"This study provides the most comprehensive information available to date about young people's attitudes and health-related behaviour in the countries surveyed," notes Erio Ziglio, Regional Adviser, Health promotion & Investment for Health at the WHO Regional Office for Europe. "It provides the evidence base to focus on the effectiveness of public health actions aimed at improving the health of young people. It provides a mechanism to make a radical departure from the tradition of top-down planning and professional dominance of the public health process. With the results of the study, young people themselves can now map out where and how behaviour change meshes with policy development; where the psychological domain connects with the economic and political domains."

The study collected data in eight areas (see selected summary attached).

• The general health and wellbeing of adolescents
• Family and peer relationships
• The school environment and the health of adolescents
• Socioeconomic inequalities in adolescent health
• Exercise and leisure activities
• Dietary habits, body image and dental care
• Substance use
• Sexual behaviour.

The data can be used in two ways: to study trends over time both within and between countries and to facilitate analysis of interrelationships between behaviour and health and the factors that affect them. Both uses are of crucial importance for the development of timely and relevant health promotion actions and health education initiatives at the national and international levels.

These comparative data are derived from core questionnaire items included in four international surveys carried out in 1985/1986, 1989/1990, 1993/1994 and 1997/1998. These questions included information on:

• demographic characteristics such as age, sex, household composition and parents' occupation;
• health-related behaviour such as the use of tobacco, alcohol, drugs and medication, exercise and eating habits, leisure activities and dental hygiene;
• general perceptions of personal health and wellbeing, and physical ailments;
• psychological adjustments, including self-assessment of mental health, body image, and family relations and support;
• peer relationships and support; and
• perceptions of the school and its influence.

New items in the 1997/1998 survey are those covering school experience, relationship with parents, socioeconomic status and body image.

This is the second international report on the HBSC Study: The first, entitled The health of youth (WHO Regional Publications, European Series, No. 69), reported the findings of the 1993/1994 survey. The current report is part of a new WHO document series, "Health Policy for Children and Adolescents", targeting experts in all parts of the world who are concerned with health-related issues or whose area of work directly or indirectly affects the health of young people.

For more information on this subject contact:

Health Promotion and Investment for Health
WHO Regional Office for Europe
Scherfigsvej 8, DK-2100, Copenhagen Ø, Denmark
Fax: +45 39 17 18 18
E-mail: vbr@who.dk

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The WHO Health Behaviour in School-Aged Children (HBSC) Study
Selected findings and discussion

The general health and wellbeing of adolescents.
Some 90% of adolescents in 23 countries reported feeling relatively healthy. The least positive were those in the countries of central and eastern Europe and in Estonia, Northern Ireland, the Russian Federation, the USA and Wales. More reported the regular occurrence of specific symptoms (e.g. headache or stomach ache) and the use of medication than reported being unhealthy. For seven of the countries and areas surveyed (Canada, England, Finland, Northern Ireland, Scotland, the USA and Wales), 50% or more of 15-year-olds reported using medication regularly.

Nerve medicine was used less often than analgesics. A relatively high level of use of nerve medicine was noted among 15-year-olds in Greenland (25%) and Israel (17%). The remaining countries1 showed a spread between almost no use (1%) in Norway to 13% in the Russian Federation.

Family and peer relationships
Communication difficulties become more frequent during puberty. Communicating with fathers was more difficult then mothers in all countries, 52% of 15-year-olds indicating it was difficult or very difficult to talk with their fathers. Difficulty in parental communication was strongly associated with difficulties in talking with other siblings, with feeling less happy (girls), with smoking and with drinking alcohol more often (13- and 15-year-old girls). Family problems, negative moods and the influence of the peer group are seen as strong predictors of the use of tobacco and alcohol. The data show a direct association between smoking and difficulties in talking to parents.

While involvement in a peer group seems to improve communication skills in the youngest group, it is associated with increased risk behaviour among older groups. For 15-year-olds the amount of time spent with friends is a decisive predictor for smoking and the experience of drunkenness.

The school environment and the health of adolescents
Students' perceptions of involvement in decision-making at school and support from their teachers are the two factors that correlate most strongly with their sense of satisfaction with school. Students who do not feel involved and supported by teachers are more likely to turn their back on school and to start smoking.

Socioeconomic inequalities in adolescent health
Here the study introduced new variables to measure wealth. In all countries and areas, greater wealth was associated with subjective happiness, and in the vast majority it was associated with feelings of confidence and of not feeling helpless, and with perceived health and infrequent experience of physical symptoms such as headaches. By contrast, there was no consistent pattern of association between the occupational status of the parents and indicators of health and wellbeing. Smoking and drinking among 15-year-olds did not appear to be associated with the socioeconomic status of the family.

Exercise and leisure activity
Levels of participation in physical activity were quite high in most countries, although great variations are noted. For example, 69% of 15-year-old boys in Denmark exercise two or more times a week, compared with 90% in Northern Ireland. Those who exercise are more likely to spend time with friends, feel confident and have access to a family car. The finding that students with one or more family cars are more likely to exercise suggests that having access to leisure facilities and wealthier parents may have some bearing on levels of exercise.

In almost all countries, less then half the students watched television for four hours or more a day. A similar picture emerged for computer games. The available data do not demonstrate that these sedentary activities have a strong link with lower levels of physical exercise.

Students who watched more television were more likely to consume so-called junk food. Snack food eating was linked more closely to watching television than to playing computer games.

Dietary habits , body image and dental care
In general, girls ate more fruit and vegetables daily, while boys drank more milk and consumed foods that were less nutritious and higher in fat and/or sugar (e.g. potato crisps, fried potatoes, candy and chocolate and soft drinks).

More then 20% of students in 13 countries reported eating potato crisps every day. The highest figures were from England, Ireland, Northern Ireland, Scotland and Wales, ranging from 45% to 78%.

Girls brushed their teeth more than boys and also dieted more, a trend that increased with age.

Substance use
Experimentation with tobacco use is increasing across all age groups in all countries (60-70% of 15-year-olds stated they had tried tobacco in previous 12 months). Clearly, in all countries, legislation that attempts to control cigarette availability is either not fully enforced or is ineffective. The strong association between tobacco experimentation and alcohol use, illustrating the clustering of risk behaviour, is weaker among younger girls.

Weekly and daily smoking varies widely, rates for 15-year-olds being, for example, 6% in Lithuania and 56% in Greenland. None of the study areas showed a decrease in weekly smoking among 15-year-olds since the previous survey.

Alcohol use increases substantially with age. Weekly drinking rates vary widely . Of concern are the high absolute rates of weekly beer drinking among 15-year-olds in Wales (50%), Denmark (43%), Greece (42%) and England (40%).The frequency of beer drinking is most clearly associated with peer involvement and school factors. Perceived drunkenness is lowest in France, Greece, Israel, Portugal and Switzerland, while in England, Northern Ireland, Scotland and Wales it is consistently high.

Sexual behaviour
Nine countries or areas were assessed with regards to sexual behaviour. Questions focused on experience of sexual intercourse, age of first intercourse, use of condoms and birth control. Among 15-year-olds, 10-38% of girls and 23-42% of boys indicated they had experienced intercourse. The average age at first intercourse ranged from 13.78 to 14.86 years for boys and from 14.22 to 15.53 years for girls. Among those sexually active at the age of 15, condoms were used by 63-87% of boys and by 55-86% of girls. Among sexually active girls, contraceptive use varied from 98% in France to 67% in Latvia.

Country profiles
The HBSC Study includes demographic data; including those on population, unemployment, family size, marriage and divorce rates, as well as on regulations in place to protect the health of children, particularly in relation to the consumption of tobacco and alcohol by adolescents.

(1) The study countries and areas comprise: Austria, Belgium, Canada, the Czech Republic, Denmark, England, Estonia, Finland, France, Germany, Greece, Greenland, Hungary, Ireland, Israel, Latvia, Lithuania, Northern Ireland, Norway, Poland, Portugal, the Russian Federation, Scotland, Slovakia, Spain, Sweden, Switzerland, the United States of America and Wales.

For more information, contact:

Communication and Public Affairs
WHO Regional Office for Europe
Scherfigsvej 8, DK-2100, Copenhagen Ø, Denmark
Fax: +45 39 17 18 80
E-mail: fap@who.dkor ana@who.dk

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