Measuring Health Literacy in Basic Education in Finland: The Development of a Curriculum- and Performance-Based Measurement Instrument.

This paper describes the development of an objective curriculum- and performance-based health literacy (HL) measurement instrument to assess Finnish 9th graders' learning outcomes in the school subject termed Health Education (HE). There were four phases: (i) construction of the theoretical framework for the measurement, (ii) item generation, (iii) the field test (n = 252), and (iv) item analysis and item selection for the main study, in which 3652 ninth grade pupils (aged 15-16) participated. Initially, 303 HL test items were formulated, of which 107 were tested in two different field test versions. Both versions exhibited high reliability as measured by Cronbach's alpha coefficient. The main study contained 55 items. Testing and item analysis enabled the development of a comprehensive competence- and curriculum-based HL measurement instrument for school-aged children. Measurement of HL in schools provides information for national policies, and for developing HE as a school subject.

Intersectoral partnerships and competencies for mental health promotion: a Delphi-based qualitative study in Finland.

The importance of intersectoral collaboration and partnership working in mental health promotion, together with the requisite competencies for effective collaboration, is widely acknowledged. This Delphi-based qualitative study examined how intersectoral collaboration and partnership work are constructed and adopted in mental health promotion practice. Descriptive data from a Delphi panel of mental health promotion practitioners working in the health sector (n = 32) were used as a data source. Thematic analysis was used to analyze the data. Applying the theory of collaborative advantage, eight themes of collaboration advantage and the related competencies were identified: management structure, leadership, communication and language, common aims, working processes, resources, trust, and commitment and determination. The themes capture the competencies required to influence and work with others to improve the mental health and wellbeing of individuals and communities. The identified theme areas can be used to inform education and training and capacity building for professional practice in mental health promotion. Future research is needed to explore other possible collaborative advantage themes in mental health promotion practice and the competencies required to facilitate effective partnerships across sectors. Further investigations are also needed on the identified theme areas in order to develop and guide capacity building and training in mental health promotion.

Objective health literacy skills among ninth graders in Finland: outcomes from a national learning assessment.

BACKGROUND: Health literacy (HL) is an important determinant for maintaining and improving health throughout the lifespan. This underlines the need to monitor HL, including among adolescents, and to understand the factors explaining HL, with a view to decreasing differences in HL. The aim of this study was to objectively measure HL, and the relationship between HL and socio-demographic factors (gender, language of instruction, pupils' educational aspirations, parents' educational background and pupils' school achievement) among pupils (n = 3652) at the end of basic education in Finland. METHODS: A nationally representative assessment, which included 55 items on HL, was conducted as a traditional paper-and-pencil test in schools. The data were analysed via descriptive statistics and a two-level hierarchical linear model to determine how the socio-demographic factors affected HL. RESULTS: The pupils' average score on the HL test items was 58.9%, indicating a satisfactory HL level. A two-level hierarchical linear model showed that the variables (gender, language of instruction, pupils' educational aspirations, parents' educational background and pupils' school achievement) predicting the HL level had statistically significant effects. CONCLUSIONS: Among ninth graders (15-16 years old), almost one third of the boys and 8% of the girls exhibited an unsatisfactory HL level. The study also confirmed the importance of school-related factors in explaining HL differences. Since low HL has been linked to several unfavourable health indicators and has been viewed as an underestimated problem in times of pandemic and other health crises, the findings suggest that the HL level of Finnish ninth graders is a clear public-health issue.

Haemoglobin, iron status and lung function of adolescents participating in organised sports in the Finnish Health Promoting Sports Club Study.

OBJECTIVES: To compare laboratory test results and lung function of adolescent organised sports participants (SP) with non-participants (NP). METHODS: In this cross-sectional study, laboratory tests (haemoglobin, iron status), and flow-volume spirometry were performed on SP youths (199 boys, 203 girls) and their NP peers (62 boys, 114 girls) aged 14-17. RESULTS: Haemoglobin concentration <120/130 g/L was found in 5.8% of SP and 5.1% NP (OR 1.20, 95% CI 0.54 to 2.68). Ferritin concentration below 15 µg/L was found in 22.7% of both SP and NP girls. Among boys ferritin <30 µg/L was found in 26.5% of SP and 30.2% of NP (OR 0.76, 95% CI 0.40 to 1.47). Among SP iron supplement use was reported by 3.5% of girls and 1.5% of boys. In flow-volume spirometry with bronchodilation test, 7.0% of SP and 6.4% of NP had asthma-like findings (OR 1.17, 95% CI 0.54 to 2.54); those using asthma medication, that is, 9.8% of SP and 5.2% of NP were excluded from the analysis. CONCLUSIONS: Screening for iron deficiency is recommended for symptomatic persons and persons engaging in sports. Lung function testing is recommended for symptomatic persons and persons participating in sports in which asthma is more prevalent.

Associations between Adolescents' Interpersonal Relationships, School Well-being, and Academic Achievement during Educational Transitions.

A youth's ability to adapt during educational transitions has long-term, positive impacts on their academic achievement and mental health. Although supportive relationships with parents, peers, and teachers are protective factors associated with successful educational transitions, little is known about the reciprocal link between the quality of these interpersonal relationships and school well-being, with even less known about how these two constructs affect academic achievement. This longitudinal study examined how the quality of interpersonal relationships and school well-being worked together to affect academic achievement during the transition from primary school to lower secondary school. Data were collected from 848 Finnish adolescents (54% girls, mean age at the outset 12.3 years) over the course of sixth and seventh grade. The results support a transactional model illustrating the reciprocal associations between the quality of interpersonal relationships and school well-being during the transition to lower secondary school. As such, the presence of high quality interpersonal relationships promoted higher academic achievement through increased school well-being, whereas high school well-being promoted higher subsequent academic achievement through increased quality of interpersonal relationships. Overall, the results suggest that promoting learning outcomes and helping adolescents with challenges during educational transitions is a critical part of supporting school well-being and the formation of high-quality interpersonal relationships.

Empowerment-enabling home and school environments and self-rated health among Finnish adolescents.

Perceived health during adolescence has not only immediate consequences for individuals and for society, but also long-term. We need to understand better the health development in this period of the lifespan. Empowerment may be one pathway through which social factors and conditions translate into health effects. This study aimed to examine whether empowerment-enabling home and school environments are associated with self-rated health among adolescents, and whether the associations differ between genders, age or majority/minority language groups. Anonymous questionnaire data from respondents aged 11, 13 and 15 years were obtained from the Health Behaviour in School-aged Children study, conducted in Finland in 2014 in Finnish- and Swedish-speaking schools (n = 5925/1877). The proportion rating their health as excellent varied between 33.6 (11-year-olds) and 23.1% (15-year-olds), boys rating their health as excellent more often than girls in all age groups. Findings showed that indicators of both empowerment-enabling home and school environments were independently and positively related to adolescents' self-rated health. Whereas a respectful, accepting, kind and helpful attitude among classmates and a good home atmosphere were quite consistently associated with excellent health, there were gender and age differences with concern to the other empowerment-enabling indicators. Moreover, there were gender-, age- and language-related differences regarding adolescents' perceptions of how empowerment enabling their environments were. Home and school environments that create opportunities through encouragement and care, and through strengthening feelings of being secure, accepted and respected are potentially empowerment enabling. This study suggests that such environmental qualities are important for the perceived health of young people.

Counselling for physical activity, life-space mobility and falls prevention in old age (COSMOS): protocol of a randomised controlled trial.

INTRODUCTION: The most promising way to promote active life years in old age is to promote regular participation in physical activity (PA). Maintaining lower extremity muscle function with good balance has been associated with fewer falls and the need of help from others. This article describes the design and intervention of a randomised controlled trial (RCT) investigating the effectiveness of a health and PA counselling programme on life-space mobility and falls rates in community-dwelling older adults at the Health Kiosk and/or Service Centre. METHODS AND ANALYSIS: Community-dwelling men and women (n=450) aged 65 years and over with early phase mobility limitation will be recruited to a 24-month RCT with a 24-month follow-up. Participants will be randomly allocated into either a health and PA counselling group (intervention) or relaxation group (control intervention). All participants will receive five group specific face-to-face counselling sessions and 11 phone calls. The counselling intervention will include individualised health counselling, strength and balance training, and guidance to regular PA. The control group will receive relaxation exercises. Outcomes will be assessed at baseline, 12, 24 and 48 months. Primary outcomes are average life-space mobility score and falls rates. Life-space mobility will be assessed by a validated questionnaire. Falls rates will be recorded from fall diaries. Secondary outcomes are data on fall-induced injuries and living arrangements, number of fallers, fracture risk, mean level of PA, physical performance, quality of life, mood, cognition, balance confidence and fear of falling. Data will be analysed using the intention-to-treat principle. Cost-effectiveness of the programme will be analysed. Ancillary analyses are planned in participants with greater adherence. ETHICS AND DISSEMINATION: Ethical approval was obtained from the Ethics Committee of the Tampere University Hospital (R15160). Outcomes will be disseminated through publication in peer-reviewed journals and presentations at international conferences. TRIAL REGISTRATION: ISRCTN65406039; Pre-results.

Test-retest reliability of adolescents' self-reported physical activity item in two consecutive surveys.

BACKGROUND: National monitoring of school-aged physical activity (PA) behaviours is necessary to inform policy makers. The Finnish School-aged Physical Activity (FSPA - LIITU in Finnish) is a physical activity monitoring study, collecting data from young adolescents aged 11 to 15 years through a nationally representative sample. This study included a single self-reported item question on moderate to vigorous intensity physical activity (MVPA) from the preceding seven days. The question is used widely in the WHO Collaborative Cross-National Health Behaviour in School-aged Children (HBSC) study as a measure of meeting international PA recommendations. This study evaluated the test-retest reliability of the aforementioned MVPA item in two consecutive surveys while observing gender and age categorisation differences. METHODS: In this study, Finnish adolescents with mean ages of 11.5y, 13.5y and 15.5y (n = 2752) completed the HBSC and FSPA surveys in two 45 min class periods without a break in 2014. The HBSC survey completion mode was through pen and paper, and the FSPA study through a web-based questionnaire. The same MVPA question appeared in both surveys. Response alternatives (0-7 days per week) were grouped into four, and two categories in the analyses. Cohen's Kappa and ICC statistics were performed to test the intra-rater test-retest reliability of the measure. RESULTS: According to Cohen's Kappa, there was moderate agreement through the use of four (0.503) and two (0.599) categories, however, the proportion of adolescents that met the recommended daily 60 min of MVPA was 8% lower in the FSPA study than in the HBSC study (19% vs 27%). In addition, ICC for MVPA, as continuous variable (0-7 days) had good to excellent reliability (range 0.694-0.765) for boys and girls aged 13 to 15 years, but only fair (0.565) for boys aged 11. CONCLUSIONS: This study demonstrated that single item MVPA item was considered to have acceptable reliability of the measure for monitoring purposes of 13- and 15-year old boys, and 11y-, 13- and 15y-old girls meeting the international PA recommendations. There were differences in the prevalence in daily MVPA due to survey design.

Mental health promotion competencies in the health sector in Finland: a qualitative study of the views of professionals.

AIMS: In this study, we aimed to investigate what competencies are needed for mental health promotion in health sector practice in Finland. METHODS: A qualitative study was carried out to seek the views of mental health professionals regarding mental health promotion-related competencies. The data were collected via two focus groups and a questionnaire survey of professionals working in the health sector in Finland. The focus groups consisted of a total of 13 professionals. Further, 20 questionnaires were received from the questionnaire survey. The data were analysed using the qualitative data analysis software ATLAS.ti Scientific Software Development GmbH, Berlin. A content analysis was carried out. RESULTS: In total, 23 competencies were identified and clustered under the categories of theoretical knowledge, practical skills, and personal attitudes and values. In order to promote mental health, it is necessary to have a knowledge of the principles and concepts of mental health promotion, including methods and tools for effective practices. Furthermore, a variety of skills-based competencies such as communication and collaboration skills were described. Personal attitudes and values included a holistic approach and respect for human rights, among others. CONCLUSIONS: The study provides new information on what competencies are needed to plan, implement and evaluate mental health promotion in health sector practice, with the aim of contributing to a more effective workforce. The competencies provide aid in planning training programmes and qualifications, as well as job descriptions and roles in health sector workplaces related to mental health promotion.

The cross-national measurement invariance of the health literacy for school-aged children (HLSAC) instrument.

BACKGROUND: Health literacy (HL) is an important determinant of health and health behaviours, and there is a need to monitor HL levels among all population groups. It is therefore essential to develop instruments to assess HL during childhood and adolescence. The aim of this study was to examine the cross-national measurement invariance of the instrument Health Literacy for School-aged Children (HLSAC) in four European countries. METHODS: The data were collected via standardized self-administered anonymous questionnaires within classrooms in Finland, Poland, Slovakia, and Belgium. There were in total 1468 respondents (aged 13, N = 690; aged 15, N = 778). The HLSAC instrument was used to measure the subjective HL of adolescents in each country. A multigroup confirmatory factor analysis was applied to test measurement invariance. RESULTS: Configural and metric invariance was established, but scalar invariance did not hold. However, the instrument exhibited high internal consistency (α = 0.85) and showed adequate fit with the data. Moreover, the partial invariance allowed comparison of mean values across the countries in question. There were significant mean value differences between countries and age-groups. CONCLUSIONS: HL mean values (as assessed via the HLSAC instrument) can be compared across countries. The instrument has utility for large-scale international HL studies on adolescents.

Musculoskeletal examination in young athletes and non-athletes: the Finnish Health Promoting Sports Club (FHPSC) study.

OBJECTIVES: To determine the inter-rater repeatability of a musculoskeletal examination and to compare findings between adolescent athletes and non-athletes in Finland. METHODS: In this cross-sectional study, a musculoskeletal examination assessing posture, mobility and movement control was carried out by a sports and exercise medicine physician on 399 athletes aged 14-17 years and 177 non-athletes. Within 2 weeks another sports and exercise medicine physician repeated the examination for 41 adolescents to test the inter-rater repeatability. RESULTS: In total, 10 of the 11 tests performed had at least moderate inter-rater reliability (κ ≥0.4 or percentage agreement >80%). Athletes more often than non-athletes had one shoulder protruded (8.0% vs 4.0%, OR 2.81, 95% CI 1.16 to 6.81). Forty-six per cent of athletes had good knee control in the two-legged vertical drop jump test compared with 32% of non-athletes (OR 1.99, 95% CI 1.29 to 3.06). Athletes had better core muscle control with 86.3% being able to remain in the correct plank position for 30 s compared with 68.6% of non-athletes (OR 2.70, 95% CI 1.67 to 4.36). In the deep squat test, good lumbar spine control was maintained only by 35.8% of athletes and 38.4% of non-athletes. CONCLUSION: A basic musculoskeletal examination is sufficiently reliable to be performed by trained physicians as a part of a periodic health evaluation. Shortfalls in mobility, posture and movement control are common in both athletes and non-athletes. These deficits could have been caused by sedentary behaviour, monotonous training, or both.

Socioeconomic differences in the use of alcohol and drunkenness in adolescents: Trends in the Health Behaviour in School-aged Children study in Finland 1990-2014.

AIMS: The aims of this study were to explore time-based trends of socioeconomic differences in alcohol use and drunkenness in Finnish adolescents from 1990 to 2014 and to investigate the significance of two indicators in detecting socioeconomic differences in alcohol use and drunkenness. METHODS: Data were retrieved from seven surveys conducted as part of the Health Behaviour in School-aged Children (HBSC) study in Finland from 1990 to 2014. The alcohol use and drunkenness of 15-year-old students, as well as socioeconomic status, including educational aspiration and perceived family wealth, were assessed via a self-report questionnaire. Logistic regression models were used to investigate the relationships between alcohol use, drunkenness and indicators of socioeconomic status. RESULTS: The study showed that the alcohol use and drunkenness of Finnish 15-year-old adolescents have decreased since the late 1990s. However, the level of decrease is not consistent among different socioeconomic groups and socioeconomic differences in drinking behaviour between two educational aspiration groups have persisted over two decades. Girls from the groups with low perceived family wealth were more likely to be frequently drunk in the time period 2006-2014. CONCLUSIONS: This study suggests that students with low educational aspiration should be the target population for interventions aiming at reducing the alcohol use and drunkenness of Finnish adolescents. In future interventions aimed at reducing heavier drinking, adolescents (especially girls) from less wealthy families should be the first priority. Further studies on trends in socioeconomic differences in alcohol use and drunkenness in adolescence should be conducted using different indicators of socioeconomic status and other social context factors should also be taken into account.

Do adolescents with long-term illnesses and disabilities have increased risks of sports related injuries?

BACKGROUND: The aim of this study is to examine the rates of sports related injuries in adolescents based on the severity of their long-term illnesses or disabilities (LTID). Few injury prevention strategies in sports and health promotion have explored disaggregation by disability. METHODS: Data obtained from the 2014 Finnish Health Behaviour in School-aged Children survey (n = 3716, mean age = 14.8, SD = 1.03) were grouped into adolescents with and without LTID. A further indicator or severity was determined when adolescents reported their LTID affected their participation (affected LTID). Odds ratio (95% CI) were used to determine the associations between sports related injuries and LTID, daily moderate to vigorous physical activities (MVPA), being a sports club member, physical competence, and family encouragement, after controlling for age, gender and family affluence. RESULTS: One in four adolescents (25%) reported to have LTID and one in eight adolescents (12.5%) reported sports injuries. The odds for adolescents with chronic conditions, functional and learning difficulties was the highest (OR 3.55, CI = 2.3-5.4) for overall injuries, when compared with adolescents without LTID. Adolescents with affected LTID (OR = 2.08, CI = 1.5-2.9) were more likely to report medically attended injuries than adolescents without LTID. Sports-related injuries (OR = 0.33, CI = 0.1-0.8) were lower in adolescents with affected LTID than those without LTID after adjusting for personal and environmental factors. CONCLUSIONS: Taking part in sport clubs increases the risk of sports related injuries in adolescents with and without LTID, but not with affected LTID. Few adolescents with affected LTID participate in sports clubs and were less likely to report the most serious type of injury to be from sports. These results could be used for devising sports based injury prevention and health promotion strategies for children with LTID.

Subjective health literacy: Development of a brief instrument for school-aged children.

AIMS: The present paper focuses on the measurement of health literacy (HL), which is an important determinant of health and health behaviours. HL starts to develop in childhood and adolescence; hence, there is a need for instruments to monitor HL among younger age groups. These instruments are still rare. The aim of the project reported here was, therefore, to develop a brief, multidimensional, theory-based instrument to measure subjective HL among school-aged children. METHODS: The development of the instrument covered four phases: item generation based on a conceptual framework; a pilot study ( n = 405); test-retest ( n = 117); and construction of the instrument ( n = 3853). All the samples were taken from Finnish 7th and 9th graders. RESULTS: Initially, 65 items were generated, of which 32 items were selected for the pilot study. After item reduction, the instrument contained 16 items. The test-retest phase produced estimates of stability. In the final phase a 10-item instrument was constructed, referred to as Health Literacy for School-Aged Children (HLSAC). The instrument exhibited a high Cronbach alpha (0.93), and included two items from each of the five predetermined theoretical components (theoretical knowledge, practical knowledge, critical thinking, self-awareness, citizenship). CONCLUSIONS: The iterative and validity-driven development process made it possible to construct a brief multidimensional HLSAC instrument. Such instruments are suitable for large-scale studies, and for use with children and adolescents. Validation will require further testing for use in other countries.

Socioeconomic differences in adolescents' smoking: a comparison between Finland and Beijing, China.

BACKGROUND: Various studies have demonstrated the associations between socioeconomic status (SES) and health and health behaviour among adolescents. However, few studies have compared the socioeconomic difference in adolescent smoking between countries with different stage of smoking. The purpose of this study was to examine and compare the relationship between socioeconomic status (SES) and adolescent smoking in Beijing, China and Finland through the Health Behaviour in School-aged Children (HBSC) study. METHODS: The data used in this study were derived from the Chinese HBSC linked project survey 2008 in Beijing and the Finnish HBSC survey 2006. The final sample included 2005 Chinese and 1685 Finnish 15-year-old schoolchildren. The associations between Family Affluence Scale (FAS), as the SES measure, and adolescents' smoking behaviour, including ever smoked, weekly smoking and the early onset of smoking were examined separately in two countries through binary logistic regression. RESULTS: Compared to students from the high FAS group, Chinese boys from the low FAS group were more likely to report having ever smoked (OR = 2.12, 95 % CI = 1.49-3.01) and being early onset of smoking (OR = 2.17, 95 % CI = 1.44-3.26). Finnish girls from the low FAS group were more likely to report being weekly smokers (OR = 1.68, 95 % CI = 1.07-2.65). No significant difference was found for Chinese girls and Finnish boys. CONCLUSIONS: This study indicated different patterns of socioeconomic difference in smoking between Chinese and Finnish adolescents by gender and by smoking behaviour, which suggests that socioeconomic inequalities in smoking are different among adolescents in countries with different stage of smoking. Country specific policies and interventions for different target groups should be encouraged and designed for reducing the prevalence of adolescents' smoking.

Piecing the puzzle together: case studies of international research in health-promoting sports clubs.

This paper seeks to review the current international health-promoting sports club (HPSC) research, drawing together findings based on case studies from various countries to illustrate the status of HPSCs. In addition, future challenges for HPSC research and implementation are considered. The review includes six case studies from five countries. In summary, there are two major research themes in this area, namely 'research into HPSC activity' and 'research into HPSC networks'. The first theme investigates the extent to which sports clubs and/or national sports organisations invest in health promotion (HP) - both in policy and practice. The latter theme is driven by an intention to widen the scope of HPSCs to reach novel internal actors, like parents, siblings, etc., and/or external non-sporting bodies, like communities, schools, etc. The future challenges for HPSC research require a better understanding of the motives, barriers and capacities of sports clubs and coaches. Sports organisations, clubs and coaches generally support the intent of the HPSC concept, but even with the best evidence- or theory-based HP programmes/guidelines/standards, nothing will happen in practice if the nature and capacities of sports clubs are not better acknowledged. Therefore, a call for embracing implementation science is finally made to enhance implementation.

Is educational differentiation associated with smoking and smoking inequalities in adolescence? A multilevel analysis across 27 European and North American countries.

This study aims to determine whether educational differentiation (i.e. early and long tracking to different school types) relate to socioeconomic inequalities in adolescent smoking. Data were collected from the WHO-Collaborative 'Health Behaviour in School-aged Children (HBSC)' study 2005/2006, which included 48,025 15-year-old students (Nboys = 23,008, Ngirls = 25,017) from 27 European and North American countries. Socioeconomic position was measured using the HBSC family affluence scale. Educational differentiation was determined by the number of different school types, age of selection, and length of differentiated curriculum at the country-level. We used multilevel logistic regression to assess the association of daily smoking and early smoking initiation predicted by family affluence, educational differentiation, and their interactions. Socioeconomic inequalities in both smoking outcomes were larger in countries that are characterised by a lower degree of educational differentiation (e.g. Canada, Scandinavia and the United Kingdom) than in countries with higher levels of educational differentiation (e.g. Austria, Belgium, Hungary and The Netherlands). This study found that high educational differentiation does not relate to greater relative inequalities in smoking. Features of educational systems are important to consider as they are related to overall prevalence in smoking and smoking inequalities in adolescence.

Physical Activity Trends of Finnish Adolescents With Long-Term Illnesses or Disabilities From 2002-2014.

BACKGROUND: Adolescents' physical activity level is a major source of concern. For adolescents with long-term illnesses or disabilities (LTID), being physically active can prevent secondary conditions. This is one of the first studies reporting trends in physical activity of adolescents with LTID in relation to gender, age, and sports club membership. METHODS: Data were collected from the Health Behavior in School-aged Children study in Finland during 2002, 2006, 2010, and 2014. In 13- and 15-year-olds (N = 2206), 17.1% reported having LTID. Daily physical activity recall was the dependent variable. Binary logistic regression analysis was conducted separately for sports club members (n = 936) and nonmembers (n = 1270). RESULTS: The proportion of physically active adolescents with LTID in 2014 was higher than in 2002 for girls (15.6% vs 8.7%) and boys (26.6% vs 13.0%). Girl sports club members were 2 times more likely to be physically active in 2014 than in 2002. The largest trend between 2014 and 2002 was among boy nonmembers (odds ratio: 4.62, 95% confidence interval, 2.02-10.58). CONCLUSIONS: More adolescents with LTID took part in daily moderate-to-vigorous physical activity in 2014 than in 2002; however, physical activity levels still remain low. Sports club membership was similar to that of the general population.

Socioeconomic inequalities in the impact of tobacco control policies on adolescent smoking. A multilevel study in 29 European countries.

INTRODUCTION: There are concerns that tobacco control policies may be less effective in reducing smoking among disadvantaged socioeconomic groups and thus may contribute to inequalities in adolescent smoking. This study examines how the association between tobacco control policies and smoking of 15-year-old boys and girls among 29 European countries varies according to socioeconomic group. METHODS: Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2005/2006 comprising 50,338 adolescents aged 15 years from 29 European countries. Multilevel logistic regression analyses were conducted to assess the association of weekly smoking with components of the Tobacco Control Scale (TCS), and to assess whether this association varied according to family affluence (FAS). Analyses were carried out per gender and adjusted for national wealth and general smoking rate. RESULTS: For boys, tobacco price was negatively associated with weekly smoking rates. This association did not significantly differ between low and high FAS. Levels of tobacco-dependence treatment were significantly associated with weekly smoking. This association varied between low and high FAS, with higher treatment levels associated with higher probability of smoking only for low FAS boys. For girls, no tobacco policy was significantly associated with weekly smoking, irrespective of the FAS. CONCLUSIONS: Results indicated that most tobacco control policies are not clearly related to adolescent weekly smoking across European countries. Only tobacco price seemed to be adequate decreasing smoking prevalence among boys, irrespective of their socioeconomic status.

Socioeconomic inequalities in adolescent smoking across 35 countries: a multilevel analysis of the role of family, school and peers.

BACKGROUND: Tobacco-related heath inequalities are a major public health concern, with smoking being more prevalent among lower socioeconomic groups. The aim of this study is to investigate the mechanisms leading to socioeconomic inequalities in smoking among 15-year-old adolescents by examining the mediating role of psychosocial factors in the peer group, family and school environment. METHODS: Data were derived from the international WHO-collaborative 'Health Behaviour in School-aged Children (HBSC)' study 2005/2006, including 52 907 15-year-old students from 35 European and North American countries. Socioeconomic position was measured by the Family Affluence Scale. Multilevel logistic regression models were conducted to examine the contribution of family, school and peer factors in explaining the association between family affluence and weekly smoking. RESULTS: Across countries, adolescents from low affluent families had an increased risk of weekly smoking (OR(boys) 1.14, confidence interval (CI) 1.05-1.23; OR(girls) 1.36, CI 1.26-1.46) compared with adolescents from high affluent families. Family and school factors mediated the association between family affluence and smoking to a high extent up to 100% (boys) and 81% (girls) in joint analyses. The most important single factors were family structure, relationships with parents, academic achievement and school satisfaction. Peer factors did not mediate the association between family affluence and adolescent smoking. CONCLUSION: The association between socioeconomic status and adolescent weekly smoking can largely be explained by an unequal distribution of family- and school-related factors. Focusing on the parent-adolescent relationship and adolescent school achievement can help to better understand inequalities in adolescent smoking behaviour.