreational and heavy users of cannabis and relate use profiles to other social and health outcomes.

3. Theoretical framework
A wide range of theories have been applied to adolescent substance use (cf. White 1996, Petraitis et al. 1995), including social cognitive and developmental theories such as primary socialisation theory (Oetting / Donnermeyer 1998); social bonding theory (Hirschi 1969); social identify theory (Terry et al. 2000); problem behaviour theory (Jessor, Jessor 1977); social exchange theory (Kelley / Thibaut 1985); social cognitive theory (Bandura 1996); and the theory of reasoned action (Fishbein / Ajzen, 1975). These theories have emphasised the cultural context of drug use, social influence of peers and parents, normative perceptions, adolescent development and personality as determining illicit drug use (Simons-Morton / Farhat 2008). Peer influence is the single most well documented influence on adolescent substance use, with parent factors, school and neighbourhood, personality, and other
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influences also important (Andrews et al. 2002, Hawkins et al. 1992, Simons-Morton / Farhat 2008). With regard to the most widely used illicit drug cannabis it has been suggested that a combination of factors, including countries wealth, the existence of drug-using older youth and young peoples generalised perception that cannabis is readily available, can explain crossnational differences in cannabis use. The sequence may be that when drugs are available and affordable, and high profile youth cultures holding positive attitudes towards drug use emerges, this fosters the growth of a drug-using community of young people. Once this community exists, it plays a crucial role in the socialisation of younger, potential drug users. Leisure opportunities for a rising middle class facilitates drug use among the most bohemian segments of its youth, and these behaviours trickle down to (some) young people with a lower socioeconomic status once they have the money and opportunity to buy drugs. As with drinking alcohol and smoking tobacco, experimentation with cannabis and other drugs may be considered from a developmental perspective. Substance use can be framed as part of the process of becoming an adult. Drug use has been explained as an attempt to assert the adult status to which adolescents aspire (Engels 1998, Engels / Ter Bogt 2001). Several studies argue that some patterns of use do not necessarily have detrimental effects, at least not socially. There is some evidence to suggest that adolescents who use alcohol or cannabis in modest doses are better adjusted and are more socially skilled than those who either totally refrain from using psychoactive substances, or those who use them in large quantities (Engels / Ter Bogt 2001, Shedler / Block 1990). Nevertheless frequent drug use is associated with of a host of negative outcomes. Those who report early onset of substance use are especially at risk (Kokkevi et al. 2006). Frequent early drug use is predictive of dropping out of school, having unsafe sex and involvement in delinquent activity (Brook et al. 1999). It is important to recognise that it is not necessarily drug use per se that causes these problems. Substance abusers, even before they start misusing alcohol and drugs, tend to be less: self-reliant, confident, likely to plan ahead, sociable and trustworthy (Shedler / Block 1990). Use of cannabis and other drugs use may only aggravate their problems but not cause them. Heavy cannabis use is associated with reduced educational attainment and school-drop-out, depression, health problems, risk taking and deviancy, and higher odds for use of other drugs (Kandell et al. 1997, Macleod et al. 2004, Monshouwer et al. 2006). A number of recent studies offer converging evidence that cannabis use may trigger psychoses and depression and, particularly amongst those who are prone to

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these disorders, precipitate the onset (Arseneault et al. 2002, Fergusson et al. 2003, Moore et al. 2007, Patton et al. 2002, Smit et al. 2004, Van Os et al. 2002, Zammit et al. 2002). Within HBSC drug use is seen as an integral part of the development towards adulthood, at least for some young people in certain youth cultural contexts. However, the results of a plethora of studies have shown that use of cannabis and harder drugs is connected to negative heath risks and psychosocial outcomes. Therefore assessing and monitoring illicit drug use and its cross-national determinants and consequences of time is a crucial dimension of our work.

4. Summary of previous work


Except for cannabis use, no questions on illicit drug consumption have been mandatory in the HBSC study, although many countries have employed their own questions since the 1980s (e.g., Wales, England). Due to the major public health concern around the issue of drug use, in particular cannabis use, mandatory questions on the life time and 12 month prevalence of cannabis use have been included in the survey for 15-year-olds from 2001/02 onwards. In the 2005/06 questionnaire, the life time and 12 month prevalence questions on cannabis use were extended with an item on the last month prevalence of cannabis use. The cannabis items have been used in several publications. On a basic level, data from HBSC have been used to describe the prevalence of substance use in specific countries or regions (e.g. Godeau et al. 2004, Navarro et al. 1996) or different countries (Godeau et al. 2007, Kokkevi et al. 2006). Some authors have tried to monitor trends in substance use (Godeau et al. 2006) and find explanations for the observed developmental patterns by linking them to differences in national policy (Simons-Morton et al., in press) or youth culture (Kuntsche et al., in press). Others have researched cross-national differences in substance use and explained them through analysing differences in cultural context (Schmid / Ter Bogt 2004, Ter Bogt et al. 2006). Substance use also has been studied in the context of adolescent development, in relation to the family social environment (Kuntsche / Silbereisen 2004), peer and school factors (Kuntsche / Delgrande Jordan 2006, Schmid 2001), ideologies enhanced by adolescent users (Kuendig et al. 2005) or use of other substances such and alcohol and tobacco (Kuntsche et al. 2004). The negative mental health effects of cannabis use were studied by Monshouwer et al. (2006). Others have operationalised cannabis use as part of a wider array of risk behaviours and studied the correlates of that set of risk behaviours (Boyce et al. 2008, Koven et al. 2005, Mullan / Nic Gabhainn 2003, Pickett et al. 2002, Simpson et al. 2006). Others still, have

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discussed drug use in relation to methodological issues (Nic Gabhainn 2000) or policy issues (Nic Gabhainn / Walsh 2000).

5. Research questions
The core research questions designed to be addressed by the substance use items include: 1. The monitoring of cannabis and other illicit substance use over time 2. The identification of those at risk for substance use problems 3. The interrelationships between risk behaviours 4. Gender patterns in cannabis consumption and their geographical/cultural variations 5. Investigation of the associations between substance use (ever, in the last year and more frequently or by user group experimenter, continued user) with indicators of child health and well-being.

6. Instruments
6.1. Mandatory items
The mandatory questions on cannabis use are split into three items: lifetime prevalence, 12 months prevalence and 30 days prevalence. The lifetime prevalence question is designed to determine the scope of cannabis use by measuring the prevalence of its use among participating students. The second item helps to define the scope of the cannabis use by measuring the prevalence of substance use within the past 12 months and to differentiate adolescents who have tried cannabis once or twice (experimenters) from other who use the drug more frequently (regular users). To identify frequent users who may be at a higher risk for the negative consequences of cannabis use the third item on last 30 days prevalence has been added. Appropriate country specific street names for cannabis should be added in brackets to ensure that the question is understood by all students and to capture all the different forms in which cannabis is used.

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Item box 1
MQ24 Have you ever taken cannabis [INSERT APPROPRIATE STREET NAMES] ? Please tick one box for each line. Never Once or 3 to 5 6 to 9 10 to 19 20 to 39 twice times times times times
1 2 3 4 5 6

40 times or more
7

In your life In the last 12 months In the last 30 days

Source: ESPAD (European School Survey Project on Alcohol & other Drugs, 1995). Adapted by HBSC in 2001/02 (items 1 & 2).

6.2 Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. Peer substance use Frequency of illicit drug consumption Age of onset

7. References
Andrews, J.A., Tildesley, E., Hops, H. & Li, F. (2002). The influence of peers on young adult substance use. Health Psychology, 21, 349-357. Arseneault, L., Cannon, M., Poulton, R., Murrey, R., Caspi, A. & Moffit, T.E. (2002). Cannabis use in adolescence and risk for adult psychosis: longitudinal prospective study. British Medical Journal, 325, 1199-1201. Bandura, A. (1996). Social foundations of thought and action. Englewood Cliffs, NJ: Prentice Hall. Boyce, W., Davies, D., Gallupe, O. & Shelley, D. (2008). Adolescent Risk Taking, Neighborhood Social Capital, and Health. Journal of Adolescent Health, 43(3), 246-252. Brook, J., Balka, E. & Whiteman, M. (1999). The risks for late adolescence of early marijuana use. American Journal of Public Health, 89, 1549-1554. Costa e Silva, J.A. (2002). Evidence based analysis of the word wide abuse of licit and illicit drugs. Human Psychopharmacology, 17, 131-140. Currie, C., Nic Gabhainn, S., Godeau, E., Roberts, C., Smith, R., Currie, D., Picket, W., Richter, M., Morgan, A. & Barnekow, V. (2008). Inequalities in young peoples health: HBSC International report from the 2005/2006 survey. Copenhagen: WHO Regional Office for Europe. EMCDDA (European Monitoring Centre for Drugs and Drug Addiction) (2003). The State of the Drugs Problem in the European Union and Norway. Lisbon: EMCDDA. Engels, R.C.M.E. & Ter Bogt, T. (2001). Influences of risk behaviors on the quality of peer relations in adolescence. Journal of Youth and Adolescence, 30, 675-695. Engels, R.C.M.E. (1998). Forbidden fruits: social dynamics in smoking and drinking behavior of adolescents. Maastricht: University of Maastricht.

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Fergusson, D.M., Horwood, L.J. & Swain-Cambell, N.R. (2003). Cannabis dependence and psychotic symptoms in young people. Psychological Medicine, 33, 15-21. Fishbein, M. & Ajzen, I. (1975). Belief, attitude, intention, and behavior: An introduction to theory and research. Reading, MA: Addison-Wesley. Godeau, E., Vignes, C., Navarro, F. & Monger, M-L. (2004). Consommation de cannabis, tabac et alcool chez les lves de quinze ans en France - Rsultats de lenqute internationale Health Behaviour in School-aged Children (HBSC) / OMS. Courrier des addictions, 6(3),117-120. Godeau, E., Vignes, C., Ter Bogt, T. Nic Gabhainn, S., Navarro, F. (2006) Consommation de cannabis par les lves de 15 ans dans 32 pays occidentaux, dont la France - Donnes issues de lenqute internationale Health Behaviour in School-aged Children (HBSC) / OMS. Alcoologie & Addictologie, 28, 135-142. Godeau, E., Vignes, C., Ter Bogt, T., Nic Gabhainn, S. & Navarro, F. (2007). Cannabis use by 15-year old school children: data from the HBSC/WHO international survey in 32 countries. Alcoologie et Addictologie, 29(4), 28S-34S. Hansen, W. B. & O'Malley, P. M. (1996). Drug use. In DiClemente, R.J., Hansen, W.B. & Ponton, L. E. eds. Handbook of Adolescent Health-risk Behaviour, pp. 161-192. New York: Plenum Press. Hawkins, J. D., Catalano, R. F. & Miller, J. Y. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112(1), 64-105. Hibell, B., Andersson, B., Ahlstrm, S., Balakireva, O., Bjarnasson, T., Kokkevi, A. & Morgan, M. (2000). The 1999 ESPAD report: Alcohol and other drug use among students in 30 European countries. The Swedish Council for Information on Alcohol and Other Drugs (CAN), The Pompidou Group at the Council of Europe. Hibell, B., Andersson, B., Bjarnason, T., Ahlstrm, S., Balakireva, O., Kokkevi, A. & Morgan, M. (2004). The ESPAD report 2003: Alcohol and other drug use among students in 35 European countries. The Swedish Council for Information on Alcohol and Other Drugs (CAN), The Pompidou Group at the Council of Europe. Hirschi, T. (1969). Causes of delinquency. Los Angeles, CA: University of California Press. Jessor, R. & Jessor, S.L. (1977). Problem Behaviour and Psychosocial Development: A Longitudinal Study. New York, NY: Academy Press. Johnston, L. D., OMalley, P. M., Bachman, J. G. & Schulenberg, J. E. (2008). Monitoring the Future national results on adolescent drug use: Overview of key findings, 2007 (NIH Publication No. 086418). Bethesda, MD: National Institute on Drug Abuse. Johnston, L. D., O'Malley, P. M., Bachman, J. G. & Schulenberg, J. E. (2004). Monitoring the Future national survey results on drug use, 1975-2003. Volume II: College students and adults ages 19-45 (NIH Publication No. 04-5508). Bethesda, MD: National Institute on Drug Abuse. Johnston, L., Bachmann, G. & OMalley, P. (1999). Monitoring the Future. Ann Arbor: Institute for Social Research. Kandel, D., Johnson, J., Bird, H. & Canino, G. (1997). Psychiatric disorders associated with substance use among children and adolescents: findings from the Methods for the Epidemiology of Child and Adolescent Mental Disorders (MECA) Study. Journal of Abnormal Child Psychology, 25, 121-132. Kelley, H.H. & Thibaut, J.W. (1985). Self-interest, science, and cynicism. Journal of Social and Clinical Psychology, 3, 26-32. Kokkevi A., Nic Gabhainn S., Spyropoulou, M. and the Risk Behaviour Focus Group of the HBSC (2006) Early initiation of cannabis use: A cross-national european perspective. Journal of Adolescent Health, 39(5), 712-719. Koven, R., McColl, M.A., Ellis, P. & Pickett, W. (2005). Multiple risk behaviour and its association with head and neck injuries: a national analysis of young Canadians. Preventive Medicine, 41(1), 240246. Kuendig, H., Delgrande Jordan, M. & Kuntsche, E. (2005). Cannabis et jeunesse: pidmiologie et idologies. Dpendances, 27, 8-10

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Kuntsche, E.N. (2004). Progression of a general substance use pattern among adolescents in Switzerland? Investigating the relationship between alcohol, tobacco, and cannabis use over a 12 year period. European Addiction Research, 10, 118-125. Kuntsche, E. N., Delgrande Jordan, M. & Schmid, H. (2002). Wird Cannabis von 15-Jhrigen in der Schweiz wie Tabak und Alkohol konsumiert? Ein faktorenanalytischer Ansatz [Is cannabis used like tobacco and alcohol among 15-year-olds in Switzerland? A latent variable approach]. Wiener Zeitschrift fr Suchtforschung, 25(4), 17-25. Kuntsche, E. & Delgrande Jordan, M. (2006). Adolescent alcohol and cannabis use in relation to peer and school factors: results of multilevel analyses. Drug and Alcohol Dependence, 84(2), 167-174. Kuntsche, E.N. & Silbereisen, R.K. (2004). Parental closeness and adolescent substance use in single and two-parent families in Switzerland. Swiss Journal of Psychology, 63(2), 85-92. Kuntsche, E., Simons-Morton, B., Fotiou, A., Ter Bogt, T., & Kokkevi, A. (in press). Decrease in adolescent cannabis use from 2002 to 2006 and links to evenings spent out with friends in 31 European and North America countries and regions. Archives of Pediatrics and Adolescent Medicine. Macleod, J., Oakes, R., Copello, A., Crome, I., Egger, M., Hickman, M., et al. (2004). Psychological and social sequelae of cannabis and other illicit drug use by young people: a systematic review of longitudinal, general population studies. The Lancet, 363, 1579-1588. Monshouwer, K., Van Dorsselaer, S., Verdurmen, J., Ter Bogt, T., De Graaf, R. & Vollebergh, W. (2006). Cannabis use and mental health in secondary school children: findings from a Dutch survey. British Journal of Psychiatry, 188, 148-153. Moore, T. H. M., Zammit, S., Lingford-Hughes, A., Barnes, T. R. E., Jones, P. B., Burke, M., et al. (2007). Cannabis use and risk of psychotic or affective mental health outcomes: a systematic review. Lancet, 370(9584), 319-32. Mullan, E. & Nic Gabhainn, S. (2003). Self-esteem and health risk behaviour: Is there a link? Irish Journal of Psychology, 23(1-2), 27-36. Navarro, F.J., Piette, D., Maes, L., Peeters, R., Prvost, M., Stevens, A.M. & de Smet, P. (1996). La consommation de drogues chez les jeunes de l'einseignement secondaire de Belgique: diffrences Nord-Sud. Revue d'Epidmiologie et de Sant Publique, 44, 395-406. Nic Gabhainn, S. (2000). Meaning and Measurement in Health Promotion Strategies to combat substance abuse. In C. Kelleher & R. Edmundson (Eds.) Health Promotion: Multidiscipline or New Discipline. Dublin: Irish Academic Press. Nic Gabhainn, S. & Franois, Y. (2000). Substance use. In C. Currie, K Hurrelmann, W. Settertobulte, R. Smith & J. Todd (Eds.) Health and Health Behaviour among Young People, pp. 97-114. Copenhagen: World Health Organization, Regional Office for Europe. Nic Gabhainn, S. & Walsh, F. (2000). Drug prevention: Perspectives on family and community interventions. In P. Dolan, J. Canavan & J. Pinkerton (Eds.) Family Support: Direction from Diversity. London: Jessica Kingsley. Oetting, E.R. & Donnermeyer, J.F. (1998). Primary socialization theory: The etiology of drug use and deviance. Substance Use and Misuse, 33, 995-1026. Patton, G.C., Coffey, C., Carlin, J.B., Degenhardt, L., Lynskey, M. & Hall, W. (2002). Cannabis use and mental health in young people: cohort study. British Medical Journal, 325, 1195-1198. Petraitis, J., Flay, B.R. & Miller, T.Q. (1995). Reviewing theories of adolescent substance use: organizing pieces in the puzzle. Psychological Bulletin, 117(1), 67-86. Pickett, W., Schmid, H., Boyce, W.F., Simpson, K., Scheidt, P., Mazur, J., Molcho, M., Godeau, E., Aszmann, A., Overpeck, M. & Harel, Y. (2002). Multiple risk behaviours and injury: an international study of youth in 12 countries. Archives of Pediatrics & Adolescent Medicine, 156, 786-793. Shedler, J. & Block, J. (1990). Adolescent drug use and psychological health: a longitudinal enquiry, American psychologist, 45, 612-630. Simons-Morton, B.G. & Farhat, T. (2008). Recent findings on peer group influences on adolescent substance use. Paper presented at the Duke University Trans-disciplinary Prevention Research

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Center Conference, Reducing Substance Use Initiation Among Adolescents: An Interdisciplinary Conversation, Durham, NH, October, 2008. Simons-Morton, B.G., Pickett, W., Boyce, W., Ter Bogt, T.F.M. & Vollebergh, W. (in press) Cross-national comparison of adolescent drinking and cannabis use in the United States, Canada, and the Neterlands. International Journal of Drug Policy. Schmid, H. (2001). Cannabis use in Switzerland: The role of attribution of drug use to friends, urbanization and repression. Swiss Journal of Psychology, 60(2), 99-107. Schmid, H., & Ter Bogt, T. (2004). Cross national comparison of cannabis use among adolescents - Does context make a difference? Psychology & Health, 19, 153-154. Simpson, K., Janssen, I., Boyce, W. & Pickett, W. (2006). Risk taking and recurrent health symptoms in Canadians adolescents. Preventive Medicine, 43(1), 46-51. Smit, F., Bolier, L. & Cuijpers, P. (2004). Cannabis use and the risk of later schizophrenia: a review. Addiction, 99(4), 425-430. Ter Bogt T. (2000) De geschiedenis van jeugdcultuur en popmuziek [On the history of youth culture and pop music]. In: T. Ter Bogt & B. Hibbel (eds.), Wilde Jaren [Wild Years] ( pp. 24130) Utrecht: Lemma. Ter Bogt, T., Engels, R., Hibbel, B., Van Wel, F. & Verhagen, S. (2002). Dancestasy: Dance and MDMA use in the Netherlands. Contemporary Drug Problems, 29, 157-181. Ter Bogt, T., Schmid, H., Nic Gabhainn, S., Fotiou, A., Vollebergh, W. (2006). Economic and cultural correlates of cannabis use among mid-adolescents in 31 countries. Addiction, 101, 241-251. Terry, D.J., Hogg, MA. & White, K. M. (2000). Attitude-behavior relations: social identity and group membership. In D.J. Terry & M.A. Hogg (Eds.) Attitudes, behavior and social context: the role of norms and group membership (pp. 47-66). Mahway, NJ: Erlbaum. Van Os, J., Bak, M., Hanssen, M., Bijl, R.V., De Graaf, R. & Verdoux, H. (2002). Cannabis use and psychosis: a longitudinal population-based study. American Journal of Epidemiology, 156, 319327. White, H.R. (1996). Empirical validity of theories of drug abuse: Introductory comments. Journal of Drug Issues, 26(2), 279-288. Zammit, S. Allebeck, P., Andreasson, S., Lundberg, I. & Lewis, G. (2002). Self-reported cannabis use as a risk factor for schizophrenia in Swedish conscripts of 1969: Historical cohort study. British Medical Journal, 325, 199-1201.

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II.5.8 Medicine use (Optional package)


Anderesen, A, Holstein, B and the Medicine Writing Group

1. Scope and purpose


Medicine use for common complaints among children and adolescents is an important and understudied kind of health behaviour. The use of medicines for aches and psychological problems is frequent among adolescents (Hansen et al. 2003a, Schmid 2000, Perquin et al. 2000, Silva / Giugliani 2004) and increasing over time (Hansen et al. 2003b, Holstein et al. 2003, Holstein et al. 2009, Tomas et al. 2006). Appropriate medicine use may contribute to public health but medicines are toxic and may have harmful side effects (Silva / Giugliani 2004). Pain relieving medicine may cause liver damage (Partiff ed. Martindale 1999, Sweetman ed. Martindale 2004), gastro-intestinal bleeding (Sweetman ed. Martindale 2004) and medication-overuse headache (Diener / Limmroth 2004, Ferrari et al. 2005). The use of tranquilizers and hypnotics may result in misuse and dependence (Partiff ed. Martindale 1999, Sweetman ed. Martindale 2004). The most commonly used drugs for deliberate self-poisoning among children and adolescents are analgesics (Borna et al. 2001, Hawton et al. 1996, Hawton et al. 2003, Townsend et al. 2001). Furthermore, medicine use is associated with smoking and alcohol use among adolescents and may be part of a cluster of risk behaviours (Andersen et al. 2006). Medicine use tracks from childhood to adulthood (Andersen et al. in press). And finally, there is the risk to public health of inappropriate or misuse of antibiotics leading to the development of resistant strains of bacteria (McGown / Tenover 1997). There are many problems associated with medicine use among children and adolescents: Parents are the most important source of supply of medicine to young adolescents (Holstein et al. 2008) but many adolescents and parents know very little about medicines (Hameen-Anttila 2006, Stoelben et al. 2000). Allotey et al. (2004) show that many parents provide their children with pain relieving medicine and one of the main reasons was to control their behaviour if they were annoying and to reduce the inconvenience of having sick children. However, it is possible to improve medicine use habits: children and their parents respond positively to interventions to promote a better use of medicines in children (Costello et al 2004). Children also show considerable autonomy in their medicine use; in some cases older siblings may provide medicines to younger siblings with little parent supervision (Iannotti / Bush 1992).
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In general, little is known about young peoples medicine use and HBSC is the main international source of data on medicine use among adolescents. HBSC focuses on use of medicine as a kind of health related behaviour. The focus is not on the content of therapeutic substances and we do not separate between Over-The-Counter (OTC) medicine and prescribed medicine, or between regular medicine and phyto-therapeutic or homeopathic medicine, as the meaning of the behaviour is the same.

2. Objectives
The objectives of our research are 1) to monitor medicine use within and across countries and 2) to increase insight into the processes which influence young peoples medicine use.

3. Theoretical framework
Research on medicine use behaviour is scarce and there are no formal theories on this issue. Two theoretical perspectives seem to be appropriate for the study of medicine use in childhood and adolescence, a psychological approach which focuses on individual factors and a sociological approach pointing to explanatory factors in the wider socio-cultural environment. The psychological approach includes the same kind of explanatory factors as we know from theory on other kinds of health behaviour, e.g. norms, attitudes, perceived control, intention, expectations, modeling, and personal resources (Bush / Iannotti 1990). A qualitative study among teenage girls showed a negative attitude to the use of medicine (Hansen et al. in press). At the same time, medicine use is a way to gain control over a busy everyday life, i.e. to prevent a headache that interferes with a desire to perform well in school and participate in highly valued activities with friends (Hansen et al. 2008). It is very likely that young peoples medicine use reflects a modeling of parents and friends medicine use (Hansen et al. in press, Maiman et al. 1986, Pelissolo et al. 2001). Medicine use can be considered as a kind of coping response to stressors which is not always appropriate (Allotey et al. 2004, Dyb et al. 2006). One example of coping and medicine use is a recent study of the association between sense of coherence (SOC) and medicine use. SOC is an individual attribute which influences the way one copes with stressors (Antonovsky 1987, 1993) and high SOC appeared to be associated with a low probability of using medicine in case of headache (Koushede / Holstein in press).

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The sociological approach focuses on how structural features of the society influence behaviour. There is a socio-economic patterning of medicine use even in childhood and adolescence but the association between socio-economic background and medicine use varies by therapeutic group (Henricson et al. 1998, Holstein et al. 2004, Tobi et al. 2003). Further, it is likely that medicine use is sensitive to policies which control the availability and accessibility of medicine, e.g. price level, marketing, number of pharmacies, the demarcation line between prescription medicine and OTC medicine. Cultural factors, such as the role of media and a promedicalising (or helthicising) public discourse may also affect the normalization of medicine prescribing practices and use (Seale et al. 2007). Even macro-economic factors such as gross domestic product and income distribution may influence the pattern of medicine use in a population.

4. Summary of previous work


Questions on medicine use were part of the mandatory HBSC-items from the very beginning of the 1980s to the 1997/1998 study. The items were omitted in the 2001/02 study and included again as an optional package in the 2005/06 study, adopted by 19 countries. The HBSC study has provided new information on adolescents medicine use: a) There are huge variations in medicine use across the countries, variations that until now remain un-explained (Hansen et al. 2003a). b) There is a consistent gender patterning of medicine use across all countries: Girls use more medicine for pains than boys. Across the age groups 11, 13, and 15 there is an increasing excess use of medicine among girls for all four symptoms studied in HBSC (Hansen et al. 2003a). Within the same age interval the prevalence of medicine use for psychological problems changes from being higher among boys to being higher among girls. c) There has been a large increase in medicine use in many countries (Hansen et al. 2003b, Holstein et al. 2003, Holstein et al. 2009). The reason for this increase is not known but it cannot be explained by increased symptom prevalence. d) Medicine use is associated with health. The strongest predictor of medicine use is the complaint for which the medicine is used, showing odds ratios for use between 4 and 8 (Due et al. 2007). Also poor self-rated health is a predictor of medicine use, even in

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multivariate analyses adjusted for the prevalence of the complaint for which the medicine is used (Holstein et al. 2008). e) Medicine use may be considered a kind of risk behaviour as it is associated with smoking and alcohol use (Andersen et al. 2006). This association is strong, even after control for the prevalence of the symptom for which the medicine is taken. f) Medicine use among adolescents is sensitive to a range of psychosocial and social factors and can be interpreted as a response to strain, e.g. low socioeconomic position (Holstein et al. 2004), exposure to bullying (Due et al. 2007), stressors in the school environment (Larsen et al. submitted, Osterbye et al. submitted), and belonging to an ethnic minority (Holstein et al. 2005). A recent study showed that the high SOC is associated with low odds of medicine use for headache (Koushede / Holstein in press).

5. Research questions
We propose to continue the research which has already been carried out and to answer the following research questions: 1. Is the prevalence of medicine use increasing and if so, how can this increase be explained? Do changes over time vary across gender, age group and country? 2. What pattern of associations exists between medicine use and other measures of health and illness behaviour? Does this pattern vary across gender, age group and country? 3. To what degree are biological factors such as gender, age, menarche, BMI and symptoms predictive of medicine use? 4. Are the children who have high levels of symptoms and low use of medicine different from the others? Are the children who have low levels of symptoms and high use of medicine different from the others? 5. To what degree are psychosocial and social factors predictive of medicine use? 6. Are cultural factors such as ethnicity, religion, population group, and the urban-rural dimension predictive of medicine use? 7. What country level factors could explain differences in prevalence of medicine use between different countries? And do differences in personal factors remain the same when country level factors are taken into account?
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6. Instruments
It is a difficult task to measure medicine use. Apart from chemical analyses of blood and urine there are three sources of data about medicine use in population studies: prescription studies, sales statistics, and self-reports (Nielsen 2004): Prescription studies have a high reputation among pharmacologists but they do not inform us about how much of the prescribed medicine is used and by whom. Moreover, prescription studies do not include OTC medicine. Sales statistics may include OTC medicine but do not inform us about who buys and uses the medicine and for which symptoms. Self-reports provide the possibility of combining information of which medicine is used for which symptoms by which individuals. The validity of self-reports has been questioned but two new validation studies of the HBSC-items on medicine use suggest that the validity is good: Andersen et al. used data from the HBSC Parent Child Validation study (Krolner et al. 2005) to examine the agreement between adolescents self reports and parents reports on adolescents medicine use. The agreement was high (Andersen et al. 2007). Tulinius (2004) conducted qualitative interviews about medicine use with 11-, 13- and 15-year old students who had just answered the HBSC questionnaire and found that the students were able and willing to report medicine use and that their responses were correct. The item box shows the items on medicine use from the 2005/06-survey which we recommend used unchanged in the 2009/10-survey. Item box 1
PH2.1 During the last month, have you taken any medicine or tablets for the following? No Headache Stomach-ache Difficulties in getting to sleep Nervousness Something else
1 1 1 1 1

Yes, once
2 2 2 2 2

Yes, more than once


3 3 3 3 3

Source: HBSC 1997/98 (mandatory), 2005/06 (optional package)

7. References
Allotey P, Reidpath DD, Elisha D. "Social medication" and the control of children: a qualitative study of over-the-counter medication among Australian children. Pediatrics 2004; 114: e378-e383. Andersen A, Holstein BE, Due P, Hansen EH. Tracking medicine use from age 15 to 27: longitudinal study. Pharmacoepidemiol Drug Saf 2009, in press.

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Andersen A, Holstein BE, Hansen EH, Due P. Is medicine use in adolescence risk behaviour? Crosssectional survey of school-aged children from 11 to 15. J Adolescent Health 2006; 39: 362-6. Andersen A, Krlner R, Holstein BE, Due P, Hansen EH. Medicine use among 11- and 13-year-olds: agreement between parents reports and childrens self-reports. Ann Pharmacother 2007; 41: 581-6. Antonovsky A. The structure and properties of the sence of coherence scale. Soc Sci Med 1993; 36: 725733. Antonovsky A. Unravelling the mystery of health. San Francisco: Jossey-Bass; 1987. Borna P, Ekedahl A, Alsen M, Traskman-Bendz L. Self-poisonings with drugs by adolescents in the Lund catchment area. Nord J Psychiatry 2001; 55:325-8. Bush PJ, Iannotti RJA. children's health belief model. Medical Care 1990;28:69-86. Costello I, Wong ICK, Nunn AJ. A literature review to identify interventions to improve the use of medicines in children. Child: Care Health Dev 2004; 30: 647-65. Diener HC, Limmroth V. Medication-overuse headache: a worldwide problem. Lancet neurol 2004; 3: 475-83 Due P, Hansen EH, Merlo J, Andersen A, Holstein BE. Is victimization of bullying associated with medicine use among adolescents: cross-sectional survey in Denmark. Pediatrics 2007; 120: 110-7. Dyb G, Holmen TL, Zwart JA. Analgesic overuse among adolescents with headache: The Head-HUNTYouth study. Neurology 2006; 66: 198-201. Ferrari A, Ottani A, Bertoloin A, Cicero AFG, Coccia CPR, Leone S, Sternieri E. Adverse reactions related to drugs for headache treatment: clinical impact. Eur J Clin Pharmacol 2005; 60: 893-900. Hmeen-Anttila K, Juvonen M, Ahonen R, Bush PJ, Airaksinen M. How well can children understand medicine related topics? Patient Educ Councel 2006; 60: 171-8. Hansen DL, Hansen EH, Holstein BE. Using analgesics as tools: young womens treatment for headache. Qualitative Health Res 2008; 18: 234-43. Hansen DL, Hansen EH, Holstein BE. Young women's use of medicines: Autonomy and positioning in relation to family and peer norms. Health, in press. Hansen EH, Holstein BE, Due P, Currie CE. International survey of self-reported medicine use among adolescents. Ann Pharmacother 2003a; 37: 361-6. Hansen EH, Holstein BE, Due P. Time trends in medicine use among adolescents in ten industrialised countries. Eur J Public Health 2003b; 13 (SUPPL): 43 (2003b). Hawton K, Faggs J, Simkin S. Deliberate self-poisoning and self-injury in children and adolescents under 16 years of age in Oxford, 1976-1993. Br J Psychiatry 1996; 169: 202-8. Hawton K, Hall S, Simkin S, et al. Deliberate self-harm in adolescents: a study of characteristics and trends in Oxford, 1990-2000. J Child Psychol Psychiatry 2003; 44: 1191-1198. Henricson K, Stenberg P, Rametsteiner G, Ranstam J, Hanson BS, Melander A. Socioeconomic factors, morbidity and drug utilization an ecological study. Pharmacoepidemiol and Drug Saf 1998; 7: 261-7. Holstein BE, Andersen A, Hansen EH og Due P. Childrens and adolescents medicine use for aches and pshycological problems: secular trends 1988-2006 (in Danish: Brns og unges brug af lgemidler mod smerter og psykologiske problemer: Udviklingen fra 1988 til 2006). Ugeskr laeger 2009; 171: 24-6. Holstein BE, Andersen A, Krlner R, Due P, Hansen EH. Children's use of medicine for headache: sources of supply and availability and accessibility at home. Pharmacoepidemiol Drug Saf 2008; 17: 40610. Holstein BE, Hansen EH, Andersen A, Due P. Self-rated health as predictor of medicine use in adolescence. Pharmacoepidemiol Drug Saf 2008; 17: 186-92. Holstein BE, Hansen EH, Due P, Almarsdttir A. Medicine use among 11- to 15-year-old girls and boys in Denmark 1988 to 1998. Scand J Public Health 2003; 31: 334-41. Holstein BE, Hansen EH, Due P. Social class variation in medicine use among adolescents. Eur J Public Health 2004, 14: 49-52.

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Holstein BE, Hansen EH. Self-reported medicine use among adolescents from ethnic minority groups. Eur J Clin Pharmacother 2005; 61: 69-70. Iannotti RJ, Bush PJ. The development of autonomy in children's health behaviors. Pp 53-74 in Susman EJ, Feagans LV, Ray W, eds. Emotion, cognition, health, and development in children and adolescents. Hillsdale, NJ: Lawrence Erlbaum; 1992. Koushede V, Holstein BE. Sense of Coherence and medicine use for headache among adolescents. J Adolesc Health 2009, in press. Krlner R, Andersen A, Holstein BE, Due P. Child-parent agreement on socio-demographic measurements in the HBSC-survey - a validity study in six European countries. Copenhagen: University of Copenhagen, Institute of Public Health, Department of Social Medicine, 2005. Larsen T, sterbye T, Hansen EH, Holstein BE. School related stressors and adolescents' use of medicine for nervousness: national representative survey. Submitted. Maiman LA, Becker MH, Katlic AW. Correlates of mothers use of medications for their children. Soc Sci Med 1986; 22: 41-51. McGowan JE & Tenover FC, Control of antimicrobial resistance in the health care system. Infect Dis Clin North Am 1997;11:297-311. Nielsen MW. Studies on medicine use and socio-economic position at the population level (PhD-thesis). Copenhagen: Danish University of Pharmaceutical Sciences, Dept. of Social Pharmacy, 2004. sterbye T, Larsen T, Hansen EH, Holstein BE. School-related stressors and medicine use for headache among adolescents. Submitted. Parfitt K, ed. Martindale. The complete drug reference. 32nd ed., London: The Pharmaceutical Press, 1999. Plissolo A, Gourion D, Notides C, Bouvard M, Lpine JP, Mouren-Simoni MC. Familial factors influencing the consumption of anxiolytics and hypnotics by children and adolescents. Eur Psych 2001; 16: 11-17. Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, Suijlekom-Smit LW, Passchier J, Wouden JC. Chronic pain among children and adolescents: physician consultation and medication use. Clin J Pain 2000; 16: 229-35 Schmid H. Use of medicine among young people (in German: Die Einnahme von Medikamenten bei Jugendlichen). Pp 49-59 in Maffli E, ed. Abuse of medicines in Switzerland (in German: Medikamentenmissbrauch in der Schweiz). Lausanne: SFA-ISPA Press, 2000. Seale C, Boden S, Williams S, Lowe P, Steinberg D. Media constructions of sleep and sleep disorders: a study of UK national newspapers. Soc Sci Med 2007;65:418-30. Silva CH, Giugliani ERJ. Consumption of medicines among adolescent students: a concern. J Pediatr (Rio J) 2004; 80: 326-32. Stoelben S, Krappweiss J, Rssler G, Kirch W. Adolescents' drug use and drug knowledge. Eur J Pediatr 2000; 159: 608-14. Sweetman SD ed. Martindale: the complete drug reference 34th. London: Pharmaceutical Press, 2004. Tobi H, Meijer WM, Tuinstra J, van den Berg LTWJ. Socio-economic differences in prescription and OTC drug use in Dutch adolescents. Pharmacy World Sci 2003; 25: 203-6. Tomas CP. Conrad P, Casler R, Goodman E. Trends in the use of psychotropic medications among adolescents, 1994 to 2001. Psychiatric Services 2006; 57: 63-69. Townsend E, Hawton K, Harriss L, Bale E, Bond A. Substances used in deliberate self poisoning 19851997: trends and associations with age, gender, repetition and suicide intent. Soc Psychiatry Psychiatr Epidemiol 2001; 36: 228-234. Tulinius D. School-children's symptom related medicine use (M.Sc.-thesis) (in Danish: Skolebrns symptomrelaterede lgemiddelanvendelse). Copenhagen: The Danish University of Pharmaceutical Sciences, 2004.

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II.5.9 Sexual health


Godeau, E, Nic Gabhainn, S

1. Scope and purpose


Reproductive and Sexual Health is an integral part of Holistic Health, and comprises the promotion of safe and healthy sexual behaviour, including reproductive choice. Reproductive and Sexual Health has a substantial contribution to make towards meeting the Millennium Development Goals. Indeed, it has been argued that these aspects of health are fundamental to human well being (UN Millenium Project 2006). Attaining mature sexuality is among the many major tasks, both, psychological and physical, inherent in the period of transition between childhood and adulthood. Indeed, sexual health is part of adolescents general, social and personal well-being. It is rooted in a life-long sexual development spanning from early childhood throughout adulthood: sexual health is a process, not a destination. Sexual health is a central component of health for all sections of the population, but the challenges for maximising the sexual health of adolescents are substantial. Across industrialised nations, a relatively high proportion of those leaving compulsory education have already experienced sexual intercourse, and have engaged in sexual risk behaviour (Avery / Lazdane 2007, Godeau et al. 2008). Addressing the sexual health of young people by raising their commitment to safer sex has become a major issue among developed countries (UN Millenium Project 2006, Avery / Lazdane 2007, WHO 2007). The potential risks associated with sexual behaviour among 15 year olds are primarily linked to the emotional and behavioral characteristics of this developmental stage. It is known that early sex has implications for self-perceptions, well-being, social status and future health behaviour (Magnusson / Trost 2006) including sexual behaviour (Fergus et al. 2007). Early sexual initiation can be seen as part of broader risk behaviour clusters including substance use and unprotected sex (Parkes et al. 2007, Eaton et al. 2006, Cooper 2002, Poulin / Graham 2001). The links between early puberty, early sexual initiation and other risk behaviours have also been documented (Kaltiala-Heino et al. 2003, Deadorff et al. 2005). Unprotected and poorly protected intercourse brings the risk of unintended pregnancy with its myriad of possible outcomes for this age group, including abortion, early motherhood and (Ellison 2003). Moreover, for those not employing barrier methods of protection, the risk of sexually

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transmitted infections (STIs) is also present, with serious short- and long-term medical, health and social implications (WHO 2007). Evidence suggests the rates of adolescent pregnancy are decreasing (Avery / Lazdane 2007, American Academy of Pediatrics 2007, Santelli et al. 2007). However, even if in many countries the average ages of coitarche have been decreasing (Bozon / Kontula 1998), there is no universal trend towards earlier sexual intercourse. Rather, there seems to be a shift towards later marriage leading to higher rates of premarital sex; this being more the case in developed countries and among men (Wellings et al. 2006). In many countries and regions there has been a reported rise in sexually transmitted infections (STIs) (Avery / Lazdane 2007, WHO 2008). Thus, while the risk profile may be changing, early and poorly protected sexual intercourse remain of central relevance to public health (Santelli et al. 2007, Anderson et al. 2006, Wellings et al 2001).

2. Objectives
Few studies on sexual behaviour and contraception use among adolescents have been conducted across countries (see Daroch et al. 2001). There has been a comparison in Canada, France, Great Britain, Sweden and the US; and Berne and Huberman (2001) in France, Germany, the Netherlands and the US, but in neither case have the same questions and methods been employed across countries. Since 2002, four standardised questions related to sexual behavior have been added to the core HBSC questions to be asked by all countries to 15 year-olds students (Ross et al. in Currie et al. 2004, Ross et al. 2004a, Ross et al. 2004b). These questions serve the following objectives:
-

To measure the proportion of students initiated into sexual intercourse, and to know at what age they have first engaged in this behaviour.

To measure the level of protected students against pregnancy. To measure the level of protected students against STIs.

3. Theoretical framework
Appropriate contraceptive use for adolescents varies somewhat from that recommended for adults. In some cases this is because the mode of contraception would endanger the reproductive future of the adolescents (e.g. sterilisation, and to some extent IUDs), and in

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other cases because of the general inappropriateness of the method to their developmental stage (e.g. rhythm method). However, the adequacy and effectiveness of each method depends on many interacting factors, some indeed related to the contraceptive itself (e.g. efficacy, availability, cost, convenience) (Department of Child and Adolescent Health and Development 2003), others to the sexual activity (e.g. type of sexual behaviors, frequency of intercourse, risk of STIs), some related to the person and/or partner (e.g. age, ethnicity, culture, religious beliefs, educational level, family characteristics) (Manlove et al. 2004, Saxena et al. 2006, Sieving et al. 2007) and others to the broader context (historical, cultural, religious and social) (Heavey et al. 2008, Sales et al. 2007, Marston / King 2006) and inter-personal relationship dynamics (e.g. duration of relationship, trust, age difference between partners) (Manlove et al. 2007). It has been suggested that failure rates for a given contraceptive may be much higher among adolescents than among adults because of differences in both compliance and capacity to use the method correctly (Department of Child and Adolescent Health and Development 2003, Ornstein / Fisher 2006). However, others have not found such differences in contraceptive failure by age group (Ranjit et al. 2001). Nevertheless, condoms and contraceptive pills are considered the most appropriate methods of protection for most sexually active adolescents, and the use of dual methods both contraceptive pill and condom at the same time confers effective protection against pregnancy and moderately effective protection against STIs (American Academy of Pediatrics 2007). Almost all behaviours can be viewed through gender stereotypes, but in the field of sexual health their current applicability is in question, at least partially. In most of the national and cultural settings in which the HBSC survey is conducted, boys were traditionally ascribed the role of being sexually aware, active, and initiators. In contrast, girls stereotypically were expected to remain unaware of sexual matters as long as possible, passive, and reactive to male sexual initiation. Bozom and Kontula (1998), drawing on data from an integrated European comparative study, found that only in a few countries (Denmark, West Germany and Norway), more women than men report first intercourse prior to 18 years in the younger cohorts while this pattern was not observed amongst the older cohorts (except in Denmark). The 2006 HBSC provides further evidence that these stereotypes are eroding in the majority of participating countries: even if in more than half of countries, boys were more likely than girls to have engaged in sexual intercourse, the difference was significant in only 13 countries. In 13 other countries more girls than boys report having experienced sexual intercourse, significantly so in Wales, Iceland, Finland and Sweden (Currie et al. 2008).

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A categorisation of cultures by their permissiveness regarding adolescent sexuality (Department of Child and Adolescent Health and Development 2003) shows that the majority of the HBSC countries belong to the group of sexually permissive cultures, in that sexuality is tolerated and sexuality among adolescents is considered normal and a valued part of life. A few HBSC countries could be regarded as sexually restrictive cultures, in that the society attempts to limit sexuality and premarital abstinence is expected, at least for women. Finally, several HBSC countries could be perceived as sexually supportive cultures, meaning that sex is seen as indispensable for human happiness, sexuality is encouraged among young people and customs and social structures provide information for responsible behaviour. Links between such societal characteristics and teenage sexual behaviours, teenage pregnancy and abortions have been established by different surveys since the 1980s and tend to show that in general the more open the society to sexual issues, the lower was the teenage birth rate; furthermore, they did not find evidence of substantial differences between countries in the actual levels of sexual activity among young people (Ingham 2007). Moreover, in his analysis of trends in sexual initiation between 1960 and 1995, Teitler found that patterns of youth sexual behaviours are converging across developed countries. The variation within and between countries in the age of sexual debut is narrowing while the influence of social class is becoming less predominant. Finally, it is important to note that within any country or political subdivision, diverse beliefs and patterns (Schmitt et al. 2004, Saxena et al. 2006) about sexual health coexist, thereby increasing the challenges inherent in delivering accurate sexual and reproductive health information and care to all of the adolescent population (Royal College of Obstetricians 2004, Ellison 2003, Department of Child and Adolescent Health and Development 2003, Marston / King 2006, Bearinger et al. 2007). And even if individual behavioural approaches are central to tackle youth sexual health, efforts that address the broader determinants of sexual behaviours are needed, particularly those addressing social context (Wellings et al. 2006), encompassing for example school ethos (Bonell et al. 2007) or parental communication (Sieving et al. 2007, Aspy et al. 2007). HBSC, because of its cross-national and cross-cultural dimensions as well as its broad scope around health determinants of young people has a lot to contribute in understanding the links between such determinants and sexual behaviours of young people, in order to improve their overall sexual health.

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4. Summary of previous work


History of the topic The 1989/90 HBSC study protocol contained an optional module on sexual health that several countries and regions adopted, at least on a once-off basis. This optional package focused on knowledge, attitudes, and a set of behaviours related to the initial expressions of sexuality. In the 1993/94 HBSC study, some countries kept some of those questions either in the same version or with a country-specific perspective, making it impossible to draw cross-national conclusions. In the 1997/98 HBSC study, fewer than half of the participating countries and regions included any questions about sexual health. The questions that were employed varied widely in scope and content; however, a sufficient number of countries (Finland, France, Hungary, Israel, Latvia, Northern Ireland, Poland, Scotland) had adopted some broadly comparable questions that were recoded into standardised categories so as to permit an exploratory, cross-national analysis, which was included in the 1997/98 International Report (Ross / Wyatt 2000). The 2001/02 HBSC study included, for the first time, a set of mandatory questions on sexual health which had been derived from the US Youth Risk Behaviour Survey (YRBS) (Kolbe et al. 1993, Brener et al. 2004, Grunbaum et al. 2002). While mandatory, a country or region was given the opportunity to opt out of these questions in extremis; i.e., if inclusion of these questions was thought likely to jeopardise the entire survey because they were considered too sensitive and/or culturally inappropriate. In an effort to reduce such circumstances, the sexual health questions were recommended for administration only to 15year-old students. Finally, 35 countries and regions asked the questions, and only four did not ask any of them: Denmark, Ireland, Norway, and the United States. It should also be noted that data from Malta had to be excluded from all analysis because different wording was used for the four questions. Data from Russia, Italy and the Czech Republic were partially missing as these countries either did not ask certain questions or asked them in a manner that deviated significantly from protocol (Currie et al. 2004). The 2005/06 Study included the same 4 questions, and data from 34i countries were presented in the 2006 international report for ever having sexual intercourse, 31ii for contraceptive pill use and 30iii for condom use (Currie et al. 2008, Nic Gahainn et al. 2008).

Review of previous HBSC work Because there are so few cross-national studies of sexual behaviours and contraception use among adolescents, the Health Behaviour in School-aged Children (HBSC) study enables a

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unique opportunity to examine sexual behaviours across a wide variety of contexts in a systematic, comparable fashion. While at national level, papers could explore sexual health of their students more in depth because of national questions Thomson et al. 1999), the first international comparative papers gave an overview of sexually initiated students across Europe and Northern America (Ross et al. 2004a, Ross et al. 2004b, Woynarowska et al. 2004). Later papers focused on contraception use, a topic where indeed the data is sparse Godeau et al. presented comparative data from the 2001/02 HBSC survey, with data on well and poorly protected students across 24 countries (Godeau et al. 2008). They found that a substantial minority of 15 year olds had engaged in sexual intercourse, and that condoms were the most frequent method of contraception at last intercourse reported by the sexually active respondents, followed by the dual use of condoms and contraceptive pills, and contraceptive pill only. However, the proportion of poorly and unprotected youth remained relatively high; a finding particularly relevant to inform prevention practice, both within countries and crossnationally. Lazaruss multilevel analysis conducted on the 2002 data (Lazarus et al. in press) suggests that while alcohol, gender, human development level, income, religion and HIV prevalence affect condom use in young Europeans, these factors do not explain all the variation. Nonetheless, since some of these factors are not traditionally associated with young peoples sexual and reproductive health, these findings should enable more nuanced health policy programming. The international report of the 2005/06 HBSC study (Currie et al. 2008) presented overall prevalence of ever having had sex and, separately, the use of condoms and contraceptive pill at first intercourse. Nic Gabhainn et als paper (2008) presented the most recent data to date on a wider range of contraception methods reported by sexually active 15 year olds in all 30 countries who asked comparative questions on contraceptive use at last intercourse. Trends between 2002 and 2006 are presented for the 24 countries who asked questions in a comparable fashion in the 2 waves of the survey. Some papers at national level have explored other aspects of sexual behaviours. For example, Godeau et al. (2008), shows among 15 year-olds French girls, that seven variables are significantly and independently linked to a higher frequency of early sexual intercourse (before the age of 15); single-parent or reconstructed family, repeated drunkenness, daily smoking, cannabis experimentation, frequent evenings out, negative life appreciation and early menarche. Such findings can inform professionals to better take care of high-risk adolescent girls.

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5. Research questions
-

Gender gap observed between boys and girls about sexual intercourse in different contexts

Characteristics of students with early sexual debut in different contexts Characteristics of students according to their level and type of protection against pregnancy and STDs

How do sexual risk behaviours relate to other risk taking behaviours? How do sexual protective behaviours relate to other protective behaviours? How does the timing of menarche relate to sexual activity across different countries?

6. Instruments
6.1 Mandatory items
Sexual behaviour is measured by items adopted from the Youth Risk Behaviour Surveillance (YRBS) (Kolbe et al. 1993, Brener et al. 2004, Grunbaum et al. 2002) : sexual experience (ever having had sexual intercourse; age at first sexual intercourse), condom use (having used a condom at last sexual intercourse), and contraceptive use (having used specified methods to prevent pregnancy at last sexual intercourse). The response options on contraceptive use in all countries included condoms, oral contraceptives (birth control pills), withdrawal, and an other option. In addition, countries can use national options. So far countries have asked about emergency contraception (morning after pill); and about natural/biological methods (such as the rhythm method). Four sexual health items are mandatory for the 2009/10 HBSC survey. These four items are largely the same as the four mandatory questions from the 2001/02 and 2005/06 HBSC surveys, to maintain comparability. These four items are to be asked only of students from the 15 year-old age group, because the overwhelming majority of younger adolescents are unlikely to have experienced sexual intercourse and because many schools and parents find such questions too sensitive to ask of younger students. The first mandatory sexual health item is designed to measure the prevalence of sexual intercourse among participating students.

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Item box 1
MQ25 Have you ever had sexual intercourse (sometimes this is called "making love," "having sex," or "going all the way or other appropriate colloquial terms)? Yes No

1 2

Source: Youth Risk Behaviour Survey (YRBS), Centres for Disease Control (CDC), USA. HBSC survey 2001/02, 2005/06.

This question includes parenthetical cues to assist the young person to understand the meaning of the term sexual intercourse. The question does not specify that sexual intercourse is restricted to vaginal intercourse. However, most young people interpret such cues as indicating vaginal intercourse, and refrain from reporting non-vaginal sex as sexual intercourse. Thus, this item results in an underestimation of the population at risk of STIs, but gives a reasonable estimate of the population at risk for pregnancy. Validity studies have shown that adolescents can report accurately whether they have engaged in sexual behaviour (Orr et al. 1997). It also should be noted that, by asking only whether young people had ever had sexual intercourse, the question does not identify those who are currently sexually active and, therefore, immediately at risk of pregnancy and STI. The second question is designed to measure age at first sexual intercourse. Item box 2
MQ26
1 2 3 4 5 6 7 8

How old were you when you had sexual intercourse for the first time? I never had sexual intercourse 11 years old or younger 12 years old 13 years old 14 years old 15 years old 16 years old 17 years old or older

Source: Youth Risk Behaviour Survey (YRBS), Centres for Disease Control (CDC), USA. HBSC survey 2001/02, 2005/06.

The age of initiation question provides pre-coded age categories ranging from 11 years old or younger to 17 years old or older. The ages above 15 years old have been included because many countries select and survey students in intact classrooms containing mixed grades and ages. However, in the international data base, older students will not remain. We recognise that the HBSC study is not the ideal means to assess age at initiation of sexual activity because

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even the oldest participants are in only their sixteenth year of life, when the majority of young people have not yet started to be sexually active. The third and fourth questions are designed to measure contraception use at last intercourse and condom use at last intercourse. The third question was used in the 2002 and in the 2006 HBSC surveys. It is a modified version of the original YRBS question to accommodate the possibility of multiple responses and keep the usual HBSC answering format (NB: the YRBS allows multiple responses in that one of the precoded responses includes condom and birth control pills). The proposed third question also closely resembles a question from the Canadian Youth, Sexual Health and HIV/AIDS study, but the HBSC uses a yes/no format instead of the check all that applies used in the Canadian survey. One of the response options shared by the US YRBS and the Canadian survey, DepoProvera (injectable birth control), has been dropped from the HBSC mandatory response options because it is not relevant for many participating countries, this is also the case for spermicides that are scarcely used in the vast majority of countries. Item box 3
MQ27 The last time you had sexual intercourse, what method(s) did you or your partner use to prevent pregnancy: Mark all that applies I have never had sexual intercourse No method was used to prevent pregnancy YES Birth control pills Condoms Withdrawal (National choice option here) Some other method Not sure
1 1 1 1 1 1

Go to the next question Go to the next question

NO
2 2 2 2 2 2

Source: Youth Risk Behaviour Survey (YRBS), Centres for Disease Control (CDC), USA.Adapted for use in HBSC 2001/02, 2005/06

The fourth question asked in HBSC since 2002 is identical to the one used in the 2005 version of the YRBS and in the Canadian Youth, Sexual Health and HIV/AIDS study, except that a skip pattern exists in the Canadian survey (Boyce et al. 2003).

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Item box 4
MQ28
1 2 3

The last time you had sexual intercourse, did you use a condom? I have never had sexual intercourse Yes No

Source: Youth Risk Behaviour Survey (YRBS), Centres for Disease Control (CDC), USA. HBSC survey 2001/02, 2005/06.

There is a strong argument, based on cognitive testing during the development of the YRBS questionnaire items, to keep the questions on condom use and other forms of contraception separate: asking about STI risk reduction (= condom use) and pregnancy prevention (= condom + other contraceptive means) in separate questions helps to ensure that respondents adequately consider what actions they took on both counts (Morris et al. 1993). Research has shown that adolescents have difficulty in summarising their use of contraceptives, even for short time periods, because their use is not consistent (ididem). Adolescents may use condoms, contraceptive pills or other methods of protection sporadically, depending on the situation and the sexual partner. In addition, if asked about typical behaviour, respondents (both adults and young people) are more likely to bias their answers by describing what they consider to be socially desirable behaviour. Therefore, responses about the last encounter have higher reliability and validity than those on typical behaviour. Results from validity studies of self-reported condom use among adolescents suggest that it is a valid indicator of risk for sexually transmitted infections (Shew et al. 1997). Based on the Canadian experience, it is recommended that this question on condom use is placed after the question on contraception use, in order to minimise inconsistencies and missing responses.

Validation work, pilot tests In anticipation of the 2001/2002 HBSC, 18 sexual health items were proposed and subjected to qualitative pilot-tests in Canada, the Republic of Ireland, and the United States. Approximately half of these questions were derived from the YRBS. The remaining questions were developed based on review and analyses of the 1989/90 sexual health optional package and subsequent adaptations of certain questions in the 1994 and 1997/98 HBSC. A few questions were newly developed. Based on qualitative pilot tests, four mandatory questions and two optional packages were developed for the 2001/02 HBSC. These included all of the YRBS sexual health questions plus several of the questions developed on the basis of earlier HBSC sexual health optional packages.

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The strongest pilot test of the mandatory sexual health questions consisted of test-retest reliability studies periodically conducted on the YRBS. In 1992 and again in 1999 test re-test reliability studies were conducted on the complete YRBS as it existed at these two points in time. The 1999 reliability study was conducted among a sample of 4,619 high school students aged 14-18. The reliability study provided kappa statistics for each of the YRBS sexual health items considered for the HBSC. Because kappa is most commonly used to measure inter-rater reliability (Fleiss 1981), it is unclear what constitutes an adequate level of kappa for behavioural questions, especially because behavioural self-reports can appropriately change from Time 1 to Time 2. Landis and Koch (Landis / Koch 1977) suggest the following qualitative labels for values of kappa: less than 0 percent, poor; 0-20 percent, slight; 21-40 percent, fair; 41-60 percent, moderate; 61-80 percent, substantial; 81-100 percent, almost perfect. As shown below, mean kappa results for the many of the sexual health items were in the substantial or almost perfect ranges (Brener et al. 2002). Results of pilot tests regarding pregnancy prevention are not presented here, as the original question was the following: The last time you had sexual intercourse, what methods did you or your partner use to prevent pregnancy and/or sexually transmitted disease? (circle all that apply).
Question Have you ever had sexual intercourse (sometimes this is called making love, having sex, or going all the way)? How old were you when you had sexual intercourse for the first time? The last time you had sexual intercourse, did you or your partner use a condom? Kappa .90 .88 .78 Score Almost perfect Almost perfect Substantial

Table 1: Reliability of Sexual Health Items

7. References
American Academy of Pediatrics. Contraception and adolesents. Pediatrics 2007; 120: 1135-1148. Anderson JE, Santelli JS, Morrow B. Trends in adolescent contraceptive use, unprotected and poorly protected sex, 1991-2003. Journal of Adolescent Health 2006; 38: 734-739. Aspy CB, Vesely SK, Oman RF, Rodine S, Marshall LD, McLeroy K. Parental communication and youth sexual behaviour. Journal of adolescence 2007; 30: 449-466. Avery L, Lazdane G. What do we know about the sexual and reproductive health of adolescents in Europe? European Journal of Contraception and Reproductive Health Care 2007; 13: 58-70. Barber, JS, Zxinn, WG, Thornton A. Unwanted childbearing, health and mother-child relationships. Journal of Health and Social Behaviour 1999; 40: 231-257. Bearinger LH, Sieving RE, Ferguson J, Sharma V. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention, and potential. Lancet 2007; 369: 12201231.

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Berne L, Huberman B. European approaches to adolescent sexual behavior and responsibility. Washington, DC: Advocate for Youth, 2001. Bonell C., Fletcher A., McCambridge J, Improving school ethos may reduce substance misuse and teenage pregnancy, British Medical Journal, 2007; 334: 614-616. Boyce W, Doherty-Poirier H, Mackinnon D, Fortin C. Canadian Youth, Sexual Health and HIV/AIDS Study: Factors Influencing Knowledge, Attitudes and Behaviours. Toronto, ON, Canada: Council of Ministers of Education, 2003. Bozon M, Kontula O. Sexual initiation and gender in Europe; a cross-cultural analysis of trends in the twentieth century. In Hubert M, Bajos N, Sandfort Th, editors. Sexual Behaviour and HIV/AIDS in Europe. London: UCL Press; 1998. p. 37--67. Brener N D, Kann L, Kinchen ST, Grunbaum J, Whalen L, Eaton D, Hawkins J, Ross JG. Methodology of the Youth Risk Behavior Surveillance System. Morbidity and Mortality Weekly Report 2004; 53 (RR12): 1-16. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 youth risk behaviour survey questionnaire. Journal of Adolescent Health 2002; 31: 336-342. Cooper, M. L.. Alcohol use and risky sexual behaviour among college students and youth: evaluating the evidence. Journal of Studies on Alcohol 2002;, 14 Suppl:101-117. Currie C, Nic Gabhainn S, Godeau E, Roberts C, Smith R, Currie D, Pickett W, Richter M, Morgan A, Barnekow V. (eds.) Inequalities in young people's health: HBSC international report from the 2005/2006 Survey. Copenhagen: WHO Regional Office for Europe, 2008. Currie C, Roberts C, Morgan A, Smith R, Settertobulte W, Samdal O, Rasmussen VR, eds. Young People's Health in Context. Health Behaviour in School-aged Children: international report from the 2001/2002 survey. Copenhagen, WHO Health Policy for Children and Adolescents, No. 4, 2004, pp 153-160. Darroch JE, Frost JJ, Singh S, and the study team. Teenage sexual and reproductive behavior in developed countries: can more progress be made?, Occasional report n 3, November, The Alan Guttmacher, Institute, New York and Washington, 2001. Deadorff J, Gonzales NA, Christopher S, Roosa M; Millsap RE, Early puberty and adolescent pregnancy: the influence of alcohol use. Pediatrics 2005; 166(6): 1451-1456. Department of Child and Adolescent Health and Development. Contraception, issues in adolescent health and development, Copenhagen: WHO office for Europe, 2003. Eaton DK, Kann L, Kinchen S, Ross J, Hawkins J, Harris WA et al. Youth risk behavior surveillance - United States, 2005. MMWR Surveill Summ 2006; 55: 1-108. Ellison MA. Authoritative Knowledge and single womens unintentional pregnancies, abortions, adoptions, and single motherhood: social stigma and structural violence. Medical Anthropology Quarterly 2003; 17: 322-347. Fergus S, Zimmerman MA, Caldwell CA. Sexual Risk Behavior in Adolescence and Young Adulthood, American Journal of Public Health 2007; 97(6): 1096-101. Fleiss JL. Statistical methods for rates and proportions. New York: Imprenta,1981. Godeau E, Nic Gabhainn S, Vignes C, Ross J, Boyce W, Todd J. Contraceptive use by 15-year-old students at their last sexual intercourse - results from 24 countries, Archives of Pediatric and Adolescent Medicine 2008; 162(1): 66-73. Godeau E, Vignes C, Duclos M, Navarro F, Cayla F, Grandjean H. Facteurs associs une initiation sexuelle prcoce chez les lles : donnes franaises de lenqute internationale Health Behaviour in School-aged Children (HBSC)/OMS, Gyncologie Obsttrique & Fertilit 2008 ; 36: 176-182. Grunbaum J, Kann L, Kinchen S A, Williams B, Ross JG, Lowry R, Kolbe L. Youth Risk Behavior SurveillanceUnited States, 2001. Morbidity and Mortality Weekly Report 2002; 51(SS-4): 1-64. Heavey EJ, Moysich KB, Hyland A, Druschel CM, Sill MW. Differences in contraceptive choice among female adolescents at a state funded family planning clinic. Journal of Midwifery and Womens Health 2008; 53: 45-52.

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Ingham R.Variations across countries the international perspective in Baker, P., Guthrie, K., Hutchinson, C., Kane, R. and Wellings, K. (eds.) Teenage Pregnancy and Reproductive Health, London: Royal College of Obstetricians and Gynaecologists, 2007. Kaltiala-Heino R, Kosunen E, Rimpel M. Pubertal timing, sexual behaviour and self-reported depression in middle adolescence. Journal of Adolescence 2003; 26: 531-545. Kolbe LJ, Kann L, Collins JL. Overview of the Youth Risk Behavior Surveillance System. Public Health Reports 1993; 108 (Supplement 1): 210. Kroelinger CD, Oths KS. Partner support and pregnancy wantedness. Birth 2000; 27; 112-19. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics 1977; 33 (1): 159-74. Lazarus J, Moghaddassi M, Godeau E, Ross J, Vignes C, stergren PO, Liljestrand J, A multilevel analysis of condom use among adolescents in the European Union, Public Health, in press 2009. Magnusson C, Trost K. Girls experiencing sexual intercourse early: could it play a part in reproductive health in middle adulthood? Journal of Psychosomatic Obstetrics and Gynaecology 2006; 27: 237244. Manlove J, Ryan S, Franzetta K. Contraceptive use and consistency in US teenagers most recent sexual relationships. Perspectives on Sexual and Reproductive Health 2004; 36(6): 265-275. Manlove JS, Ryan S, Franzetta K. Risk and protective factors associated with the transistion to a first relationship with an older partner, Journal of Adolescent health, 2007; 40: 135-143. Marston C, King E. Factors that shape young peoples sexual behaviour: a systematic review. Lancet 2006; 368: 1581-1586. Morris L, Warren CW, Aral SO. Measuring adolescent sexual behaviors and related health outcomes. Public Health Reports 1993; 108 (Supplement 1): 3136. Nic Gabhainn S, Godeau E, Baban A, Boyce W and the HBSC sexual health behaviour focus group. How well protected are sexually active 15 year olds across Europe and Canada? Data from the 2006 WHO-HBSC study, International Journal of Public Health 2008 (forthcoming?). Ornstein RM, Fisher MM. Hormonal contraception in adolescents: special considerations, Paediatric Drugs 2006; 8(1): 25-45. Orr DP, Fortenberry JD, Blythe M. Validity of self-reported sexual behaviors in adolescent women using biomarker outcomes. Sexually Transmitted Diseases 1997; 24: 261266. Parkes AP, Wight D, Henderson M, Hart G, Explaining association between adolescent substance use and condom use, Journal of Adolescent Health 2007; 40(3): 180.e1-180.e18. Poulin C, Graham L, The association between substance use, unplanned sexual intercourse and other sexual behaviours among adolescent studets, Addiction 2001; 96: 607-621. Ranjit N, Bankole A, Darroch JE, Singh S. Contraceptive failure in the first two years of use: differences across socio-economic subgroups, Family Planning Perspectives 2001; 33(1): 19-27. Ross J, Godeau E, Dias S, Vignes C, Gross L. Setting politics aside: sexual health in young people findings from the HBSC study. SEICUS Report 2004; 32(4): 28-34. Ross J, Godeau E, Dias S. Sexual health in young peopleFindings from the HBSC study. Entre Nous 2004a; 58: 20-23. Ross J, Godeau E, Dias S. Sexual health. In: Currie C, Roberts C, Morgan A, Smith R, Settertobulte W, Samdal O, Rasmussen VR, (eds.) Young People's Health in Context. Health Behaviour in Schoolaged Children: international report from the 2001/2002 survey. Copenhagen, WHO Health Policy for Children and Adolescents, No. 4, 2004b, pp 153-160. Ross J, Wyatt W. Sexual Behaviour. In: C Currie, C Hurrelman, W Settertobulte, R Smith, J Todd, Health and Health Behaviour among Young People: Health Behaviour in School-aged Children: A WHO cross-national study (HBSC) International Report. Copenhagen: WHO Regional Office for Europe, 2000. Royal College of Obstetricians and Gynaecologists. The care of women requesting induced abortion. 2004. RCOG evidence-based clinical guideline 7. Available at http://www.rcog.org.uk/index.asp?PageID=662 (accessed on 25 June 2008).

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Sales JM, DiClemente RJ, Rose ES, Wingood GM, Klein JD, Woods ER. Relationship of STD related shame and stigma to female adolescents condom protected intercourse. Journal of Adolescent Health 2007; 40: 573.e1-573.e6. Santelli JS, Lindberg LD, Finer LB, Singh S. Explaining declines in adolescent pregnancy in the United States: the contribution of abstinence and improved contraceptive use. American Journal of Public Health 2007; 97: 150-156. Saxena S, Cpas AJ, Mercer C. et al. Ethnic vairations in sexual activity and contraceptive use: national cross-sectional servey, Conrtaception 2006; 74; 224-233. Schmitt DP, Alcalay L, Allensworth M, Allik J, Ault L, Austers I. Patterns and universals of adult romantic attachment across 62 cultural regions: are models of self and of other pancultural constructs? Journal of Cross-Cultural Psychology 2004; 35: 367-402. Shew ML, Remafedi GJ, Bearinger LH, Faulkner PL, Taylor BA, Potthoff SJ, Resnick MD. The validity of self-reported condom use among adolescents. Sexually Transmitted Diseases 1997; 24: 503-510. Sieving, RE, Bearinger LH, Resnick MD, Pettingell S, Skay C. Adolescent dual method use: relevant attitudes, normative beliefts and self-efficacy. Journal of Adolescent Health 2007; 40: 15-22. Teitler JO. Trends in youth sexual initiation and fertility in developed countries: 1960-1995, the annals of the American Academy of Political and Social Science 2002; 580: 134-152. Thomson C, Currie C, Todd J, Elton R. Changes in HIV/AIDS education, knowledge and attitudes among Scottish 15-16 year olds, 1990-1994: findings form the WHO: Health Behaviour in School-aged Children Study (HBSC). Health Education Research 1999; 14: 357-370. UN Millennium Project. Public choices, private decisions: sexual and reproductive health and the millennium development goals. New York: United Nations Development Project, 2006. Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N. Sexual behaviour in context: a global perspective. Lancet 2006; 368: 170628. Wellings K, Nanchahal K, Macdowell W, McManus S, Erens B, Mercer CH, Johnson AM, Copas AJ, Korovessis C, Fenton KA, Field J. Sexual behaviour in Britain: early heterosexual experience. Lancet 2001; 358: 1843-1850. World Health Organisaion. Global strategy for the prevention and control of sexually transmitted infections: 2006-2013: Breaking the chain of transmission. Geneva, World Health Organisation, 2007. World Health Organisation. Centralised information system for infectious diseases (CISID) [online]. Available from: http://data.euro.who.int/cisid/. (accessed 17 June 2008). Woynarowska B, Izdebski Z, Kololo H, Mazur J. Sexual initiation and use of condoms and other methods of contraception among 15-year-old adolescents in Poland and other countries. Ginekologia Polska 2004; 75: 621-632.

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II.5.10 Injuries
Molcho, M, Picket, W, Harel, Y, Aasvee, K, Varnei, D

1. Scope and purpose


With advances in hygiene and the control of infectious diseases in the developed world during the latter half of the 20th century, injuries have emerged as the largest cause of death in children and youth beyond one year of age (National Center for Health Statistics-World Health Organization, 2000). It is estimated that injuries account for 36% of deaths in children under 15 years (WHO 2006), and 23% of deaths among under 19 years (Valent et al. 2004). Not all injuries result in death. In fact, it is estimated that for every death, injuries send 30 people to hospital and 300 others to Emergency Departments for outpatient treatment and many more are treated in the community (Sethi et al. 2006, WHO 2006). Injuries that do not result in death may have a short or long term effects on the health of the injured person, often leaving one with disability. Injuries account for 19% of the Disability-Adjusted-Life-Year lost among 019 year olds (Valent et al. 2004). However, injuries are now regarded as largely preventable (Peden et al. 2002), with an estimated two out of three deaths and most non-fatal injuries can be prevented (Sethi et al. 2006, WHO 2006). The risk for injury rises dramatically during adolescence. As the greatest single cause of death and serious morbidity to youth in most developed countries, the study of factors that influence the health of adolescents must include the assessment of injuries, injury circumstances and factors that affect the risk for injury. Understanding the mechanisms and causal factors that result in injury morbidity is necessary to contribute to the development of interventions to control and prevent serious injuries and death in youth (Scheidt 1998, Holder et al. 2001, Sethi et al. 2006). The conceptual frameworks for injury prevention, reviewed by Andersson and Menckel (1995), are based on the public health principles of prevention and systematic analyses of factors contributing to the outcome of injury. Perhaps most well known, Haddons model of agents (host-vector-environment) and phases (pre-event, event, post-event) reflects the heterogeneity of injuries and the importance of event specific information to guide the development of interventions (Haddon 1980). Thus epidemiological and surveillance data are the cornerstone of successful injury prevention efforts (Holder et al. 2001, Zimmermann / Bauer 2003). Injury is arguably the leading acute health problem among adolescents in most developed countries. Injury can also be viewed as a marker for a high risk adolescent lifestyle that
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includes multiple risk-taking behaviours and experimenting and associated health consequences (Jessor / Jessor 1990, Michaud 1999). Medical and other consequences associated with injury impose a significant burden on society. The assessment of injury, and its immediate causes and effects, is an important component of the HBSC survey and indeed, to policy makers. Another aspect of injury is intentional injury, and primarily, suicides. Suicide and suicide ideation have been recognized as topics of contemporary importance for adolescent populations. In the United States there has been an emerging public concern over the escalating rates of suicide among youth people (US Public Health Service 1999). As many as 9% of young adults in some parts of the US population attempt suicide over a one year period (Grunbaum et al. 2004), and completed suicide accounts for more deaths among young adults than all other leading natural causes of death, including cancer, heart disease, AIDS and congenital defects (US Public Health Service 1999). Suicide attempts are common, with as many as 150 youths attempting suicide for every completed suicide leading to death (Centers for Disease Control and Prevention 2002). Suicide attempts are a marker for serious mental disorders and ongoing medical problems with associated societal costs (Walrath et al. 2001).

2. Objectives
The objectives of the injury items within HBSC are: 1. To document injury prevalence in young people; 2. To document the determinants of injury; 3. To analyse international differences and similarities in injury prevalence; 4. To identify activities and locations in which injury occurs, and compare results over time; 5. To document severe injuries, their immediate causes and effects of young peoples health; 6. To document the prevalence and determinants of suicidal ideation and attempts.

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3. Theoretical framework
Injuries are the leading cause for mortality and morbidity among young children. In order to provide vital information for injury prevention, data regarding prevalence, activity during which an injury occurred, location in which an injury occurred, injury mechanism and injury severity need to be collected. Such information is considered to be the very basic information required (Holder et al. 2001) and support the understanding of injury following Haddons model (Haddon 1980). The approach taken to investigate such information is the population health approach. The population health approach focuses on the interaction between individual and contextual factors that influence the health of populations over the life course. This approach tries to identify systematic variations in health outcomes and their patterns of occurrence, and applies the resulting knowledge to develop and implement policies and actions to improve health and well-being of those populations (Kindig / Stoddart 2003). This approach developed from Bronfenbrenners work on the ecological model for human behaviour (Bronfenbrenner 1979). Bronfenbrenner was the first to look on human behaviour in context, dividing the context to several layers: Microsystems, Mesosystems, Exosystems, and later on, the Macrosystems w added. These layers and the interaction between them were used to explain ones health and wellbeing. With the Microsystems including the individual, the Mesosystems including the peer, family, classroom etc. and the Exosystems including the school system, community, mass media etc., the HBSC provides a real opportunity to utilise this model for analysis and interpretation of results. This model allows explaining various health outcomes, with injury being one of them.

4. Summary of previous work


4.1 Injuries
The topic of injury was introduced to the HBSC during the 1993/94 survey in response to a perceived need to introduce additional health outcomes within the HBSC instrument. Seven mandatory injury items were introduced. These items were derived from the questions used in several national and international studies on childhood and adolescent injuries, including the 1988 Child health supplement to the U.S. National Health Interview Survey (CHS-NHIS; Scheidt et al. 1995). Analyses of the injury data from the 1998 CHS-NHIS led to the development of a refined set of injury outcome measures. These included questions pertaining to the most serious injury (if any) experienced during the past 12 months: frequency of medically treated

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injury, injury severity defined by medical treatment and time lost from school or other usual activities, month and year of injury occurrence, location of injury, activity at the time of injury, and main results (damage to the body) of injury. In the 1997/98 HBSC survey, there were no mandatory items on injury. A revised optional package of eight close-ended injury questions was developed. For continuity, this package contained multiple questions used in 1994. However, the biggest change was the introduction of two open-ended items that requested information about the external cause of injury (described via two dimensions: what were you doing at the time of the injury; how did the injury happen). Data collected via these questions were subsequently coded into close-ended categories and these were used to refine the injury questions in subsequent versions of the HBSC, and to inform the development of a new coding system for external causes of injury (the International Classification of External Causes of Injury, or ICECI). The use of open-ended items was not repeated in subsequent surveys. In 2001/02, one question (frequency of medically treated injury) was added as a mandatory question. An optional package of eight questions was offered, including questions pertaining to the most serious injury experienced during the past 12 months: location of injury, activity at the time of injury, level of organization of this activity, location of injury treatment, time lost from school or other usual activities, main results (damage to the body) of the injury, month of injury, and year of injury. All questions were close-ended and most required multiple responses. In 2005/06, two optional items were dropped (main results (damage to the body) of the injury, month of injury, and year of injury) but the rest of the package remained unchanged. HBSC investigators and their research teams have made extensive use of the mandatory and optional injury items for peer-review publication. What follows is a brief summary of the types of analyses that have been conducted and involved past versions of the mandatory and optional injury items. This list of publications is not exhaustive and is meant to be illustrative. There have been a few cross-national manuscripts written from HBSC that focused on injury control topics. These include papers on etiological studies that examine the prevalence of injury across countries as well as a variety of social determinants of injury (Mazur et al. 2001, Pickett et al. 2005a, Pickett et al. 2005b, Molcho et al. 2006). A third cross-national study examined the phenomenon of multiple risk behaviour (simultaneous engagement in multiple risks such as substance use, truancy, and failure to use safety precautions) and its association with various forms of injury (Pickett et al. 2002a).

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The vast majority of published manuscripts on injury topics have been national in scope and origin. Selected topics include: lifestyle behaviours as determinants of injury in Canada (Pickett et al. 2002b, Janssen et al. 2007) and Lithuania (Starkuviene / Zaborskis 2005); social determinants of repeated injuries in Polish students (Tabak et al. 2004); prevalence studies of injury rates and patterns (Ardern et al. 2001, Williams et al. 1998); and studies of socioeconomic status and injury (Williams et al. 1997, Simpson et al. 2005).

4.2 Suicides
Suicide and suicide ideation were introduced to HBSC as part of the protocol on the 2005/6 survey. They were developed in response to repeated suggestions of member countries (Lithuania, Israel) that have employed country-specific items on suicide in past versions of the HBSC. The VIP Focus Group has worked with members of the Positive Health focus group in the development of this optional package. There are several available sources of questions for the study of suicide in adolescent health surveys. One source is the Youth Risk Behavior Survey (YRBS) conducted in the United States (Chatterji et al. 2004). Items selected for use from the YRBS have been employed for at least five iterations of the national YRBS survey, as well as within national student surveys in Israel. They include items on mental well-being; the contemplation, planning and attempting of suicide during the past 12 months; as well as injuries experienced due to one or more suicide attempts. The questions cover a continuum of items that are fundamental to the measurement of mental health status in adolescent populations. The HBSC injury and suicide items continue to provide a rich source of information on an important aspect of adolescent health.

5. Research questions
General research areas identified include questions surrounding the description of violence and injury, determinants of specific forms of violence and injury, and the consequences of violence and injury. More specifically: 1. What are the trends and epidemiology of injuries and suicidal behaviours among young adolescents of participating countries of the HBSC?

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2. What are the demographic, social, cognitive and behavioural determinants for injuries of various types among young adolescents of participating countries of the HBSC? 3. What are the psychosocial and other health-related consequences of injuries among young adolescents of participating countries of the HBSC? 4. What are the prevalence and characteristics of suicide ideation and attempts among young people?

6. Instruments
6.1 Mandatory items
6.1.1 Frequency of medically treated injury The study of injuries in youth requires the identification and definition of injury as a primary dependent variable of interest. However, some consistent criteria must be applied to avoid overwhelming the data set with frequent and insignificant events that are unrelated to mortality and morbidity and occur on a daily basis (e.g. cut finger, skinned knee). Although a variety of definitions and coding schemes have been employed to identify the occurrence of an injury of some significance, the most commonly used criteria are the requirements for medical attention and impairment of activity. Because most studies are conducted in medical settings and identify the injuries by the presence of a victim, the most frequent definition is an event that requires medical attention in some fashion (for example, being admitted to hospital, requiring a visit to an emergency department or receiving medical attention). Item box 1
MQ29 Many young people get hurt or injured from activities such as playing sports or fighting with others at different places such as the street or home. Injuries can include being poisoned or burned. Injuries do not include illnesses such as Measles or the Flu. The following questions are about injuries you may have had during the past 12 months. During the past 12 months, how many times were you injured and had to be treated by a doctor or nurse?
1 2 3 4 5

I was not injured in the past 12 months 1 time 2 times 3 times 4 times or more

Source: HBSC surveys 1993/4 (mandatory); 19978 (optional package); 2001/02 (mandatory).

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For consistency with this widely accepted approach, medical attention will be used as the definition of a significant injury in the HBSC 2009/10 survey. The alternative criterion, loss of normal activity to some degree, is proposed as an optional question and is strongly recommended to further define injury and identify biases resulting from different medical systems (Centers for Disease Control 1994, 1996, Durbin et al. 1999).

6.2 Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. Injuries Suicides

7. References
Anderson R, Menckel E. On the prevention of accidents and injuries: A comparative analysis of conceptual frameworks. Accident Analysis and Prevention, 1995;27:757-768 Ardern C, Pickett W, King MA, Boyce WF. Injury in Canadian youth: a brief report from the Health Behaviour in School-Aged Children Survey. Canadian Journal of Public Health 2001;201-3. Bronfenbrenner U. (1979). The ecology of human development. Harvard University Press. Centers for Disease Control and Prevention/National Center for Health Statistics. Methodology of the Youth Risk Behaviour Surveillance system. MMWR 2004; 53(RR-12). Centers for Disease Control and Prevention/National Center for Health Statistics. Proceedings of the International Collaborative Effort on Injury Statistics, Vol I, DHHS Publication no. (PHS) 95-1252, Bethesda, Maryland 1994 Centers for Disease Control and Prevention/National Center for Health Statistics. Proceedings of the International Collaborative Effort on Injury Statistics, Vol II, DHHS Publication no. (PHS) 96-1252, Bethesda, Maryland 1996 National Center for Injury Prevention and Control, Center for Disease Control and Prevention, U.S. Department of Health and Human Services. Web-based Injury Statistics Query and Reporting System. World Wide Web site: http://www.cdc.gov/ncipc/wisquars. 2000. Chatterji P, Dave D, Kaestner R, Markowitz S et al. Alcohol abuse and suicide attempts among youth. Economics and Human Biology 2005; 2:159-80. Christoffel KK, Scheidt PC, Agran PF, et al. Standard Definitions for Childhood Injury Research. NIH Publication No. 92-1586, Bethesda, MD, 1992 Durbin DR, Winston FK, Applegate SM, et al. Development and validation of the injury severity assessment survey/parent report. Archives of Pediatric Adolescent Medicine, 1999;153:404-408 Grunbaum JA, Kann L, Kingchen S et al. Youth risk behaviour surveillance United States, 2003. Morbidity and Mortality Weekly Report Surveillance Summaries 2004; 53:1-96. Haddon W. The basic strategies for reducing damage from hazards of all kinds. Hazard Prevention 1980;16:8-11

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Holder P, Peden M, Krug E, Lund J, Gururaj G, Kobusingye O (Eds.). Injury surveillance guidelines. Geneva: World Health Organization, 2001. Janssen I, Dostaler S, Boyce WF, Pickett W. Influence of multiple risk behaviors on physical activity related injuries in adolescents. Pediatrics, 2007, 119: e672-e680. Jessor R, Jessor S. 1980. A social-psychological framework for studying drug use. National Institute on Drug Abuse Research Monograph. March 30: 102-109. Kindig D, Stoddart G. What is population health? American Journal of Public Health, 2003; 92(3): 380383. Mazur J, Malkowska A. Risk behaviour syndrome and subjective health and life satisfaction in youth aged 15 years. Medycyna wieku rozwojowego (Polish) 2004; 8(3 Pt 1):567-83. Molcho M, Harel Y, Pickett W, Scheidt PC, Mazur J, Overpeck MD. The epidemiology of non fatal injuries among 11, 13 and 15 year old youth in 11 Countries: Findings from the 1998 WHO-HBSC cross national survey. International journal of Injury Control and Safety Promotion, 2006, 13(4), 205211. Peden M, McGee K, Sharma G. The injury chart book: a graphical overview of the global burden of injuries. Geneva: world Health Organization, 2002. Pickett W, Craig W, Harel Y, Cunningham J, Simpson K, Molcho M, Mazur J, Dostaler S, Overpeck M, Currie C on behalf of the HBSC Violence and Injuries Writing Group. Cross-national study of fighting and weapon carrying as determinants of adolescent injury. Pediatrics, Vol. 116, No. 6, December 2005a, pp. e855-e863 Pickett W, Molcho M, Simpson K, Janssen I, Kuntsche E, Mazur J, Harel Y and Boyce W. Cross-national study of injury and social determinants in adolescents. Injury Prevention, 2005b, 11: 213 - 218 (BMJ Publications). Pickett W, Brison RJ, Mackenzie SG et al. Youth injury data in the Canadian Hospitals Injury Reporting and Prevention Program: do they represent the Canadian experience? Injury Prevention 2000; 6:9-15. Pickett W, Garner MJ, Boyce WF, King MA. Gradients in risk for youth injury associated with multiple-risk behaviours: a study of 11,329 Canadian adolescents. Social Science in Medicine. 2002a ;55:105568. Pickett W, Schmid H, Boyce WF et al. Multiple risk behaviour and injury: an international analysis of young people. Archives of Pediatrics and Adolescent Medicine 2002b; 156:786-93. Scheidt PC, Harel Y, Trumble AC, et al. The epidemiology of nonfatal injuries among US children and youth. American Journal of Public Health, 1995;85:932-938. Sethi D, Racioppi F, Baumgarten I, Vida P. Injuries and violence in Europe: why they matter and what can be done. Copenhagen: WHO Regional Office for Europe, 2006 Simpson K, Jansen I, Craig W, Pickett W. Multilevel analysis of associations between socioeconomic status and injury among Canadian adolescents. Journal of Epidemiology and Community Health; 2005, 59 (12):1072-1077. Starkuviene S, Zaborskis A. Links between accidents and lifestyle factors among Lithuanian children. Medicina (Kaunas) 2005;41:73-80. Tabak I, Mazur J, Jodkowska M, Oblacinska A. Social determinants of repeated injuries in pupils aged 1115 years, in Poland. Medycyna wieku rozwojowego (Polish) 2004; 8(3 Pt 1):595-610. United States Public Health Service. The Surgeon Generals Call to Action to Prevent Suicide. Washington: USPHS, 1999. Valent F, Little D, Bertollini R, Nemer LE, Barbone F, Tamburlini G. Burden of disease attributable to selected environmental factors and injury among adolescents in Europe. The Lancet, 2004. 3663:2032-2039. Walrath CM, Mandell DS, Liao Q et al. Suicide attempts in the comprehensive community mental health services for children and their families program. Journal of the American Academy of Child and Adolescent Psychiatry 2001; 40:1197-1205. Williams JM, Currie CE, Wright P, Elton RA, Beattie TF. Socioeconomic status and adolescent injuries. Social Science and Medicine 1997; 44:1881-91.

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Williams JM, Wright P, Currie CE, et al. Sports related injuries in Scottish adolescents aged 11-15. British Journal of Sports Medicine, 1998;32:291-296. World Health Organization. 1997-1999 World Health Statistics Annual Report. 2000. Available at: URL http://www.who.int.whosis/statistics. World Health Organization Matching the lowest injury mortality rate could save half a million lives per year in Europe. Fact sheet EURO/02/06, 2006. Zimmermann N, Bauer R. Maintenance, development and promotion of the ISS Hospital Survey in the current and enlarged EU (EU-Injury Database IDB). Vienna: Austrian Road Safety Board, 2003.

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II.5.11 Violence and Bullying


Molcho, M, Craig, W, Picket, W, Harel, Y, Aasvee, K, Varnei, D

1. Scope and purpose


1.1 Violence
Violence is a major concern in most countries with youth violence being one of the most visible forms of bullying in society (Krug et al. 2002). To understand this problem and to examine the factors that influence and contribute to it, core measures of violence as problem behaviour are essential. This initial violence package will address fighting and weapon carrying. These two behaviours were identified by expert consensus as the highest priority behaviours associated with youth violence and intentional injuries (i.e. Kann et al. 2000). Physical fighting is the most common manifestation of interpersonal violence in adolescence and often associated with substance use and other problem behaviours (Molcho et al. 2004, Kuntch / Gmel 2004, Centers for Disease Control 1992). Much has been written about a syndrome of multiple problem behaviours that describes youth at high risk and predicts increased frequency of subsequent morbidity and mortality. Physical fighting is included among these high-risk behaviours of youth. The theory that a cluster of co-varying problem behaviours contribute to and comprise a pattern of risk was articulated by Jessor and Jessor nearly three decades ago (Jessor / Jessor 1980) and is confirmed by the Youth Risk Behaviour Survey and various other studies (Molcho et al. 2004, Brener et al. 1999). Because it is highly visible and often results in contact with health professionals, fighting behaviour has been proposed as one of the most reliable markers of multiple risk behaviours and other problem behaviours (Sosin et al. 1995). This epidemic of violence among youth has stimulated a search for modifiable factors and precursors that contribute to the problem. A second marker of youth violence that is highly visible is weapon carrying (Krug et al. 2002). In addition to being a defensive act, weapon carrying can also represent an extreme form of aggression that can have dire effects on the health of children and the societies that they live in.

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1.2 Bullying
Another form of youth violence is school bullying. Bullying is a relationship problem it is the assertion of interpersonal power through aggression (Pepler / Craig 2000). Bullying has been defined as negative physical or verbal actions that have hostile intent, cause distress to victims, are repeated over time, and involve a power differential between bullies and their victims (Olweus 1991, Pepleret al. 1997). Bullying is a subset of aggressive behaviours characterized by a power imbalance. With repeated bullying, the power relationships between bullies and their victims become consolidated: bullies increase in power, and victims lose power. In such a relationship, young people who are being bullied become increasingly powerless to defend themselves. All aggressive behaviours are not bullying because there may or may not be a power imbalance, but all bullying involves aggressive behaviours. Pepler and Craig (2000) have examined bullying from a developmental perspective and argue that this type of aggressive behaviour merits attention because it underlies many problems related to interpersonal violence. From this perspective, the lessons learned in bullying within peer relationships can be applied to other developmentally significant relationships. The use of power and aggression found in playground bullying is an indicator of future sexual harassment, marital aggression, child abuse, and elder abuse (Pepler et al. 1997). Victims of bullying also experience a range of problem behaviours, such as psychological maladjustment (Nansel et al., 2001), psychosomatic health problems (Nansel et al. 2001, Due et al. 2005, Due et al. 2007), medicnce use (Due et al. 2007) depression and anxiety; in extreme cases, suicide has occurred (Kaltiala-Heino et al. 2000, Craig 1998). Those students who engage in bullying others may be less interested in school and more likely to engage in health-risk behaviours such as smoking, drug use and excessive drinking (Nansel et al. 2001, Karatzias et al. 2002, Molcho et al. 2004, Nansel et al. 2004). Thus, understanding and preventing bullying during adolescence has important implications for the immediate health of young people, and long-term societal health.

2. Objectives
The objectives of the violence and bullying items within HBSC are: 1. To document the prevalence of fighting, weapon carrying and bullying in young people. 2. To analyse international differences and similarities in violence and bullying.

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3. To identify time trends in violence and bullying. 4. To document predictors and consequences of bullying and violence behaviours.

3. Theoretical framework
Violence and, more specifically, bullying, are very prevalent among young people. To address the problem of youth violence and the associated behaviours as portrayed by Jessor and Jessor (1990) in their Problem Behaviour theory, we follow the public health approach. The principles of public health provide a useful framework for both continuing to investigate and understand the causes and consequences of violent behaviour and to offer potential routes for prevention. The public health approach to violence prevention seeks to improve the health and safety of all individuals by addressing underlying risk factors that increase the likelihood that an individual will become a victim or a perpetrator of violence. The four basic steps in the public health approach include (a) identifying the magnitude, scope, characteristics of consequences of youth violence; (b) establish potential causes and correlates of violence including risk and protective factors; (c) work towards prevention through designing, implementing and evaluating interventions; and (d) implement effective interventions in a wide range of settings. The nature of the HBSC study limits us to follow primarily the two initial steps, however, knowledge gained from HBSC had informed policy makers in some countries. Through cyclic data collection, some information on effectiveness of programmes could be achieved, although the information is very general and could not point to any specific effort.

4. Summary of previous work


4.1 Violence
The topic of violence was introduced to the HBSC in 1998. Four optional questions were taken from the US Youth Risk Behavior Study (US-YRBS) and offered as an optional package. This included questions about the number of times students were in a physical fight during the past 12 months, a follow-up question on whom the student fought with, followed by a follow-up question on fights that caused injuries that required medical treatment. A single question about the frequency of weapon carrying in the past 30 days was also introduced. Since the 2001/02 round, optional package on violence was a variation of the package used in 1998. The initial question describing frequency of physical fighting became a mandatory item.

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Optional questions remaining from 1997/98 included the question about with whom the student fought and the frequency of weapon carrying. An additional question from the USYRBS was introduced on the type of weapon carried most recently.

4.1.1 Historical Publications Adolescent violence is an emerging topic of great contemporary importance, and this is reflected in the increasing number of peer-review manuscripts that have been produced on these topics by HBSC investigators. The following description of manuscripts is meant to be illustrative rather than exhaustive. Existing manuscripts have included a number of studies that were submitted to high profile biomedical journals. These include: a cross-national study of youth violence in European countries (Harel 1999); analyses of weapon carrying, physical fighting and injury, and relationships between these factors among US youth (Nansel et al. 2003); a cross-national analysis of violence as a determinant of serious injury (Pickett et al. 2005); and a study examining the etiology of violence-related behaviours in multiple countries (Smith-Khuri et al., 2004). Additional peer-review manuscripts were mainly national in scope and addressed a variety of topics surrounding the causes and consequences of adolescent violence. These include studies of: social determinants of aggression (Pickett et al., in press); drinking patterns as a determinant of violence (Kuntsche and Gmel, 2004); the association between exposures to violent media and the occurrence of hostility in adolescents (Kuntsche 2004); gender differences in the context of weapon-carrying and violence in Swiss students (Kuntsche and Klingemann 2004); risk behaviour syndromes that include violent behaviours as determinants of life satisfaction; the importance of family, peer and school environments as risk factors for youth violence (Laufer / Harel 2003); and the role of substance use in the etiology of youth violence (Molcho et al. 2004).

4.2 Bullying
Mandatory questions on bullying (perpetration) and being bullied (victimization) were introduced to the HBSC in 1997/98. Since 2001/02, these mandatory items were augmented with the two optional questions based upon Dr. Olweus research that described specific types

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of bullying. These were subsequently used in a variety of reports and peer-review publications at national and cross-national levels. Since the 2002 HBSC survey, there is an ongoing discussion surrounding the length of these items (particularly the introductory text), cultural differences in the translation of the concept of bullying, and whether or not children truly comprehend their meaning. These discussions remain unresolved. For the 2009/10 survey, our perspective remains that these items are well tested, they have provided fodder for a large amount of peer-review work during the last few years, and they continue to be of great contemporary interest. Therefore, they continue to be included in their intact forms as mandatory and optional items in this version of the survey. The current version of optional items have been modified slightly to reflect the opinions of Dr. Olweus and to include questions on cyber bullying. The latter were introduced by Wendy Craig, Queens University, and have employed successfully in provincial studies of bullying conducted in the province of Ontario, Canada.

4.2.1 Historical Publications Similar to the topics of physical fighting and weapon carrying, there is an emerging academic interest in the social topic of bullying within the scientific community. This is reflected in the number and quality of HBSC manuscripts that have been produced on issues related to bullying behaviours. Indeed, some of the existing HBSC manuscripts on this topic have been published in leading biomedical journals: a cross national study on victimisation and medicine use (Due at al. 2007); a study of bullying behaviours and various dimensions of adolescent health published in the Journal of the American Medical Association (Nansel et al. 2001); a Canadian study of obesity as a risk factor for bullying perpetration published in Pediatrics (Janssen et al. 2004); a cross-national study of bullying behaviours and psychosocial adjustment (Nansel et al. 2004); an international comparative study of bullying and psychosomatic symptoms based upon the 1998 survey (Due et al. 2005); and a cross-national study on bullying typology (Craig et al., in press). Additional studies include examining the prevalence of bullying in Poland along with substance use as a risk factor (Mazur and Malkowska 2003); examining bullying behaviours and psychosocial health in Turkey (Alikasfoglu et al. 2007); a study on bullying and perceived family, peer and school relationships (Spriggs et al. 2007) and a study of different types of bullying victimisation (Volk et al. 2006).

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5. Research questions
General research areas identified include questions surrounding the description of violence and injury, determinants of specific forms of violence and injury, and the consequences of violence and injury. More specifically: 1. What are the trends and epidemiology of bullying, fighting and weapon carrying among young adolescents of participating countries of the HBSC? 2. What are the demographic, social, cognitive and behavioural determinants for injuries of various types and for bullying, fighting, weapon carrying, and suicidal behaviours among young adolescents of participating countries of the HBSC? 3. What are the psychosocial and other health-related consequences of injuries, bullying, fighting, weapon carrying, and suicidal behaviours among young adolescents of participating countries of the HBSC?

6. Instruments
6.1. Mandatory items
6.1.1 Frequency of physical fighting The concern about fighting and its place in society raises a number of questions about the frequency, nature, origins and health effects of physical fights. These are all questions in need of answers if fighting behaviour is to be considered a marker for at-risk youth and a contributor to the violence-related morbidity and mortality of adolescents. Therefore, frequency of physical fighting is assessed as a measure of aggression and violence and a component of multiple problem and risk behaviours. Frequency of fighting has been well validated and reliability ascertained with extensive use in the US Youth Risk Behaviour Survey (Kann et al. 2000, Brener et al. 1995). The Violence package includes one mandatory item examining the frequency of involvement in physical fight during the last 12 months.

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Item box 1
MQ30
1 2 3 4 5

During the past 12 months, how many times were you in a physical fight? I have not been in a physical fight in the past 12 months 1 time 2 times 3 times 4 times or more

Source: Brener ND, Collins JL, Kann L, Warren CW, Williams BI. Reliability of the Youth Risk Behavior Survey questionnaire. American Journal of Epidemiology. 1995;141:575-580. HBSC survey 2001/02.

6.1.2 Bullying (Perpetration) and Being Bullied (Victimization) The mandatory items on the frequency of bullying and being bullied start with a preamble that was developed by Dr. Olweus in order to introduce the concept of bullying in its many forms to students, and to distinguish bullying from other forms of conflict. The preamble illustrates that bullying can take many forms, be they physical, emotional, or exclusionary. Despite its length, it is important to include this preamble in the questionnaire in order that bullying is described in a complete and clear fashion and for better cross-cultural compatibility of the questions. These frequency-based questions have now been used on multiple occasions within HBSC surveys, and their inclusion permits the ongoing monitoring of this phenomenon over time. The questions asked about the frequency of school bullying perpetration and victimization. Item box 2
MQ31 Here are some questions about bullying. We say a student is BEING BULLIED when another student, or a group of students, say or do nasty and unpleasant things to him or her. It is also bullying when a student is teased repeatedly in a way he or she does not like or when he or she is deliberately left out of things. But it is NOT BULLYING when two students of about the same strength or power argue or fight. It is also not bullying when a student is teased in a friendly and playful way. How often have you been bullied at school in the past couple of months?
1 2 3 4 5

I have not been bullied at school in the past couple of months It has only happened once or twice 2 or 3 times a month About once a week Several times a week

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Item box 3
MQ32 How often have you taken part in bullying another student(s) at school in the past couple of months? I have not bullied another student(s) at school in the past couple of months It has only happened once or twice 2 or 3 times a month About once a week Several times a week

1 2 3 4 5

Source: HBSC surveys 1993/94, 1997/98. Revised in 2001/02 to conform with: Olweus, D, 1996: The revised Olweus Bully/Victim Questionnaire. Mimeo. HEMIL, University of Bergen, N-5015 Bergen, Norway

6.2 Optional items


The optional packages/items listed below can be found in the item bank on the HBSC website. Violence (physical fight; carry a weapon) Types of Bullying (Bullying Others or Perpetration)

7. References
Alikasifoglu M, Erginoz E, Ercan O, Uysal O & Albayrak-Kaymak D. Bullying behaviours and psychosocial health: results from a cross-sectional survey among high school students in Istanbul, Turkey. European Journal of Pediatrics, 2007, 166 (12), 1253-1260. Centers for Disease Control. Physical Fighting Among High School Students United States, 1990. Morbidity and Mortality Weekly Report,1992, 41(06): 91-94, February 14. Craig WM. The relationship among bullying, victimization, depression, anxiety, and aggression in elementary school children. Personality and Individual Differences 1998; 24:123-130. Craig WM Harel Y. Bullying, physical fighting and victimization. In: Currie C, Roberts C et. al, Young peoples health in context. Health Behaviour in School-aged Children: international report from the 2001/2002 Survey. Copenhagen, WHO Regional Office for Europe, 2004 (Health Policy for Children and Adolescents, No. 4). Craig W, Harel Y, Grinvoald H, Molcho M, Hetland J, Simons-Morton B, Gaspar de Matos M, Overpeck M, Due P, Aasvee K, Pickett W, Violence & Injuries FG & Bullying Writing Group. A cross-national profile of bullying typology among young people in 40 countries. In press, International Journal of Public Health. Due P, Holstein BE, Lynch J et al. Bullying and symptoms among school-aged children: international comparative cross-sectional study in 28 countries. European Journal of Public Health 2005; Advance access published March 8, 2005. Due P, Hansen EH, Merlo J, Andersen A, Holstein BE. Is victimization from bullying associated with medicine use among adolescents? A nationally representative cross sectional survey in Denmark. Pediatrics. 2007; 120 (1): 110- 7. Harel Y. A cross-national study of youth violence in Europe. International Journal of Adolescent Medicine and Health, 1999. 11:121-134. Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviours in school-aged children. Pediatrics 2004; 113:1187-94.

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i ii

No data available for French Belgium, Ireland, Malta, Norway, Poland, Turkey and USA.

No data available for French Belgium, Czeck Republic, Ireland, Italy, Luxembourg, Malta, Norway, Poland, Turkey and USA.

iii

No data available for French Belgium, Czeck Republic, Iceland, Ireland, Italy, Luxembourg, Malta, Norway, Poland, Turkey and USA.

325