CROSS NATIONAL RESEARCH ON RISK BEHAVIOURS:
Experiences from the HBSC Study
CHALLENGES AND IMPACT
Candace Currie, HBSC International CoordinatorChild and Adolescent Health Research UnitUniversity of St Andrews
OUTLINE OF PRESENTATION
HBSC study overview
Risk behaviours among 11 -15 year olds across Europe and North America
Social determinants of risk behaviour
Evidence for policy decision makers at international level
National policy case study - HBSC in Scotland
1. HBSC study overview
HISTORY OF HBSC STUDY
HBSC started in 1983 in 3 countries; World Health Organization Collaborative study
Now 44 countries in Europe and North America; network of > 350 researchers
Adaptation and use of HBSC Protocol in other regions - HBSC ‘linked projects’
Works with NGOs and government departments at national/ international levels
AIMS OF THE HBSC STUDY
Raise awareness of adolescent health
internationally
Gather cross-nationally comparable data
Advance scientific field of adolescent health
Encourage use of data in policy and
practice
Build research network and international
capacity
Collaborate with partners with advocacy role
HBSC SURVEYS: DATA COLLECTION
School based surveys every four years; self-complete questionnaire in classroom under ‘exam’ conditions
8 surveys completed to date, 9th in 2013/2014 – countries currently submitting data to international databank
Nationally representative samples – 1550 pupils aged 11, 13 and 15 years
Standardised survey protocol and survey instrument – validated through cross-national testing
HBSC SURVEY: CHALLENGES
To maintain quality standards as study grows in size and diversity
To innovate and improve in context of limited financial resources
To meet the need for trend data while developing questionnaire content each survey cycle
To meet differing requirements of scientific and policy audiences
HBSC SURVEY PROTOCOL
Produced by network for each survey cycle – 2.5 year process
Work of topic area ‘focus groups’
Brought together by Scientific Development Group
Input from Policy and Methodology Development Groups
2013/14 RESEARCH PROTOCOL: Public Access @ www.hbsc.org
HBSC SURVEYS: THE 2009/10 SURVEY DATA
More than 200,000 young people were surveyed
• Health and wellbeing
• Health behaviours and risk behaviours
• Family, peers, school, neighbourhood, socioeconomic conditions
Over >60 topic areas with child indicators for:
HBSC SURVEYS: QUESTIONNAIRE
Set of HBSC mandatory items used by all countries
Selection of HBSC optional packages
National items
NATIONAL Q’AIRE
HBSC SURVEYS: METHODOLOGICAL CHALLENGES OF STUDYING ADOLESCENTS
Permission: from education authorities and schools;
Consent: young people and parents; implications of active v passive consent
Administration: methods and settings
Questions: age appropriate in content and vocabulary
Ethical considerations: ethics approval
HBSC SURVEYS: METHODOLOGICAL CHALLENGES OF CROSS-NATIONAL RESEARCH
Translation
Variation in guidelines for consent
Different school systems
Cultural relevance, acceptability or understanding of specific concepts
Ethical approval - not all countries have such systems in place
HBSC SURVEYS: METHODOLOGICAL CHALLENGES OF STUDYING RISK BEHAVIOURS
Cultural acceptability in some countries
Ethical considerations – asking young people about illegal activities
Accuracy of self-reports
Non-response
Skip or filtering instructions can be hard to understand
HBSC’S LATEST RESEARCH FINDINGS
International Report (2012)
Journal Publications
Factsheets and briefing papers
Data visualisations
HBSC INTERNATIONAL REPORT (2012)
Social determinants of health and well-being among young people
WHO Report Series: ‘Health Policy for Children and Adolescents’(6; 2012)
HBSC INTERNATIONAL REPORT CONTENT
Report focus:
comparative data on health and wellbeing of young people in 39
countries
highlights risk behaviours and how these vary across countries
examines inequalities related to age, gender and affluence
Information for action:
adolescence a critical developmental stage in life course
opportunities for intervention and health improvement
value of building on ‘early years’ investment
COMPARATIVE DATA: FIRST AND FOREMOST
risk behaviours
health and wellbeing
social contexts of
health
health behaviours
Vital information for national policy makers benchmarking on:
COMPARATIVE DATA: current and future policy issues
tobacco use, alcohol,
cannabis, sexual behaviour,
fighting, bullying
self-rated health, life satisfaction,
health complaints, body image and BMI
family, peers, school,
socioeconomic conditions
breakfast, fruit, physical activity, toothbrushing
Comparative data on:
COMPARATIVE DATA: VALUE FOR NATIONAL POLICY
Countries can see how they are doing on any particular health/social
Can ascertain whether issue is common to all countries or particular to theirs
Evaluate evidence of strong cultural/ social differences between countries
Importance of examining developmental trajectories
2. Risk behavioursamong 11 -15 year olds across Europe and North America
23 countries B=G 10 countries B>G (mainly E and SE Europe) 3 countries G>B (England, Wales, Czech Rep)
GENDER
TOBACCO USE WEEKLY:15-YEAR-OLDS
Boys: range 8-53%
TOBACCO USE WEEKLY:15-YEAR-OLDS
Girls: range 1-61%
30% or more
25-29%
20-24%
15-19%
10-14%
Less than 10%
32 countries B>G 7 countries B=G 0 countries G>B
GENDER
ALCOHOL USE WEEKLY:15-YEAR-OLDS
Boys: range 6-44%
ALCOHOL USE WEEKLY:15-YEAR-OLDS
Girls: range 5-34%
40% or more
30-39%
20-29%
10-19%
Less than 10%
20 countries B>G 13 countries B=G 5 countries G>B (Greenland, Scotland,
Finland, Sweden, Spain)
GENDER
DRUNK 2+ TIMES:15-YEAR-OLDS
Boys: range 15-57%
Girls: range 8-56%
DRUNK 2+ TIMES:15-YEAR-OLDS
55% or more
45-54%
35-44%
25-34%
15-24%
Less than 15%
23 countries B>G 14 countries B=G 0 countries G>B
GENDER
CANNABIS EVER USED*:15-YEAR-OLDS*no data for Sweden, Turkey
Boys: range 4-33%
Girls: range 1-33%
CANNABIS EVER USED:15-YEAR-OLDS
30% or more
25-29%
20-24%
15-19%
10-14%
5-9%
Less than 5%
19 countries B>G 11 countries B=G 6 countries G>B (Greenland*, Scotland*,
Finland*, Germany)
GENDER
HAVE HAD SEXUAL INTERCOURSE*:15-YEAR-OLDS* no data for Belgium (Fr), Turkey, US
*countries where drunkenness rates also higher among girls than boys
Boys: range 15-46%
Girls: range 3-71%
HAVE HAD SEXUAL INTERCOURSE:15-YEAR-OLDS
55% or more
45-54%
35-44%
25-34%
15-24
Less than 15%
0 countries B>G 24 countries B=G 10 countries G>B
GENDER
PILL USE AT LAST INTERCOURSE*:15-YEAR-OLDS* no data for Belg (Fr), Czech Rep, Russian Fed, Turkey, US
Boys: range 3-54%
Girls: range 2-62%
PILL USE AT LAST INTERCOURSE:15-YEAR-OLDS
55% or more
45-54%
35-44%
25-34%
15-24%
5-14%
Less than 5%
9 countries B>G 23 countries B=G 0 countries G>B
GENDER
CONDOM USE AT LAST INTERCOURSE*: 15-YEAR-OLDS* no data from Belg (Fr), Czech Rep, Denmark, Greenland, Russ Fed, Turkey & US
Boys: range 69-91%
Girls: range 58-89%
CONDOM USE AT LAST INTERCOURSE: 15-YEAR-OLDS
85% or more
80-84%
75-79%
70-74%
65-69%
Less than 65%
3. Social determinants of risk behaviour
HBSC FAMILY AFFLUENCE SCALE (FAS)
Summed to produce FAS
score
Number of cars
Own bedroom Family holidays
Computers in the home
FAMILY AFFLUENCE DISTRIBUTION BY COUNTRY
Norway 2% low affluence76% high affluence
USA 11% low affluence54% high affluence
Turkey 62% low affluence 8% high affluence
Family affluence according to composite scores (all ages)
UNDERSTANDING FAS CHARTS
ARMENIAProportion of boystaking soft drinks daily higher among those from higheraffluence families
SCOTLANDProportion of girls taking soft drinks daily higher among those from lower affluence families
KEY FINDINGS: Health and family affluence
+vely
associated with higher
FAS
Self-rated health
Life satisfaction
Health complaints
Medically attended injuries – higher prevalence associated with affluence
Overweight and obesity - associated with affluence in poorer countries
However
Gender effects
Differentials between poorer and more affluent greater for girls in self rated health and life satisfaction
KEY FINDINGS: FAMILY AFFLUENCE AND LIFE SATISFACTION
SOCIAL CONTEXT and Family Affluence
+velyassociated
with higher FAS
Easy to talk to mother
Easy to talk to father
Having 3+ close
friends
Daily electronic
media contact
Good school performance
Both easy to talk to mother and to father show greater effects of FAS for girls
Gender effects
KEY FINDINGS: FAMILY AFFLUENCE AND PERCIEVED SCHOOL PERFORMANCE
KEY FINDINGS: FAMILY AFFLUENCE AND WEEKLY TOBACCO USE
FAMILY AFFLUENCE AND RISK BEHAVIOURS
Risk behaviours associated with
FAS in only a minority of countries
Smoking associated with low affluence
Weekly alcohol use associated with high affluence among boys
Cannabis use generally associated with low affluence among boys
Mixed picture for sexual behaviour
DISCUSSION POINTS: GENDER AND SOCIOECONOMIC ISSUES
Gender patterns vary between countries andmay be explained by cultural differences in gender socialisation
Social expectations and social restrictions have a role to play as do gender roles in adult society
Patterns of risk taking are changing - in some western countries girls show higher rates of risk behaviour than males which have seen a decline
Risk behaviours are less influenced by family affluence than healthy behaviours
4. Evidence for policy decision makers at international level
VALUE OF INTERNATIONAL REPORT: PROMOTING USE OF HBSC
HBSC provides a rich source of data that can be translated into action:
to inform and guide policy and
practice
to improve the health of all young
people
to limit the impact of social
inequalities
and invest sufficiently to build
on early years
ELEMENTS OF BROADER COMMUNICATIONS AND IMPACT PLAN:
World Health Organization
Longstanding partnership with WHO has led to
many opportunities for data use:
HBSC international reports and
special reports
WHO-HBSC Forums
Child and Adolescent
Health Strategy in Europe
BUILDING RELATIONSHIPS WITH DATA USERS
ELEMENTS OF BROADER COMMUNICATIONS AND IMPACT PLAN:
UNICEF Innocenti Research Centre (Florence) and HQ (New York)
Provided data for Report Card 7: ‘Child Poverty in Perspective: An overview of child well-being in rich countries’ 2007
Produced background paper including HBSC data analysis for Report Card 9: ‘The Children Left Behind: A league table of inequality in child well-being in the world's rich countries’ 2010
Regular consultations about future work of HBSC and UNICEF and opportunities for partnership activities
BUILDING RELATIONSHIPS WITH DATA USERS
ELEMENTS OF BROADER COMMUNICATIONS AND IMPACT PLAN:
OECD
Provided data for OECD reports including: ‘Doing Better for Children’ ; ‘Doing Better for Families’; ‘Health at a Glance’
Presented invited papers based on HBSC data to OECD international conference on Education, Social Capital and Health in Oslo, 2010
Participated two high level conferences ‘UNICEF/ OECD/ EC consultations on Child Wellbeing’ contributing evidence from HBSC study on children indicators and data
Contributed input to OECD/EC review of child surveys in Europe
BUILDING RELATIONSHIPS WITH DATA USERS
IMPACT OF DATA AT INTERNATIONAL LEVEL
International policy change would be through, for
example, European legislation and hard to trace process by which data could be said to
have effected change
Many countries following same
legislative or policy change
would be a more likely route
How to measure this is complex as policy impact will
probably first occur at national level
IMPACT OF DATA AT NATIONAL LEVEL
National data use:
Data can drive change in policy and practice –
especially with unfavourable
international comparisons
Power of time trends – e.g. in Scotland 20 years of data –change and lack of change
Analysis of relationship between trends in health and policy environment –trace impact of policy and
practice change?
5. National policy case study -HBSC in Scotland
NEED FOR POLICY ACTION ON TEEN SMOKING INDICATED BY INCREASING RATES IN 1990’S
Evidence of impact indicated by decreasing trends in 2000s (including smoking in public places ban 2006)
INTERPRETING NATIONAL FINDINGS
How can international data
enhance our understanding of young people’s
health in Scotland?
How does Scotland rank
compared with other countries?
Has rank changed over
time?
How do national trends compare
with international
trends?
How does prevalence
compare across age and gender
groups?
Are age and gender
differences the same as in other
countries?
What are the levels of relativesocio-economic
inequality?
INTERNATIONAL COMPARISON
HIGH
• Top ⅓ countries (rank = 1-13)
MEDIUM
• Middle ⅓ countries (rank = 14-26)
LOW
• Bottom ⅓ countries (rank = 27-39)
SEXUAL HEALTH: SCOTLAND V INTERNATIONAL
Sexual intercourse
• 27% boys and 35% girls report having had sexual intercourse
• HIGH ranking = 7th (out of 36)
Condom use
• 72% boys and 70% girls report using a condom at last intercourse
• LOW ranking = 27th (out of 32)
Pill use
• 14% boys and 21% girls report use of contraceptive pill at last intercourse
• MEDIUM ranking = 18th (out of 34)
RELATIVE INEQUALITY: SEXUAL INTERCOURSE
RELATIVE SOCIO-ECONOMIC INEQUALITY
Scotland has HIGH relative
inequality
Soft drink consumption
Sexual intercourse
Classmate support
Having been
bullied
Self-rated health
Tobacco initiation
(girls only)
Lifetime cannabis use (girls
only)
Communication with mother (girls only)
WHERE IS SCOTLAND DOING WELL?
High life satisfaction
Positive peer relationships
Low smoking rates
Low cannabis use
Good oral health
THREE KEY ELEMENTS OF IMPACT
Articulation of the problem through data
Policy based solution
Political will
6. New WHO Collaborating Centre for Child and Adolescent Health Policy
ACHIEVING RESEARCH IMPACT: HBSC COMMUNICATIONS AND IMPACT PLAN
Achieving ‘impact’ has been planned as a key goal of HBSC Study from outset (written into study Terms of Reference 30 years ago)
Data can be used at national and international levels in a large variety of ways to inform and influence policy and practice
Evaluating impact is still under development so range of evidence should be gathered to gain a comprehensive picture
Role of new WHO Collaborating Centre in Child and Adolescent Health Policy at St Andrews School of Medicine is to better understand process of policy impact through research communication (www.whoccstandrews.org)
CURRENT ACTIVITIES (year 1)
• SYSTEMATIC REVIEW (July to Dec 2014) Does the involvement of children and young people improve programme effectiveness?
• 3rd POLICY EVENT (27TH Oct)Educational session: What are New Psychoactive Substances (‘Legal Highs’)? Expert speaker: Professor Fabrizio Schifano, University of Hertfordshire.
Round table discussion: with key stakeholders including school and university students, teachers and student services
ACKNOWLEDGEMENTS
Young people FundersHBSC network
members
WHO – HBSC study partner
University of St Andrews
(International Coordinating Centre)
University of Bergen (Data Management
Centre)
University of Southern Denmark (Support Centre for
Publications)
Ludwig Boltzmann Institute (supports
protocol production)