Trends in health inequalities in childhood and adolescence in Germany: Results of the HBSC study 2009/10 - 2022.

Background: Many studies have identified health inequalities in childhood and adolescence. However, it is unclear how these have developed in recent years, particularly since the COVID-19 pandemic. Methods: Analyses are based on the German data from the international Health Behaviour in School-aged Children (HBSC) study from 2009/10 (n = 5,005), 2013/14 (n = 5,961), 2017/18 (n = 4,347), and 2022 (n = 6,475). A total of 21,788 students aged approximately between 11 and 15 years were included. Socioeconomic status (SES) was assessed using the Family Affluence Scale (FAS). Several health indicators were analysed stratified by gender using bivariate and multivariate analysis methods. Results: In 2022, there are clear socioeconomic inequalities in life satisfaction, self-rated health, fruit and vegetable consumption, and physical activity. These inequalities remained largely constant or increased between 2009/10 and 2022. Between 2017/18 and 2022, no significant changes in inequalities were found. Conclusions: Health inequalities are persistent and reduce the chances of growing up healthy. There is no evidence that inequalities in the analysed outcomes have changed during the pandemic period (between 2017/18 and 2022). Rather, the changes in the health indicators seem to affect all adolescents in a similar way.

Concept and methodology of the Health Behaviour in School-aged Children (HBSC) study - Insights into the current 2022 survey and trends in Germany.

Background: Health Behaviour in School-aged Children (HBSC) is one of the largest international studies on child and adolescent health and cooperates with the World Health Organization (WHO). In Germany, adolescents aged 11, 13 and 15 are surveyed every four years about their health, health behaviour and social conditions. This article describes the HBSC study and in particular the methodology of the current 2022 survey and prior surveys conducted between 2009/10 and 2017/18. Method: 174 schools with a total of 6,475 students participated in the 2022 survey. The survey was conducted using questionnaires and covered a wide range of topics (including mental health, physical activity, bullying experiences, social determinants of health and experiences related to COVID-19). The 2022 survey was complemented by a school principal survey (N = 160). In addition to the current sample, the samples of the three previous surveys with representative data for Germany are presented: 2009/10 (N = 5,005), 2013/14 (N = 5,961) and 2017/18 (N = 4,347). Discussion: The health of children and adolescents is of great public health importance. The HBSC study makes a substantial contribution by providing internationally comparable results, analysing trends, and providing stakeholders with comprehensive and representative health monitoring data.

The international Family Affluence Scale (FAS): Charting 25 years of indicator development, evidence produced, and policy impact on adolescent health inequalities.

In the absence of suitable indicators of adolescent socioeconomic status, the Family Affluence Scale (FAS) was first developed in Scotland 25 years ago. Since then, it has been adapted for use in the Health Behaviour in School-Aged Children (HBSC) Study to research inequalities in adolescent health in Europe and North America. FAS has also been used as an indicator of adolescent socioeconomic status in research studies outside of HBSC, worldwide. There has been a need for FAS to evolve and change its component items over time in order to take into account social and technological changes influencing the families of adolescents. This paper uniquely charts the development of FAS describing the methodological work carried out to validate the measure internationally and over time. It also presents an overview of the body of evidence on adolescent health inequalities produced over years from the HBSC Study and other research studies. Interviews conducted with policy stakeholders reveal that the evidence from FAS-related HBSC work has influenced their strategic work to raise awareness of inequalities and make the case for action to address these. Finally, the future of FAS is discussed with respect to its continual evolution in the context of technological, environmental and social change.

Income inequality and socioeconomic differences in bullying perpetration among adolescents in post-communist countries of Europe: Findings from the HBSC study.

Background: Adolescent bullying is a major public health concern in post-Communist countries of Europe (PCCE). We studied the impact of income inequality on the prevalence of and socioeconomic differences in bullying perpetration. Methods: Nationally representative samples of adolescents aged 11-15 years from 14 PCCE participating in the Health Behavior in School-aged Children survey during 2017-18 years were included. Multilevel logistic regression models were fitted. Results: Overall, 71,119 adolescents participated in the survey. About 27.7 % of country differences in bullying perpetration were attributable to high income inequality. Adolescents with low and high family socioeconomic status (SES) had a 10-15 % greater risk (P < 0.05) of bullying perpetration compared to middle-SES adolescents. In cross-level interaction, the risk of bullying perpetration was the highest among high-SES adolescents from countries with wider income inequality (P-interaction = 0.003). The odds ratios of bullying perpetration comparing high- vs. low-SES adolescents ranged from 0.67 in the least unequal to 1.59 in the most unequal countries. Conclusions: Our findings suggest that high income inequality might contribute to school bullying among adolescents in PCCE, particularly those from high-SES families. The necessary political and economic interventions should focus on improving the country socioeconomic environment in PCCE. Moving towards less neoliberal policies and creating a strong welfare state that promotes the population's economic and social well-being and reduces income inequality might be a necessary component of macro-level strategies aimed at preventing bullying among adolescents. Targeted public health interventions might be required for high-SES adolescents in countries with wide income inequality.

Trend of Correlations between Psychological Symptoms and Socioeconomic Inequalities among Italian Adolescents: Cross-Sectional Study from 2006 to 2018 in Tuscany Region.

Adolescence is a critical moment in life; people become individuals, create new relationships, develop social skills and learn behaviours that they will use for the rest of their lives. During this phase, adolescents establish patterns of behaviour that can protect their health. This study aims to 1. assess the presence of psychological disorders in adolescents of both genders, 2. determine their relation to socio-economic differences based on the Family Affluence Scale (FAS), and 3. assess trends from 2006 to 2018. Data were collected from the Italian Health Behaviour in School-aged Children survey given to a representative sample of Tuscan adolescents aged 11-15 years. Participants (n. 12,550) filled out questionnaires to assess whether psychological symptoms such as feeling low, irritability, nervousness, or sleeping difficulties manifested weekly or more often over the past six months. For the study we utilized a cross-sectional survey method and linear regression to examine the association between psychological symptoms (dependent variable measured on an interval scale (0-16)), gender and FAS. We conducted similar analyses using logistic regressions for each of the four symptoms. An increase in psychological symptoms in both genders was revealed between 2006 and 2018, with a statistically significant presence in females: 0.29 (95% Confidence Interval [CI], 0.17 to 0.41), 1.43 (95% CI, 1.37 to 1.48) and 1.43 (95% CI, 1.34 to 1.52) in low-, medium- and high-affluence families, respectively; whereas males presented 0.14 (95% CI, 0.01 to 0.27), 0.71 (95% CI, 0.65 to 0.77) and 0.31 (95% CI, 0.22 to 0.39), respectively. The probability of a predictive episode of psychological symptoms (feeling low, irritability, nervousness, sleeping difficulties) occurring weekly, or more, often was greatly increased in females of all socioeconomic classes. These findings suggest that the increase in psychological disorders in adolescents should be considered a public health problem and further investigated through longitudinal studies and continuous monitoring of health trends.

Inequalities in health complaints: 20-year trends among adolescents in Scotland, 1998-2018.

This study examined trends in inequalities in health complaints among early adolescents in Scotland from 1998 to 2018. We analysed data from the Health Behaviour in School-aged Children (HBSC) survey conducted in Scotland in 1998, 2002, 2006, 2010, 2014 and 2018. A self-report questionnaire was administered in schools to a nationally representative sample of 11-, 13-, and 15-year-olds (n = 29,250). Health complaints were measured using a scale comprising four psychological symptoms (feeling low, feeling nervous, irritability and sleep difficulties) and four somatic symptoms (headache, backache, stomachache and dizziness). Socio-economic status was measured using the Family Affluence Scale. Between 1998 and 2018, there were significant increases in the proportion of girls and boys reporting feeling low, feeling nervous, sleep difficulties and backache. Prevalence of the eight individual health complaints was higher among girls and adolescents from lower affluence families. Socio-economic inequalities increased over time, such that declines in mental health were greatest among low affluence adolescents. The data show worsening trends in health complaints among Scottish adolescents between 1998 and 2018, particularly for girls and adolescents from low affluence families. Increasing inequalities in mental health highlight the need to address the underlying social and structural determinants of adolescent mental health.

Socioeconomic inequalities in adolescent health behaviours across 32 different countries - The role of country-level social mobility.

Higher family affluence is associated with healthier behaviours in adolescents, but the strength of this association varies across countries. Differences in social mobility at the country-level, i.e. the extent to which adolescents develop a different socioeconomic status (SES) than their parents, may partially explain why the association between family affluence and adolescent health behaviours is stronger in some countries than in others. Using data from adolescents aged 11-15 years from 32 countries, participating in the 2017/2018 wave of the Health Behaviour in School-aged Children (HBSC) study (N = 185,086), we employed multilevel regression models with cross-level interactions to examine whether country-level social mobility moderates the association between family affluence and adolescent health behaviours (i.e. moderate-to-vigorous physical activity, vigorous physical activity, healthy and unhealthy foods consumption, having breakfast regularly, and weekly smoking). Higher family affluence was more strongly associated with higher levels of adolescent physical activity in countries characterized by high levels of social mobility. No cross-level interactions were found for any of the other health behaviours. Differences in social mobility at the country-level may contribute to cross-national variations in socioeconomic inequalities in adolescent physical activity. Further research can shed light on the mechanisms linking country-level social mobility to inequalities in adolescent physical activity to identify targets for policy and interventions.

Gender Differences in Bullying Reflect Societal Gender Inequality: A Multilevel Study With Adolescents in 46 Countries.

PURPOSE: Social patterns in bullying show consistent gender differences in adolescent perpetration and victimization with large cross-national variations. Previous research shows associations between societal gender inequality and gender differences in some violent behaviors in adolescents. Therefore, there is a need to go beyond individual associations and use a more social ecological perspective when examining gender differences in bullying behaviors. The aim of the present study was twofold: (1) to explore cross-national gender differences in bullying behaviors and (2) to examine whether national-level gender inequality relates to gender differences in adolescent bullying behaviors. METHODS: Traditional bullying and cyberbullying were measured in 11-year-olds to 15-year-olds in the 2017/18 Health Behaviour in School-aged Children study (n = 200,423). We linked individual data to national gender inequality (Gender Inequality Index, 2018) in 46 countries and tested their association using mixed-effects (multilevel) logistic regression models. RESULTS: Large cross-national variations were observed in gender differences in bullying. Boys had higher odds of perpetrating both traditional and cyberbullying and victimization by traditional bullying than girls. Greater gender inequality at country level was associated with heightened gender differences in traditional bullying. In contrast, lower gender inequality was associated with larger gender differences for cyber victimization. DISCUSSION: Societal gender inequality relates to adolescents' involvement in bullying and gendered patterns in bullying. Public health policy should target societal factors that have an impact on young people's behavior.

Test-retest reliability of selected HBSC items in Vietnam: well-being, physical and sedentary activities, and eating behaviours.

BACKGROUND: Valid and reliable research tools to assess children's and adolescent's health-related behaviour are highly needed across the globe. Rapid economic development, globalization, and associated lifestyle challenges observed in most countries support the need for high-quality evidence in adolescents to target health-promoting policies and interventions. This study aims to examine the test-retest reliability of selected well-being, physical and screen-time related siting activities, and eating behaviour items of the Health Behaviour in School-Aged Children (HBSC) questionnaire in a sample of Vietnamese adolescents. METHODS: Data were collected in autumn 2018 in Vietnam (3-week interval). The sample consisted of 410 adolescents (41.0% of boys; mean age = 12.61; SD = 1.24).Test-retest reliability was evaluated using the single measure Intraclass Correlation Coefficients (ICC) and Cohen's kappa statistic stratified by sex, grade and place of residence (urban or rural). RESULTS: The reliability analyses of the well-being items were poor to good ICC values (0.43-0.79) and moderate to large Cohen's kappa values (0.33-0.77). The physical activity and eating behaviour items were moderate (ICC = 0.54-0.65; Cohen's kappa = 0.38-0.57). The screen-time related siting activities items were moderate to large (ICC = 0.51-0.72; Cohen's kappa = 0.42-0.53). There was more item stability among females than males. The social media item was not as stable for 6th graders (ICC = 0.45) compared with older adolescents (ICC 0.68-0.77). CONCLUSIONS: The findings show that with regards to age, sex and place of residence, self-reported health, life satisfaction, physical and screen-time related siting activities, as well as eating behaviour items of the HBSC questionnaire have a sufficient test-retest reliability to be used in national self-report surveys for Vietnamese adolescents while health complaints items showed borderline reliability.

Longitudinal associations between different measures of socioeconomic status and health behavior among adolescents. Data from a wealthy Italian region.

We investigate the association between socio-economic status and unhealthy behaviors among adolescents. By using different measures of socio-economic status, we capture both subjective aspects, as operationalized by perceived family affluence, and objective aspects, such as parents' educational levels and family affluence scale. We use data from a sample of 11,623 adolescents who participated in the Health Behavior in School-aged Children (HBSC) study in 2007, 2010, and 2014 in the Lombardy region of Italy. Results show that all of our measures of socio-economic status are correlated with unhealthy behaviors among adolescents. In particular, perceiving a family affluence below average is significantly correlated with a higher probability of reporting all of the unhealthy behaviors included in our analysis. Having at least one parent with university education significantly decreases the odds of being obese or overweight, having an unbalance diet, being physically inactive, and reporting sedentary behaviors. However, adolescents with at least one university educated parent are more likely to make use of cannabis. When controlling for all of our SES measures simultaneously, we find that family affluence scale is no longer significant in determining adolescents' behaviors. Our findings suggest that, when focusing on health inequalities among adolescents, self-perceptions and non-material dimensions of SES have more explanatory power than its material dimensions.

Socioeconomic inequalities in adolescent health complaints: A multilevel latent class analysis in 45 countries.

Our study evaluated the relationship between adolescent health complaints and socioeconomic position in 45 countries. Data are from the 2017/2018 international Health Behaviour in School-aged Children survey which used proportionate sampling among adolescents aged 11 to 15 years old (n=228,979). Multilevel, multinomial regression analysis assessed the association between the multilevel latent classes with socioeconomic status (SES; at the household and country level). Three distinct latent classes were identified: No Complaints, Psychological Complaints, and a Physical and Psychological Complaints class; where, low household SES was highest for the physical and psychological complaints class. The findings suggest that health promotion policies and interventions among adolescents should consider the specific needs of adolescents living with low household SES as they report more subjective health complaints.

Associations between the self-reported happy home lives and health of Canadian school-aged children: An exploratory analysis with stratification by level of relative family wealth.

BACKGROUND: Connections between home life, level of family wealth, happiness and health are strong, yet these relationships are complex and for Canadian adolescents not well studied. The objective of this investigation was to explore associations between aspects of health and self-reported happy home life among Canadian adolescents aged 10-16 years and to determine if level of self-reported relative family wealth modified associations. MATERIAL AND METHODS: This was a secondary analysis of Canadian data from the 2018 Health Behaviour in School-aged Children (HBSC) study (n=21,745). Theory drove the selection of 26 health-related HBSC variables. Bivariate analyses and calculation of adjusted odds ratios, considering level of self-reported relative family wealth in a stratified analysis, were undertaken. RESULTS: Overall, proximal, micro-level factors were most strongly associated with reports of a happy home life, with distal, macro-level factors less strongly associated. Differences existed between the health and home-life associations for adolescents of different levels of self-reported relative family wealth indicating effect modification. Family support and levels of adolescent self-reported overall health and mental health were common factors that were strongly associated with reporting a happy home life. CONCLUSION: We believe happy home lives are central and critical for thriving youth and families. This was an exploratory analysis. Many of the factors and relationships in this study are potentially modifiable and represent important possible areas of future focus for adolescent and family health improvement.

Trends in gender and socioeconomic inequalities in adolescent health over 16 years (2002-2018): findings from the Canadian Health Behaviour in School-aged Children study. / Évolution des inégalités en santé chez les adolescents selon le genre et le statut socioéconomique sur 16 ans (2002 à 2018) : résultats de l'Enquête sur les comportements de santé des jeunes d'âge scolaire.

INTRODUCTION: Monitoring health inequalities in adolescents informs policy approaches to reducing these inequalities early in the life course. The purpose of this study was to investigate trends in gender and socioeconomic inequalities in six health domains. METHODS: Data were from five quadrennial survey cycles of the Health Behaviour in School-aged Children (HBSC) study in Canada (pooled n = 94 887 participants). Differences in health between socioeconomic groups (based on material deprivation) and between genders were assessed using slope and relative indices of inequality in six health domains: daily physical activity, excess body weight, frequent physical symptoms, frequent psychological symptoms, low life satisfaction, and fair or poor self-rated health. RESULTS: Over a 16-year period, adolescents in Canada reported progressively worse health in four health domains, with those at the lowest socioeconomic position showing the steepest declines. Socioeconomic differences increased in excess body weight, physical symptoms, low life satisfaction, and fair or poor health. Gender differences also increased. Females showed poorer health than males in all domains except excess body weight, and gender differences increased over time in physical symptoms, psychological symptoms and low life satisfaction. CONCLUSION: Socioeconomic and gender inequalities in health are persistent and widening among adolescents in Canada. Policies that address material and social factors that contribute to health disparities in adolescence are warranted.

Time trends in schoolwork pressure among Dutch adolescents, 2001-2017: Gender and educational differences.

AIMS: This study investigated gender and educational differences in trends in schoolwork pressure between 2001 and 2017 in nationally representative samples of Dutch adolescents in secondary education. METHODS: Data from five surveys of the Dutch Health Behaviour in School-aged Children study were used. RESULTS: Across the surveys, an increase in perceived schoolwork pressure was observed. Girls and adolescents enrolled in the higher educational levels reported higher levels of perceived schoolwork pressure and the strongest increase in schoolwork pressure over time. Especially for girls, there was a stronger increase in schoolwork pressure for those enrolled in higher educational tracks. CONCLUSIONS: Increases in schoolwork pressure over time were stronger among Dutch girls and students in the higher educational levels. Over time, schoolwork pressure increased most among girls in the highest educational levels. Explanations and implications for these results are discussed.

Chronic backpain among adolescents in Denmark: trends 1991-2018 and association with socioeconomic status.

Chronic backpain among adolescents is important because the prevalence is high, above 10%, and more than 10% of all adolescents experience impacts on important day-to-day activities. Chronic backpain tracks into adulthood and is associated with several health problems. The objective was to study trends in the prevalence of chronic backpain among adolescents 1991-2018, to examine the association with socioeconomic status (SES), and whether this association changed over time. The study used data from eight comparable cross-sectional school surveys of nationally representative samples of 11-15-year-olds in 1991, 1994, 1998, 2002, 2006, 2010, 2014, and 2018, which constitute the Danish arm of the international Health Behaviour in School-aged Children (HBSC) study. The participation rate was 74.6% of the eligible study population, n = 29,952. Chronic backpain was defined as self-reported backpain daily or several days a week during the last 6 months. The prevalence of chronic backpain was 11.1%, significantly increasing from 8.9% in 1991 to 11.7% in 2018. The OR for chronic backpain was 1.20 (95% CI: 1.10-1.31) in middle, and 1.56 (95% CI: 1.41-1.73) in low compared to high SES. Sensitivity analyses with two other cut-points for backpain frequency showed similar associations.Conclusion: Chronic backpain is common among adolescents and the prevalence increased from 1991 to 2018. The prevalence was highest in lower SES families. We recommend increased efforts to prevent chronic backpain. What is Known: • Chronic backpain among adolescents is common, has a high burden of disability, is associated with several health problems, and tracks into adulthood. What is New: • The prevalence of chronic backpain among adolescents in Denmark increased from 8.9% in 1991 to 11.7% in 2018. • The prevalence was highest among adolescents from lower SES families.

Transport to School and Mental Well-Being of Schoolchildren in Ireland.

Objectives: We explored whether modes of transport (cycling, walking, public transport or private vehicle) between home and school are associated with mental well-being in children aged 10-17 years, participating in the Irish Health Behaviour in School-aged Children (HBSC) study. Methods: Scores on the World Health Organization Well-being Index and the Mental Health Inventory five-item versions, self-reported life satisfaction, happiness with self, body satisfaction, excellent self-rated health, and multiple health complaints of 9,077 schoolchildren (mean age: 13.99 ± 1.91 years, percentage girls: 52.2%) were compared across modes of transport, unadjusted and adjusted for gender, age, family affluence and area of residence. Results: Those who reported using public transport reported poorer mental well-being than those using other means of transport, but adjusting for sociodemographic variables obscured these differences. The only exception was excellent health, where children who cycled outperformed the other three groups, even after adjustment for sociodemographic variables. Conclusions: Cycling can improve well-being in children. However, in promotion of cycling, social and environmental determinants and inequalities which influence adolescents' and their parents' decisions on modes of transport, need to be considered.

Socioeconomic status, social support, and oral health-risk behaviors in Canadian adolescents.

OBJECTIVES: We tested hypotheses regarding how adolescent oral health-related behaviors are associated with socioeconomic status (SES) and family and peer social support, including the extent to which such associations differ for boys and girls. METHODS: We analyzed data from the 2013/2014 Canadian Health Behavior in School-aged Children Study for 20,357 adolescents ages 12-18 years. Family Affluence Scale was used to assess SES. Family and peer social support were assessed using the Multidimensional Scale of Perceived Social Support. We estimated average marginal effects from multivariable binary logistic regression models for three oral health-risk behaviors outcomes: infrequent toothbrushing, high sugar-sweetened beverage (SSB) intake, and high sweets consumption across both genders. RESULTS: Adolescents from low SES households had lower probability of parental and peer support, and were significantly more likely to report infrequent toothbrushing and high SSB consumption, both before and after controlling for both types of support. Lower family support was associated with higher probability of engaging in infrequent toothbrushing and high SSB intake, while lower peer support was associated with higher probability of engaging in infrequent toothbrushing and lower likelihood of engaging in high SSB consumption. The associations of family support with oral health-related behaviors were somewhat stronger for boys than girls. CONCLUSIONS: Low SES and low family support were associated with a higher likelihood of oral health-risk behaviors (infrequent toothbrushing and SSB consumption). Regardless of adolescents' gender, parental support exerted a protective role, but peer support had countervailing risk and protective roles on oral health-related behaviors.

Connected, Respected and Contributing to Their World: The Case of Sexual Minority and Non-Minority Young People in Ireland.

Outcome 5 of the Irish Better Outcomes, Brighter Futures national youth policy framework ("Connected, respected, and contributing to their world") offers a suitable way to study psychosocial determinants of adolescent health. The present study (1) provides nationally representative data on how 15- to 17-year-olds score on these indicators; (2) compares sexual minority (same- and both-gender attracted youth) with their non-minority peers. We analyzed data from 3354 young people (aged 15.78 ± 0.78 years) participating in the Health Behaviour in School-aged Children (HBSC) study in Ireland. Age and social class were associated with the indicators only to a small extent, but girls were more likely than boys to report discrimination based on gender and age. Frequency of positive answers ranged from 67% (feeling comfortable with friends) to 12% (being involved in volunteer work). Sexual minority youth were more likely to feel discriminated based on sexual orientation, age, and gender. Both-gender attracted youth were less likely than the other groups to report positive outcomes. Same-gender attracted youth were twice as likely as non-minority youth to volunteer. The results indicate the importance of a comprehensive approach to psycho-social factors in youth health, and the need for inclusivity of sexual minority (especially bisexual) youth.

Time trends in adolescent mental wellbeing in the Czech Republic between 2002 and 2018: gender, age and socioeconomic differences.

OBJECTIVES: Recent literature indicates a decline over time in adolescent mental wellbeing but results are inconsistent and rely mainly on data from Western societies. This study investigates time trends in adolescent mental wellbeing (psychological and somatic complaints, life satisfaction) among Czech adolescents and explores the moderating role of gender, age and socioeconomic status. METHODS: Nationally representative data from 29,376 Czech adolescents (50.8% girls, mean age = 13.43; SD = 1.65) across five Health Behaviour in School-aged Children (HBSC) surveys (2002, 2006, 2010, 2014, 2018) were used. Hierarchical regression models estimated national trends in adolescent mental wellbeing and established the moderating role of gender, age and socioeconomic status. RESULTS: From 2002 to 2018, an increase in the psychological complaints was observed. Life satisfaction decreased over time up to 2014 only, whereas somatic symptoms increased until 2010, followed by a decline in 2014 and 2018. Girls, older adolescents and those from low family affluence reported poorer mental wellbeing. Gender gap increased over time for psychological complaints and life satisfaction. Socioeconomic inequalities gap remained stable over the investigated timeframe. CONCLUSIONS: Our findings do not provide evidence for substantial temporal changes in mental wellbeing among adolescents in the Czech Republic. Yet, the increase in psychological complaints has been consistent which is an indicator of a small decline over time in adolescent mental wellbeing. Furthermore, the gender gap in mental wellbeing increased over time, whereas the age and socioeconomic differences remained relatively stable. This calls for the attention of public health professionals and policy makers from the Czech Republic.

Adolescents' sleep quality in relation to peer, family and school factors: findings from the 2017/2018 HBSC study in Flanders.

PURPOSE: While a multitude of studies focused on biological and behavioral determinants of adolescents' sleep quality, a paucity of research examined the impact of social factors. The current study therefore examines the relationship between adolescents' sleep quality and peer, family and school factors. METHODS: Data of Flemish participants in the 2017/2018 Health Behavior in School-aged Children survey (HBSC) were used, which is representative of the adolescent population (11-18 years) in Flanders. Adolescents' sleep quality was linked to individual-level data on peer relationships (i.e., peer support), family relationships (i.e., family support, perceived family wealth, caregiving responsibilities) and school relationships (i.e., teacher support, school support, school pressure) and contextual-level data on the school culture. Three-level multilevel models were fitted to account for the clustering of individuals (N = 8153) within classes (N = 769) and classes within schools (N = 177). RESULTS: The individual-level results indicated that adolescents' sleep quality was positively related to family support, teacher support, student support and perceived family wealth. In contrast, adolescents' sleep quality was negatively related to caregiving responsibilities and school pressure. In addition, the contextual-level results pointed out that adolescents tended to report better sleep quality in less-demanding schools. CONCLUSION: These findings highlight the need to consider social factors in promoting better sleep in adolescence.