1. Workshop II Health inequalities among children and adolescents Matthias Richter University of Bielefeld School of Public Health Department of Prevention and Health Promotion matthias.richter@uni-bielefeld.de Conference “Reducing Health Inequalities: What Do We Really Know About Successful Strategies?” Berlin, May 8/9, 2009 Matthias Richter | Workshop introduction 1

2. Health inequalities: The status syndrome Mortality, morbidity as well as risk behaviour are unequally distributed across socioeconomic groups: Health inequalities cross the entire social structure of society (the social gradient): This association was found for all countries for which data is available: 2 Individuals with lower socioeconomic status (SES) have a higher prevalence of adverse health and die earlier than those with high SES (Mackenbach 2006, Mielck 2005). The risk of mortality and morbidity increases stepwise with decreasing SES (= linear relationship) (Marmot 2005). Also for Germany several empirical results support this finding (Lampert et al. 2005, Richter/Hurrelmann 2009). Matthias Richter | Workshop introduction

3. Why bothering about adolescence? Compared to childhood and adulthood there is no consistent pattern of social inequalities in health, esp. for early youth (West, 1997, Spencer 2006, Hanson & Chen 2007). Where inequalities exist, they are less pronounced than in any other part of the life-course. There are a number of exceptions and variations (e.g. health outcomes, gender, countries and SES indicators). (Koivusilta et al. 2006, Currie et al. 2008, Richter et al. 2009) Equalisation of health inequalities in adolescence? 3 Life course Matthias Richter | Workshop introduction

4. Theoretical models of the relationship between SES and health in childhood and adolescence (Chen et al. 2002) low SES medium SES high SES 1. persistent model2. childhood-limited model3. adolescent-emergent model 1. patterns unchanged2. patterns change for example: Mortality (due to accidents/injuries) severe asthma for example: injuries Infections diseases for example: passive smoking - smoking physical activity adolescence Patterns of socioeconomic differences childhood Matthias Richter | Workshop introduction 4

5. Health inequalities in adolescence: Findings from the HBSC study 5 Socioeconomic patterns in risk behaviour among 11- to 15-year olds Consumption of tobacco, alcohol and cannabis as well as bullying: No association between parental occupation and family affluence – but strong relationship with type of school and academic achievement. (Richter 2005, Richter et al. 2006, 2008) Nutrition and physical activity: All outcomes show a social gradient – independently of gender (Richter et al. 2009) The effects of type of school and academic achievement were substantial but smaller than for tobacco and alcohol use. (Richter/Lampert 2008) These findings are consistent across countries and over a 12 year period (1994 to 2006). (Richter et al. 2006, 2008, Currie et al. 2008) The changes in prevalences over time took place independently of parental SES and type of school in all sub groups. (Richter/Leppin 2007) Matthias Richter | Workshop introduction

6. 1 2 3 2 1 3 Description Explanation Reduction Source: Richter/Hurrelmann 2006/2009 Prevention/health promotion and health care research Epidemiology and empirical social research Basic public health research Applied public health 6 Health inequalities as a key issue of public health Matthias Richter | Workshop introduction

7. Explaining health inequalities among young people 7 Studies on the relationship between SES and health in adolescence have mainly focussed on descriptive approaches and bivariate relationships. Little is known about underlying factors and mechanisms on the relation between SES and health in adolescence including possible equalisation processes. Similar to the description of social inequalities in health, attempts to explain these differences have mainly focused on adults. Matthias Richter | Workshop introduction

8. Different patterns, different explanations… 8 Two different patterns of inequalities in health in adolescence: 1. Persistent inequalities in health 2. Changing inequalities in health What we need are two different explanatory models: 2. to explain the changing/equalising inequalities in health 1. to explain (persisting) inequalities in health Matthias Richter | Workshop introduction

9. 1. Explanations for changing/ equalising inequalities in health in adolescence: Latent differences –Inequalities in health are already present, but not (yet) measurable with current outcome measures of health. –The prelude is visible in the unequal distribution of different determinants (behavioural/ structural factors) of health among social groups.. Changing Health inequalities 1 Matthias Richter | Workshop introduction 9

10. Buffer hypothesis –Central elements of adolescence (school, peers, youth culture) and related mechanisms „break“ the traditional SES-barriers (family, neighbourhood) and form a buffer for young people against the health-damaging effect of SES –As children develop, other factors (may) play a more important role in determining adolescent health while the strength of parent SES decreases. 2. Explanations for changing/ equalising inequalities in health in adolescence: Changing Health inequalities 2 Matthias Richter | Workshop introduction 10

11. Persistent Inequalities So far several models exist which try to combine the different approaches into a theoretical framework (for Germany e.g. Elkeles/Mielck 1997, Steinkamp 1999). However, these models often discount the dimensions of time and place. Different age groups or a reflection of the life course are largely ignored in these models. 11 Psychosocial factors BehavioursHealthSES Material factors modified according to Mackenbach (2006) Matthias Richter | Workshop introduction

12. 1.Explaining health inequalities Which determinants and mechanisms - over the life course - and on „macro level“ (e.g. welfare regimes) are responsible for social differences in health? 2.Reducing health inequalities How can these determinants and processes be faced in order to tackle social inequalities in health? Aims of the workshop 12 Matthias Richter | Workshop introduction

13. Friday, 8 May, 14.00-17.45 Uhr 14.00-14.20 Introduction (Matthias Richter, Bielefeld) 14.20-15.00 Welfare regimes and health inequalities in adolescence (Alessio Zambon, Torino) 15.00-15.40 Critical periods in the development of educational careers: Implications for health inequality (Leena Koivusilta, Turku) 15.40-16.00 Break 16.00-16.40 Life-course determinants of health, health behaviour and health inequalities in early adulthood (Laura Kestilä, Helsinki) 16.40-17.20 Searching for evidence of inequalities in health in youth: the role of violence and gang culture (Patrick West, Glasgow) 17.20-17.45 Discussion The schedule for today Matthias Richter | Workshop introduction 13