Educational inequalities in life satisfaction among teens – what do we know? A closer look at the role of health behaviour and gender differences

This post, written by HBSC's Irene Moor and Joseph Hancock, discusses a newly released study on life satisfaction among German adolescents. It also presents the health behaviour inequalities among German girls and boys following different education tracks. The blog is a part of Wikichild's series on Health.

       Research has identified a clear link between people’s social position and their health. Mackenbach (2006) found health inequalities among people with higher and lower socio-economic status in all European countries and, furthermore, a widening of some of these inequalities during the last decades. In some countries, differences in life expectancy amount to 10 years or more due to these inequalities in educational level, occupational class and income inequalities. In addition to social status, we know that gender also substantially affects an individual's health. In general, the social gradient in health is more pronounced among men than women. However, these gender differences vary by age, health outcome, and also social status. In a birth cohort from 1958, for instance, Matthews et al. (1999) found greater social inequalities among men in their 30’s for long-standing illness but greater inequalities among women for psychological distress at the same age.

      Previously, studies focusing on gender differences in health inequalities have looked almost exclusively at adults. There is now a growing body of work suggesting that inequalities in health and health behaviours are already well-established by the time of transition from adolescent to adult, resulting from the social experiences and living conditions that young people experience during this formative period. For example, behavioural factors such as smoking, physical activity, fruit and vegetable consumption, or illegal drug use have been shown to be socially patterned behaviours, ingrained during the teenage years. Understanding the mechanisms which link the social position and health of adolescents is essential if we want develop effective strategies that help place socially disadvantaged teens on healthier, happier trajectories into adult life.

      Previous international research from the Health Behaviour in School-aged Children study (HBSC) revealed that life satisfaction, a multi-factorial psychological concept of well-being, is unequally distributed among different social groups. Adolescents from families with high social positions were found to have higher levels of life satisfaction than adolescents from families with lower social positions. These socially determined inequalities appear in nearly all countries across Europe and North America, in both boys and girls, and are stronger for life satisfaction than other subjective health indicators among teens.

      Using data from over 5,000 school children, members of the German HBSC national team investigated the role of health behaviour in explaining educational inequalities in adolescent life satisfaction nationally.

In particular they looked at:

1. The significance of differences in life satisfaction by educational track, in boys and girls. 
2. The presence of gender differences in terms of how behavioural factors impact life satisfaction. 
3. The different patterns of health behaviours among adolescents on different educational tracks.  
4. The extent to which educational inequalities in life satisfaction can be explained by behavioural factors.

The main results can be summarised as follows:

1. Significant inequalities in life satisfaction by educational track were found for both genders. The higher the educational track, the more likely it is that an adolescent would report high levels of life satisfaction. This effect was found to be stronger among boys than girls.

2. Several behavioural factors were found to be associated with low life satisfaction in both boys and girls. Such as not eating breakfast every day and drinking soft drinks daily. However, gender differences in the effect of behavioural factors on life satisfaction were also found. For example, the association between low life satisfaction and not having breakfast every school day was much stronger for girls than boys. Other behaviours such as smoking regularly, drinking alcohol, having been drunk, both watching TV and eating fruits daily were associated with lower life satisfaction in girls but not in boys. Whereas lower levels of physical activity were more strongly related to lower life satisfaction in boys than girls.

3. Regular smoking, having been drunk, watching TV, drinking soft drinks and eating breakfast less than daily were more prevalent among boys and girls from lower education tracks. Whereas frequent alcohol drinking, fruit consumption (less than daily) and daily sweet consumption were associated with lower education tracks only in girls, and physical activity only in boys.

4. In boys, three indicators were significantly linked to life satisfaction as well as to their educational track, including physical activity levels, eating breakfast and the consumption of soft drinks. Whereas a total of seven indicators, including smoking, drinking alcohol, having been drunk, watching TV, eating breakfast, fruits, and the consumption of soft drinks, were significantly linked to life satisfaction in girls. Altogether, up to 40% of educational inequalities in life satisfaction among girls were explained by behavioural determinants, which is nearly twice the figure for boys.

German adolescent health behaviors from Wikiprogress_slides

      The study's findings confirm that educational inequalities in life satisfaction are already established by adolescence. These findings also indicate that behavioural factors are an important mediating force, acting upon educational inequalities in adolescent life satisfaction for both boys and girls, but to a much greater extent among girls. In order to tackle inequalities in adolescent health, targeting health behaviours among teens from lower educational tracks, with a gender specific perspective, looks like a promising approach. 

More information on the analysis
 

Moor I, Lampert T, Rathmann K, Kuntz B, Kolip P, Spallek J, Richter M (2013): Explaining educational inequalities in adolescent life satisfaction: do health behaviour and gender matter? International Journal of Public Health. DOI 10.1007/s00038-013-0531-9

About the HBSC Study

      The HBSC research network is an alliance of researchers who collaborate to collect data on the health, well-being, health behaviours, social environments and economic contexts of adolescents. The HBSC study is currently conducted in 44 countries across Europe and North America, and the network includes over 450 experts from a wide range of disciplines. Members of the HBSC network collaborate to develop a standardized questionnaire, which is used to survey nationally representative samples of school-aged children in each participating country.

      HBSC's research themes currently include: chronic conditions, eating and dieting, electronic media, family culture, gender, medicine-use, peer culture, physical activity, positive health, puberty, risk behaviours, school, sexual health, social inequality, and violence and injuries.

For more information visit www.hbsc.org

See also:

The HBSC 30th Anniversary Summary Report

The HBSC Ireland Trends Report 1998-2010

The synthesis report for the online discussion "How should child well-being be measured?"

Cannabis Use among Adolescents in Europe, 2002-2010: Overall Decrease, but Increasing Inequalities

This blog, written ­by Dr. Margaretha de Looze (researcher and lecturer at Utrecht University, the Netherlands), discusses HBSC's study on cannabis use among adolescents in Europe. The post is part of the Wikichild series on Adolescent health, examining cross-national changes in frequent adolescent cannabis use (40+ times consumed over life-time at age 15) over time and relating these trends to societal wealth, family affluence and gender.

Cannabis use among adolescents in wealthy European countries is decreasing, while in poorer European countries it is on the rise. In particular, Russia, Latvia, Lithuania, and FYR Macedonia experienced increased cannabis consumption amongst adolescents between 2002 and 2010. These findings come from a recent publication by members of the Health Behaviour in School-aged Children (HBSC) study and research network.

Decrease in wealthy countries

 

This analysis, from 14 members of the international WHO collaborative study, looked at trends over time in frequent adolescent cannabis use (40+ times consumed over lifetime at age 15) in 2002, 2006 and 2010. We found that frequent cannabis use has decreased among adolescents in the more affluent western and southern European and North American countries. In some of these countries, the decreases were dramatic. For example, in 2010, frequent cannabis use among German boys decreased from 6.6% in 2002 to 1.2%, and  among Dutch girls it decreased from 4.1% in 2002 to 1.5%.  

This decline in frequent cannabis use in the wealthier countries of Europe is consistent with a general decrease in a range of other risk behaviours among these young people. In many of these countries, adolescent tobacco use, alcohol consumption, sexual risk behaviors and fighting have also declined.

How can this decline in adolescent risk behaviours be explained? One possible answer lies in substance use policies. Legislations to limit underage access and to restrict illicit substance use in general are enforced in all Western countries, with stricter substance use prevention policies coming into action in recent years. Additionally, a stronger focus on educating young people on the harmful effects of substance use has changed social norms leading to lower tolerance and acceptance of substance use among teenagers. 

Increase in Russia, Latvia, Lithuania, and FYR Macedonia

 

In contrast to Western European countries, frequent cannabis use stabilized or increased between 2002 and 2010 in the poorer Eastern European countries. For example, frequent cannabis use among boys in Latvia increased from 1.1% to 3.3%, with Russian girls showing an increase from 0.2% to 0.8%. 

Although the rates in these countries are still lower than those in Western Europe, the increasing trends over time are steady - and thus alarming. Adolescents from less affluent countries seem to be adopting consumption patterns consistent with their peers in richer countries. 

The growing wealth of Eastern European countries appears to have fostered adolescent substance use due to the increased availability of substances and the emergence of a flourishing youth culture. However, this apparent effect of national wealth seems to have leveled off in Western European countries, potentially due to the implementation of stricter cannabis use policies.

Importantly, adolescent cannabis use appears not only to have ‘trickled down’ from richer to developing countries, but also from more affluent to less affluent youth within countries. While cannabis consumption emerged as a central component of the ‘Bohemian’ ideals of the 1960’s and 1970’s and was first popularized by middle class youth, it now appears to have spread to the youth population of a lower socioeconomic status.

Girls do not catch up with boys

While one might have expected that gender differences would narrow between 2002 and 2010, as a result of girls’ and women’s continuing liberation, cannabis use has actually become (even) more characteristic of males during this period. This rather surprising finding might be explained by the de-normalization of cannabis use over the past decade. While cannabis use was widespread and quite ‘normalized’ among well-adjusted, non-risk-taking young people at the end of the 20th century, the recent declining rates may have changed young people’s perception of cannabis use as de-normalized and highly risky behaviour. As risk-taking increases social status among boys but less so for girls, it may be easier for boys to remain part of a cannabis-using scene.

Although it is reassuring that, overall, cannabis use has decreased for both genders, male adolescents have always been, and remain, at higher risk for excessive use, dependence and associated health problems.

What next?

Future studies should closely monitor tendencies for ‘trickle down’ and ‘de-normalization’ effects in frequent cannabis use as fundamental indicators of substance use and health in adolescent populations. Currently, data for the new HBSC cycle are being collected in more than 40 countries in Europe and North America. Within a year, we will be able to conclude whether the observed trends have continued into 2014

The HBSC Study

The HBSC research network is an alliance of researchers who collaborate to collect data on the health, well-being, health behaviours, social environments and economic contexts of adolescents. The HBSC study is currently conducted in 44 countries across Europe and North America, and the network includes over 450 experts from a wide range of disciplines. Members of the HBSC network collaborate to develop a standardized questionnaire, which is used to survey nationally representative samples of school-aged children in each participating country.
HBSC's research themes currently include: chronic conditions, eating and dieting, electronic media, family culture, gender, medicine-use, peer culture, physical activity, positive health, puberty, risk behaviours, school, sexual health, social inequality, and violence and injuries. 

- Dr. Margaretha de Looze
Researcher and lecturer at Utrecht University, the Netherlands 

For more information visit www.hbsc.org 

See also:
- Injury Among Young Canadians: A national study of contextual determinants
- Health Behaviour in School-Aged Children
- Adolescence

FGM: the Dynamics of Change

This blog, by Wikichild Co-ordinator Melinda Deleuze, is part of the Wikiprogress Series on the Wikiprogress Africa Network. This post provides a summary of the UNICEF report entitled “Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change.” 

When I first heard of female genital mutilation/cutting (FGM/C), I was mortified. Upon reading this UNICEF report, I realized that my previous impressions - that this practice it only occurs in small African villages and affects very few women -  were misconceptions. Only now is reliable data on FGM/C available, giving us a clearer picture about the practice, at least for all 29 countries where the practice is concentrated. The report addresses key questions: How many girls and women have undergone FGM/C? Where is the practice most prevalent? How does this concentration vary within countries and across population groups? 

This WHO report defines FGM/C as “all procedures involving partial or total removal of the female external genitalia or other injury to the female genital organs for non-medical reasons,” and the Organization categorizes the procedure into 4 types. In 2012, the UN General Assembly unanimously passed a resolution that banned FGM/C. Twenty-six countries in Africa and the Middle East have prohibited FGM/C by law; however, the legislation has proven ineffective. The practice remains widespread in 24 countries where FGM/C is illegal. 

There is a social obligation to perform the procedure and the belief that if one does not, then the consequences could include exclusion, criticism, ridicule, stigma or inability to find suitable marriage partners. Relatively few women reported concern over marriage prospects as justification for FGM/C, except in Eritrea and Sierra Leone. The primary benefit cited among men and women was social acceptance and preserving virginity.

In the 29 countries assessed, more than 125 million girls and women alive today have undergone FGM/C, and in the next decade, another 30 million are at risk. There is a large variation in percentages of cut females across the countries. The countries are divided into 5 categories based on their prevalence levels of FGM/C. One in five cut girls live in one country: Egypt.

 

Variation among regions within a country can be striking, as seen in this map of Senegal (right).

The age at which the procedure is carried out varies across countries. In Somalia, Egypt, Chad and the Central African Republic, at least 80% of cut girls were between 5 and 14 years old. In Nigeria, Mali, Eritrea, Ghana and Mauritania, at least 80% of cut girls were younger than 5. Half of cut girls in Kenya were older than 9 when they had the procedure performed.

Initially, opposition towards the practice focused on health risks, which may have unintentionally encouraged medical professionals to carry out the practice. Traditional practitioners and, more specifically, traditional circumcisers usually perform FGM/C. Though, in countries such as Egypt, Sudan and Kenya, many medical personnel now complete the procedure. In Egypt, for example, 77% of procedures were carried out mostly by doctors, and around half of those procedures were performed at the girl’s home.

Ethnicity still plays a strong role in some countries, as it may be a proxy for shared norms and values. Also, the practice remains to be a physical marker of insider/outsider status. This graph below shows the degree of variability in FGM/C prevalence among ethnic lines by contrasting ethnic groups with the highest and lowest prevalence in countries.

Regarding religion, the practice is most prevalent among Muslim girls and women; however, it is also found among Catholic and other Christian communities. In Niger, for example, 55% of Christian girls and women have undergone FGM/C, compared to 2% of Muslim girls and women.

There is also a rural-urban divide, an income divide, and an education divide. In Kenya, for example, the percentage of girls in rural areas was four times that of those in urban areas. In most instances, daughters of wealthier families were less likely to be cut. In terms of education, the prevalence of FGM/C was highest among daughters of women with no education, and tends to diminish considerably as the mother’s educational level rises. The reason given for these trends is due to the fact that those in urban areas, in wealthier households, or with a higher educational level are more likely to interact with individuals and groups that do not practice FGM/C, shifting normative expectations around FGM/C as a result.

Support for the continuation of FGM/C varies across countries. In most countries (19 out of 29), a majority of girls and women think the practice should end (see graph below). Nevertheless, more than half the female population in Mali, Guinea, Sierra Leone, Somalia, Gambia and Egypt think FGM/C should continue. More men than women favored stopping the practice, especially in Guinea, Sierra Leone and Chad. When fathers were included in the decision-making, their daughters were less likely to be cut. 

FGM/C remains a complicated issue, and this report does not give the whole picture; FGM/C is being performed outside these 29 countries, including  in Europe and North America. The fight against FGM/C has just begun. Stronger efforts will be essential in order to transform the cultural traditions and expectations ingrained in these societies. 

Fortunately, this report gives us a better understanding of FGM/C and, more importantly, an evidence base to begin measuring progress in this area. We know there have already been steps forward in terms of awareness, decreased health risks and legislative bans, but now we can track progress inside countries regarding specific population groups, procedures and attitudes. Hopefully, this evidence base will help us be more effective in promptly eliminating the practice.

- Melinda Deleuze

*This week's Wikiprogress spotlight is on the e-Frame Net (European Network on Measuring Progress).  

Abstinence doesn’t do the trick

This blog, written by Wikichild co-ordinator Melinda Deleuze, discusses the negative impact that adolescent pregnancies can have on the child, the mother and all of society. It is a contribution to the last day of the Wikiprogress spotlight on the Wikigender Network.

When I was 16 years old, I had one week of sex education required by my American high school. However, my state’s curriculum revolved around abstinence as the preferred means of birth control, along with fear as the method to encourage restraint until marriage. In my class, at least one girl, aged 15, already had an abortion before taking the course, and one boy, also aged 15, was a father. The course provided too little, too late. YES, abstinence has a 100% success rate. YES, it is the best way to avoid catching a sexually transmitted infection. NO, I’m not surprised that the US ranks second to last among the rich countries for number of teen births: 36 per 1,000 births among 15-19 year old girls (read more in this blog). 

Rich countries vs. the US in teen births (per 1,000 15-19 years old)

*Legend: In the lefthand graph, the UNICEF 

colors  represent the first, second and third 

Data from UNICEF's 11th Report Card and KIDS COUNT Data Book. 

tiers of countries' ranking. In the graph on the right, the colors match states with the country tiers. In this case,  the darkest blue indicates the 21 states which have a higher rate of teen births than the lowest ranking country (i.e. Bulgaria).

This year’s UN World Population Day focused on adolescent pregnancies, a persistent occurrence in both developing and developed countries. Around 16 million adolescent girls aged 15 to 19 give birth each year, according to the WHO. While there may be varying opinions on this issue, the fact is that adolescent pregnancies gravely affect the teen mother, the child and the rest of society (i.e. you and me). Despite misleading perceptions, these consequences can occur among married and unmarried adolescents in developed and developing countries for both intended and unintended pregnancies.

 How does it affect the well-being of the child?

The immediate health of children born to adolescent mothers is at risk, and the younger the mother, the higher the risk. This WHO Report states that “in low- and middle-income countries, stillbirths and death in the first week and first month of life are 50% higher among babies born to mothers younger than 20 years than those born to mothers aged 20–29 years.” Also, babies born to adolescent mothers are more likely to be pre-term, have a lower birth weight and have asphyxia, which all increase the baby’s chance of death or future health problems. Substance abuse during pregnancy is higher among adolescent girls, which contributes to a higher percentage of low birth-weight babies and infant mortality, along with other health issues.

How does it affect the well-being of the young mother?

First of all, the health of young mothers is severely compromised, as pregnant teenagers face double the risk of dying from pregnancy-related complications relative to women in their 20s.* This UNFA report summary states that “across developing countries, complications from pregnancy and unsafe abortion are the leading cause of death for girls aged 15-19.” The younger the mother, the more she is at risk of maternal complications, death and disability, including obstetric fistula. Up to 65% of women with obstetric fistula developed this during adolescence, says this WHO Report. Additionally, adolescent pregnancies are at higher risk for sexually transmitted diseases. Younger girls are less likely to practice safe sex and make up 64% of all new infections among young people worldwide, states this UNFPA factsheet.

Additionally, adolescent pregnancy contends with secondary education. In developed countries, motherhood during adolescent years increases girls’ chances of dropping out of school. In the United States, teen mothers are 10% less likely to obtain a high school diploma, as shown in this UNFPA report summary. Whereas in developing countries, the longer girls remain in school, the less likely they are to become pregnant in their teens. In Timor-Leste, for example, total fertility rates vary from 6 to1 ratio births per woman with no education to only 2 to 9 ratio births for women with secondary schooling or above, as indicated in this Women Deliver background paper. Delaying childbearing also increases chances of obtaining a higher income and better careers, among with other aspects of well-being, such as mental and psychological.

How does it affect the overall well-being of society?

Adolescent pregnancies concern us all as they negatively impact the development of a society. This UNFPA report summary states that “investing in family planning helps reduce poverty, improve health, promote gender equality, enable adolescents to finish their schooling and increase labour force participation.” In the UN Secretary-General Ban Ki-moon’s message for this year’s World Population Day, he stated that “when we devote attention and resources to the education, health and well-being of adolescent girls, they will become an even greater force for positive change in society that will have an impact for generations to come.”

I’m grateful that the World Population Day addressed adolescent pregrancy. While we often talk about maternal and infant mortality rates, as well as low birth-weight babies, we overlook at times this major proponent. I hope that there can be more open conversations with teens in order to overcome some of the obstacles to preventing teen pregnancies. And believe me, teaching abstinence just doesn't do the trick.

Melinda Deleuze

* Gennari, Pamela, J. 2013. “Adolescent Pregnancy in Developing Countries.” International Journal of Childbirth Education 28:57

Adolescent Well-Being in Focus

Image taken from HBSC International Study 2011

Last week, Wikichild launched its first online discussion at Health Behavior in School-Aged Children’s 30thAnniversary event in St. Andrews, Scotland. The event, which spread over three days, featured a diverse range of speakers including participants from UNICEF, the OECD and Johns Hopkins University, who each in turn offered their insight into the field of child well-being.

The Wikichild presentation and following discussion were a great success with members of the audience showing enthusiasm for the online consultation platform. At Wikichild, Wikiprogress and Wikigender, it is our hope that these online discussions will allow researchers and policy makers to interact with members of the public and thus garner a more comprehensive perspective on important topics such as child well-being.

An interesting point that was raised during our presentation was that the online discussion references children without specifying what we mean by the word. Do we mean someone younger than 18 years or young people between 10 and 19 years? The consultation is intended to encapsulate opinions on the well-being of very young children and adolescents, however, the audience member who raised the issue, stipulated that the well-being of each group must be measured separately, both now, and in the future.

According to a recent Lancet paper on adolescent health, the health of young people between the age of 10-24 has improved far less than that of younger children over the past 50 years. This is due in part to the inadequate identification by researches and policy makers of adolescents as an individual group. It seems that the term young person not only has a number of different meanings but a range of definitions, which often overlap: a ‘child’ is defined by the Convention on the Rights of the Child as a person younger than 18 years, ‘adolescence’ is categorized by the World Health 0rganization as the period between 10 and 19 years, the UN defines ‘youth’ as people aged between 15 and 24 years and so on (‘Adolescence: a foundation for future health’ – The Lancet). As a  result, governing bodies have struggled to focus investments to address the needs of adolescents.   

‘Building a worldwide agenda for adolescent health needs an escalation in the visibility of young people and an understanding of challenges to their health and development.’ Seizing the opportunities of adolescent health – The Lancet

While child well-being in itself is a fairly new topic of study, adolescent health is a much younger discipline by comparison. Decades of clinical experience and research has generated noticeable improvements in the growth and the integration of child public health, and members of the Lancet team argue that the same process must be applied to the field of adolescent well-being. 

The present generation of young people is the largest in history – with a population of 1.8 million, the majority of which live in low-income countries. In Africa for example, Young people aged between 15 and 25 represent more than 60 per cent of the continent’s total population and account for 45 per cent of the total labour force. Adolescents face notably different challenges from previous generations including rising poverty, inadequate education and mass unemployment and as a result there are increasing calls by experts for adolescent well-being to be high on the agenda for future development frameworks such as Post-2015.

To have your say on what you believe are the most important domains of well-being for young people, and how these areas should be measured, leave a comment on our discussion page. The conversation has already had some excellent input and we want to hear your opinion. Make your voice heard!

Robbie Lawrence

Wikichild Coordinator