Inequalities in young peoples health across the UK Getting it together for young peoples health AYPH Conference February 26th 2009 Professor Candace Currie Child and Adolescent Health Research Unit (CAHRU) University of Edinburgh

Patterns of inequalities in young peoples health in UK Are there differences in health experience of young people in England, Scotland and Wales? What kind of health inequalities are observed within UK countries? Are these similar or different to inequalities observed in other countries in Europe and N America? What can we learn from this and what are implications for improving young peoples health experience in UK?

Drawing on evidence from Health Behaviour in School-Aged Children Study HBSC purpose to increase knowledge and understanding of adolescent health in social and developmental context HBSC surveys are conducted every four years in member countries common questionnaire and survey method data collected on 11,13 and 15 year olds in each country sample size: 1,550 per age group in each country

Growth of HBSC study: countries by survey year 1983/ / / / / / /6 1. England 2. Finland 3. Norway 4. Austria 5. Denmark 1. Finland 2. Norway 3. Austria 4. Denmark 5. Belgium 6. Hungary 7. Israel 8. Scotland 9. Spain 10. Sweden 11. Switzerland 12. Wales 13. Netherlands 1. Finland 2. Norway 3. Austria 4. Belgium (French) 5. Hungary 6. Scotland 7. Spain 8. Sweden 9. Switzerland 10. Wales 11.Denmark 12. Netherlands 13. Canada 14. Latvia 15. N. Ireland 16. Poland 1. Finland 2. Norway 3. Austria 4. Belgium (French) 5. Hungary 6. Israel 7. Scotland 8. Spain 9. Sweden 10. Switzerland 11. Wales 12. Denmark 13. Canada 14. Latvia 15. Northern Ireland 16. Poland 17. Belgium (Flemish) 18. Czech Republic 19. Estonia 20. France 21. Germany 22. Greenland 23. Lithuania 24. Russia 25. Slovakia 1. Finland 2. Norway 3. Austria 4. Belgium (French) 5. Hungary 6. Israel 7. Scotland 8. Sweden 9. Switzerland 10. Wales 11. Denmark 12. Canada 13. Latvia 14. Northern Ireland 15. Poland 16. Belgium (Flemish) 17. Czech Republic 18. Estonia 19. France 20. Germany 21. Greenland 22. Lithuania 23. Russia 24. Slovakia 25. England 26. Greece 27. Portugal 28. Ireland 29. USA 1. Finland 2. Norway 3. Austria 4. Belgium (French) 5. Hungary 6. Israel 7. Scotland 8. Spain 9. Sweden 10. Switzerland 11. Wales 12. Denmark 13. Canada 14. Latvia 15. Poland 16. Belgium (Flemish) 17. Czech Republic 18. Estonia 19. France 20. Germany 21. Greenland 22. Lithuania 23. Russia 24. England 25. Greece 26. Portugal 27. Ireland 28. USA 29. tfyr Macedonia 30. Netherlands 31. Italy 32. Croatia 33. Malta 34. Slovenia 35. Ukraine 1. Finland 2. Norway 3. Austria 4. Belgium (French) 5. Hungary 6. Israel 7. Scotland 8. Spain 9. Sweden 10. Switzerland 11. Wales 12. Denmark 13. Canada 14. Latvia 15. Poland 16. Belgium (Flemish) 17. Czech Republic 18. Estonia 19. France 20. Germany 21. Greenland 22. Lithuania 23. Russia 24. England 25. Greece 26. Portugal 27. Ireland 28. USA 29. tfyr Macedonia 30. Netherlands 31. Italy 32. Croatia 33. Malta 34. Slovenia 35. Ukraine 36. Luxemburg 37. Turkey 38. Slovakia 39. Romania 40. Iceland 41. Bulgaria

HBSC scope Includes measures on physical, emotional and social health and well-being Measures comprehensive range of behaviours that both risk and promote health Places health and behaviour of young people in social and developmental context

Health related behaviours measured in HBSC Tobacco, alcohol and cannabis Physical activity Consumption of food and drinks Toothbrushing Weight control behaviour Fighting and bullying Sexual behaviour TV and computer use Electronic communication

Health and well-being measures in HBSC self-rated health life satisfaction health complaints body image Body Mass Index (BMI) injuries

Social context measures in HBSC Family School environment Peer relations

Report from the Health Behaviour In School-Aged Children 2005/06 Survey in 41 countries Currie et al, WHO, Copenhagen Health Policy for Children and Adolescents, No. 5 Inequalities in Young Peoples Health

Inequalities in young peoples health report HBSC report presents evidence of widespread and diverse types of inequality in young peoples health experience why is this important? –indicates negative health experience and poor quality of life for many young people in Europe and North America –this affects their education and social development –tracks through to adulthood affecting health, social and economic outcomes

Defining health inequalities measurable differences in health experience and health outcomes according to various characteristics such as: gender age geography socioeconomic status

Gender United Nations has stated there is an international responsibility to achieve equality between the genders very little attention is given to gender differences in most youth health reports data are usually presented for both boys and girls together – e.g. recent UNICEF report - and so issue of gender inequality not addressed

Age as with gender, age differences are neglected in many studies adolescent age group often merged with younger children or with young adults in health statistics HBSC looks at ages 11, 13 and 15 separately different stages of puberty, physical and emotional development, growing independence and choice some health risks already established by age 11, others begin and increase during teenage years

Geography countries in HBSC span North America and Europe to manage country comparisons, UN country groupings (based on geographic and economic factors) were used: North Europe and North America Western Europe Eastern Europe South Europe and Western Asia

Socioeconomic status socioeconomic inequalities are related to social status and resources such as material possessions there are a number of ways to measure socioeconomic status of adolescents HBSC report uses family material affluence as a measure of socioeconomic status (HBSC Family Affluence Scale)

Family affluence low medium high Iceland Turkey Chart showing country variation in levels of family affluence

Key questions How does health experience of young people in England, Scotland and Wales compare? What kind of health inequalities are observed within UK countries? Are these similar or different to inequalities observed in other countries in Europe and N America?

15 year olds who rate their health as fair or poor UK countries have similar ranks (E:8 th, S:7 th & W:6th) In UK and all other countries significant gender difference: girls poorer self rated health Among girls in most countries reporting of poorer health increases with age

family affluence fair/ poor health Negative association between family affluence and self–rated health

Self-rated health health experience of young people in England, Scotland and Wales is very similar find same gender, age and socioeconomic inequalities throughout UK similar to inequalities observed in other countries in Europe and N America

15 year olds who eat fruit daily Ranks are E: 3 rd, W: 20 th and Scotland: 21 st In UK and all other countries girls > boys Fruit eating declines with age in almost all countries

family affluence daily fruit Associations between family affluence and daily fruit consumption

Daily fruit consumption higher levels in England compared to Scotland and Wales same gender, age and socioeconomic inequalities throughout UK similar to inequalities observed in other countries in Europe and N America

15 year olds who smoke weekly England ranks low (29 th ) compared to Wales (19 th ) and Scotland (16 th ) but differences are due to girls In UK girls are more likely to smoke than boys and same is true in about half of countries; reverse is true in other countries (split is west/ east)

family affluence weekly smoking Associations between family affluence and weekly smoking found in north (Europe and N America) and western Europe found among girls more commonly than boys

Weekly smoking among girls weekly smoking levels lower in England compared to Scotland and Wales same gender, age and socioeconomic inequalities throughout UK gender and socioeconomic differences same as in other western/ northern countries

15 year olds who have been drunk at least twice All UK countries have high rates of drunkenness In UK girls are as or more likely to get drunk than boys unlike most other countries

Drunkenness Rates similar across UK countries same gender and age patterns throughout UK gender patterns different to most other countries

Overview of UK Picture across UK is similar in terms of prevalence and gender patterns Self-reported health Patterns of alcohol use Otherwise we find variation in patterns of health across the UK

Overview of UK inequalities Eng relatively positive cf Scotland & Wales –Food habits Breakfast consumption Fruit consumption Soft drink consumption –Hours spent TV watching –Smoking –Cannabis use –Condom use England relatively negative cf Scotland & Wales Medically attended injury Daily 60 minutes of physical activity Bullying

Explanations for similarities and differences across UK? Cultural similarities – eg youth drinking culture across the UK? Cultural similarities in health reporting? Difference found in UK health patterns may be explained by social/demographic factors or differences in policy and practice? Further analysis of HBSC and other data sources required to answer these questions

Social context of health HBSC countries show quite marked differences in social contextual dimensions - some of these are now highlighted

15 year olds who find it easy to talk to their mother England ranks 26th (Wales is 23rd and Scotland 32nd ) In most countries boys > girls

15 year olds who have three or more close friends England ranks 4th (Wales is 6th and Scotland 3rd) No gender difference in UK but in some countries boys > girls

15 year olds who like school a lot England ranks 13 th (Wales 20 th and Scotland 28 th ) No gender difference in England and Wales but in a girls> boys in around half of countries

Variation in supportive social contexts in UK England is doing well in terms of positive socioeconomic environment and in terms of liking school compared to other UK countries All UK countries score high on friendships with peers Family support appears weaker in UK than many other countries

15 year olds who feel pressured by schoolwork England ranks 3rd (Wales 2nd and Scotland 24th) Girls> boys in England and most other countries at age 15

15 year olds who spend four or more evenings out with friends England ranks 15th (Wales 12th and Scotland 7th) Boys > girls in most countries

Variation in risky social contexts in UK Young people in England and Wales report a high level of pressure stemming from schoolwork – can impact on mental health Being out in evening with friends 4 or more nights a week is a known factor in risk taking behaviour – less prevalent in England than other UK countries

Inequalities in health of young people across the UK there is variation in different dimensions of health experience across UK – we need to understand more about underlying causes common sources of inequality are seen to prevail related to gender, age and family affluence overall these are similar to inequalities experienced by young people throughout Europe and North America but gender/ socioeconomic patterns do vary

Implications when developing policy and practice for health improvement existing inequalities (age, gender and socioeconomic) need to be taken into account important for priority setting as well for developing different strategies and approaches to prevention/ intervention

Influencing policy and sharing good practice at international and national levels WHO/ HBSC Forum Established in 2007 to address social and economic determinants of young peoples health Aim to raise awareness among policy makers of health inequalities that young people experience Showcasing of good practice at national level to reduce inequalities and improve health Demonstration of utility of HBSC to stimulate action and monitor health improvement at national and international levels

WHO/ HBSC Forum themes 2006 healthy physical activity and nutrition 2007 social cohesion for mental health 2009 environment and health Reports including country case studies available from WHO or download via link from HBSC website

Forthcoming report: 2006 healthy physical activity and nutrition 2007 social cohesion for mental health 2009 environment and health Reports including country case studies available from WHO or download via link from HBSC website

HBSC contacts and information HBSC International Coordinating Centre Child and Adolescent Health Research Unit, University of Edinburgh HBSC web-site:

Acknowledgements The young people we study The HBSC Network The HBSC partner WHO Funding organisations Further information on HBSC including and its publications at