Country-level sociocultural context and socioeconomic inequalities in adolescent dietary behaviours: A multilevel analysis in 21 European countries.

Studies to date have predominantly focused on countries' socioeconomic conditions (e.g., income inequality) to explain cross-national differences in socioeconomic inequalities in adolescent health (behaviours). However, the potential explanatory role of sociocultural contexts at country-level remains underexamined. This study examined whether the country-level sociocultural context and changes thereof were associated with adolescent socioeconomic inequalities in dietary behaviours. International comparative data of 344,352 adolescents living in 21 countries participating in 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey were combined with aggregated levels of openness-to-change from the European Social Survey (ESS). Four dietary behaviours (i.e., fruit, vegetable, sweets and soft drink consumption) and two measures of socioeconomic status (SES) on the individual level (i.e., family affluence scale [FAS] and occupational social class [OSC]) were studied. Multilevel logistic regression analyses returned contrasting results for the two SES measures used. In countries with higher levels of openness-to-change, smaller FAS inequalities in daily fruit, sweets and soft drink consumption were observed, but no such inequalities were found for vegetable consumption. Conversely, in these countries, larger OSC inequalities in soft drink consumption were found. Country-specific changes in openness-to-change over time were not associated with the magnitude of adolescent dietary inequalities. Findings underscore the importance of including country-level sociocultural contexts to improve the understanding of cross-national differences in socioeconomic inequalities in adolescents' diets. Future studies, spanning a longer timeframe, are required to examine whether such associations exist within countries over time since our timeframe might have been too small to capture these long-term trends.

Parental SES and family support as predictors of educational level: Testing the buffering effect of effortful control and peer support.

INTRODUCTION: Exposure to family risk factors increases adolescents' chances of attaining a lower educational level. However, some adolescents attain a high educational level despite being exposed to family risk factors such as a lower parental socioeconomic status (SES) or receiving less family support. METHOD: Using data from the Dutch TRAILS cohort study (NT1 = 2175; Mage = 11.1, SD = 0.55, 50.8% female), we investigated if higher levels of effortful control and peer support can buffer against the negative effects of a lower parental SES and less family support on educational level. Two multinomial logistic regressions were performed (from early to mid-adolescence and from mid-adolescence to young adulthood) with post hoc tests to contrast four ordinal educational levels: practical vocational, theoretical vocational, higher general, and (pre-)university. RESULTS: Adolescents with a higher parental SES were consistently more likely to end up at a higher educational level, but family support was hardly associated with educational level. Neither effortful control nor peer support buffered the associations of parental SES and family support with educational level. Effortful control did have a positive direct (compensatory) effect on the educational level. CONCLUSION: We conclude that other individual competencies or more structural changes may be more helpful buffers for reducing socioeconomic inequalities in educational attainment.

The Relation between Residential Mobility and Internalizing and Externalizing Problems in Adolescence: The Role of Subjective Moving Experience, Gender, and Friendship Quality.

Adolescent residential mobility can be a stressful life event, potentially aggravating internalizing or externalizing problems. However, the longitudinal effects of residential mobility are understudied and may be context-dependent. This study investigates the longitudinal associations between adolescent residential mobility and internalizing and externalizing problems. Additionally, this study examines for whom residential moves are most detrimental by including subjective moving experience, gender, and friendship quality before the move as moderators. Longitudinal data from 2,029 adolescents (51% female) from the TRacking Adolescents' Individual Lives Survey (TRAILS) were used (Mage [SD] at T1 = 11.1 [0.55], T2 = 13.6 [0.52], and T3 = 16.3 [0.70]). Results from stepwise multi-level random-effect models showed that adolescents who experienced an unpleasant move remained stable in internalizing problems, while others decreased over time. Adolescents who moved increased stronger in externalizing problems than adolescents who did not move, independent of whether they experienced the move as unpleasant. Gender and friendship quality before the move did not moderate the relation between residential mobility and internalizing or externalizing problem development. These results emphasize that residential moves in adolescence, especially when experienced as unpleasant, can have long-lasting negative effects on adolescent development.

Self-reported quantity and quality of sleep in children and adolescents with a chronic condition compared to healthy controls.

To assess self-reported quantity and quality of sleep in Dutch children with a chronic condition compared to healthy controls and to the recommended hours of sleep for youth. Sleep quantity and quality were analyzed in children with a chronic condition (cystic fibrosis, chronic kidney disease, congenital heart disease, (auto-)immune disease, and medically unexplained symptoms (MUS); n = 291; 15 ± 3.1 years, 63% female. A subset of 171 children with a chronic condition were matched to healthy controls using Propensity Score matching, based on age and sex, ratio 1:4. Self-reported sleep quantity and quality were assessed with established questionnaires. Children with MUS were analyzed separately to distinguish between chronic conditions with and without an identified pathophysiological cause. Generally, children with a chronic condition met the recommended amount of sleep, however 22% reported poor sleep quality. No significant differences in sleep quantity and quality were found between the diagnosis groups. Children with a chronic condition and with MUS slept significantly more than healthy controls at ages 13, 15, and 16. Both at primary and secondary school, poor sleep quality was least frequent reported in children with a chronic condition and most often reported in children with MUS.  Conclusion: Overall, children with chronic conditions, including MUS, met the recommended hours of sleep for youth, and slept more than healthy controls. However, it is important to obtain a better understanding of why a substantial subset of children with chronic conditions, mostly children with MUS, still perceived their sleep quality as poor. What is Known: • According to the Consensus statement of the American Academy of Sleep medicine, typically developing children (6 to 12 years) should sleep 9 to 12 h per night, and adolescents (13 to 18 years) should sleep 8 to 10 h per night. • Literature on the optimal quantity and quality of sleep in children with a chronic condition is very limited. What is New: Our findings are important and provide novel insights: • In general, children with a chronic condition sleep according to the recommended hours of sleep. • A substantial subset of children with chronic conditions, perceived their sleep quality as poor. Although this was reported mostly by children with medically unexplained symptoms (MUS), the found poor sleep quality was independent of specific diagnosis.

The role of social cognitions in the social gradient in adolescent mental health: A longitudinal mediation model.

The social gradient in adolescent mental health is well established: adolescents' socioeconomic status is negatively associated with their mental health. However, despite changes in social cognition during adolescence, little is known about whether social cognitions mediate this gradient. Therefore, this study tested this proposed mediational path using three data waves, each 6 months apart, from a socioeconomically diverse sample of 1,429 adolescents (Mage = 17.9) in the Netherlands. Longitudinal modeling examined whether three social cognitions (self-esteem, sense of control, and optimism) mediated associations between perceived family wealth and four indicators of adolescent mental health problems (emotional symptoms, conduct problems, hyperactivity, and peer problems). There was evidence of a social gradient: adolescents with lower perceived family wealth reported more concurrent emotional symptoms and peer problems and an increase in peer problems 6 months later. Results also showed evidence of mediation through social cognitions, specifically sense of control: adolescents with lower perceived family wealth reported a decrease in sense of control (though not self-esteem nor optimism) 6 months later, and lower sense of control predicted increases in emotional symptoms and hyperactivity 6 months later. We found concurrent positive associations between perceived family wealth and all three social cognitions, and concurrent negative associations between social cognitions and mental health problems. The findings indicate that social cognitions, especially sense of control, may be an overlooked mediator of the social gradient in adolescent mental health.

The social gradient in adolescent mental health: mediated or moderated by belief in a just world?

PURPOSE: A social gradient in adolescent mental health exists: adolescents with higher socioeconomic status (SES) have fewer mental health problems than their peers with lower SES. Little is known about whether adolescents' societal beliefs play a role in this social gradient. Belief in a just world (BJW) may be a mediator or moderator of the social gradient in adolescent mental health. METHODS: Using data from 848 adolescents (Mage = 17) in the Netherlands, path analyses examined whether two indicators of BJW (general and personal) mediated or moderated the associations between two indicators of SES (family affluence and perceived family wealth), and four indicators of adolescent mental health problems (emotional symptoms, conduct problems, hyperactivity, and peer problems). RESULTS: Adolescents with lower family affluence and lower perceived family wealth reported more emotional symptoms, and the association between perceived family wealth and emotional symptoms was mediated by lower personal and general BJW. Furthermore, higher personal BJW amplified the negative association between SES and peer problems. CONCLUSION: This study suggests BJW may both mediate and amplify the social gradient in adolescent mental health. Adolescents' beliefs about society may be important to include in research aimed at understanding this social gradient.

Educational level, attention problems, and externalizing behaviour in adolescence and early adulthood: the role of social causation and health-related selection-the TRAILS study.

Social causation and health-related selection may contribute to educational differences in adolescents' attention problems and externalizing behaviour. The social causation hypothesis posits that the social environment influences adolescents' mental health. Conversely, the health-related selection hypothesis proposes that poor mental health predicts lower educational attainment. From past studies it is unclear which of these mechanisms predominates, as attention problems and externalizing behaviour have the potential to interfere with educational attainment, but may also be affected by differences in the educational context. Furthermore, educational gradients in mental health may reflect the impact of 'third variables' already present in childhood, such as parental socioeconomic status (SES), and IQ. We investigated both hypotheses in relation to educational differences in externalizing behaviour and attention problems throughout adolescence and young adulthood. We used data from a Dutch cohort (TRAILS Study; n = 2229), including five measurements of educational level, externalizing behaviour, and attention problems from around age 14-26 years. First, we evaluated the directionality in longitudinal associations between education, externalizing behaviour, and attention problems with and without adjusting for individual differences using fixed effects. Second, we assessed the role of IQ and parental SES in relation to attention problems, externalizing behaviour, and educational level. Attention problems predicted decreases in education throughout all of adolescence and young adulthood. Differences in parental SES contributed to increases in externalizing behaviour amongst the lower educational tracks in mid-adolescence. Childhood IQ and parental SES strongly predicted education around age 14. Parental SES, but not IQ, also predicted early adolescent attention problems and externalizing behaviour. Our results provide support for the health-related selection hypothesis in relation to attention problems and educational attainment. Further, our results highlight the role of social causation from parental SES in determining adolescent educational level, attention problems, and externalizing behaviour.

Decline in positive future orientations among adolescents during covid-19: The role of socioeconomic status, parental support, and sense of control.

INTRODUCTION: Before coronavirus disease (covid-19), adolescents from a lower socioeconomic status (SES) background tend to have less positive future orientations, receive less parental support, and have a weaker sense of control than adolescents from a higher SES background. The covid-19 pandemic has potentially increased the socioeconomic gaps in positive future orientations, parental support, and sense of control among adolescents who are currently in vocational education. As societies are aiming to return back to precovid norms, certain groups of adolescents might require more attention for ensuring a stable future than others. METHODS: Two-wave questionnaire data of 689 Dutch adolescents (Mage = 17.8; 56% female) from the Youth Got Talent project was analyzed. Latent Change Score models are a relatively novel approach that allows two-wave data to estimate associations between precovid predictor variables and changes in outcome variables from before to during covid-19 (e.g., SES, positive future orientations, parental support, and sense of control). Analyses were preregistered. RESULTS: The precovid socioeconomic differences in adolescent's positive future orientations and sense of control remained stable during covid-19, whereas the socioeconomic difference in parental support decreased during covid-19. A decline in parental support, an increase in sense of control, and more covid-19 hardships were associated with an increase in future orientations. CONCLUSION: The covid-19 situation has not substantially increased socioeconomic differences in positive future orientations and sense of control, but did decrease socioeconomic differences in parental support among adolescents. Short-term policies should aim to facilitate parental support and positive future orientations to all adolescents who experienced a decline, while also long-term focusing on the more consistent socioeconomic difference in sense of control among adolescents.

When Too Much Help is of No Help: Mothers' and Fathers' Perceived Overprotective Behavior and (Mal)Adaptive Functioning in Adolescents.

Although parental overprotection is theorized to have lasting negative effects throughout a child's life, there is limited empirical evidence available on its long-term significance on adolescent well-being. This preregistered, three-wave longitudinal study investigated the association of maternal and paternal perceived overprotection in early adolescence with the development of (mal)adaptive psychological, academic, and social functioning throughout adolescence. Data (N = 2229; 50.7% girls) from the longitudinal TRacking Adolescents' Individual Lives Survey (TRAILS) in the Netherlands were used (Mage T1 = 11.11, T2 = 13.57, T3 = 16.28). At T1, adolescents reported on their mothers' and fathers' overprotection. From T1 to T3 adolescents and teachers reported about internalizing problems, academic achievement, prosocial, and antisocial behavior. The results showed concurrent associations between higher levels of perceived overprotection and higher levels of internalizing problems, antisocial behaviors, and (after controlling for parental warmth and rejection) lower levels of academic achievement. Perceived overprotection was positively associated with decreased internalizing problems over time. This longitudinal association disappeared after controlling for baseline levels of internalizing problems, suggesting that this result was less robust than expected. Mothers and fathers did not differ in their associations between perceived overprotection and (mal)adaptive functioning. The findings showed that perceived overprotection is mainly concurrently associated with (mal)adaptive adolescent functioning. Future research recommendations are discussed in terms of stability and bidirectional relations.

Psychosocial functioning in adolescents growing up with chronic disease: The Dutch HBSC study.

Many adolescents worldwide (indirectly) grow up with a chronic disease, which may impact their functioning and wellbeing. The objective of this study is to assess whether adolescents with a (family member with a) chronic disease differ from their healthy counterparts in terms of psychosocial functioning. Data from the Dutch 2013 HBSC-survey were used, including 7168 adolescents (Meanage = 13.7, SD = 1.57, 50.5% female). Participants indicated whether they or one of their family members had a long-term (> 3 months) disease or disability (mental/physical) and were categorized into four groups based on disease presence (none, other, self, both). Psychosocial functioning was assessed in terms of life satisfaction, self-rated health, psychosomatic health, mental health problems, support, substance use, physical exercise, screen time, and school liking. Chronically diseased adolescents (n = 162) reported lower life satisfaction, self-rated and psychosomatic health, more mental health problems, lower peer support, more substance use, and less physical exercise compared to healthy peers. Chronically diseased adolescents who also had a family member with a chronic disease (n = 74) showed comparable outcomes on these life domains, although they did not differ from their healthy peers regarding peer support, substance use, and physical activity. Healthy adolescents with a chronically diseased family member (n = 737) reported significantly lower life satisfaction, self-rated and psychosomatic health, more mental health problems, and less family support compared to healthy peers who grew up in healthy families; however, they reported more positive outcomes than adolescents who had a chronic disease themselves.Conclusion: Having a (family member with a) chronic disease is associated with impaired psychosocial functioning on various life domains. Our findings aid in understanding the psychosocial associates of chronic disease and imply that caregivers should be observant of psychosocial problems among vulnerable adolescents to provide appropriate guidance. What is Known: • Adolescents who grow up with a (family member with a) chronic disease encounter numerous challenges that may be related to poorer developmental outcomes on the long term. What is New: • This study adds a comprehensive overview of the psychosocial functioning of adolescents with a (family member with a) chronic disease, as compared to healthy counterparts that grow up in a healthy family.

The course of problematic social media use in young adolescents: A latent class growth analysis.

Using four waves of longitudinal data collected in 2015-2019 from 1419 Dutch adolescents (Mage  = 12.5, 45.9% female, 21.9% immigrant), this study identified trajectories of problematic social media use (SMU) in parallel with trajectories of SMU frequency. Latent class growth analysis identified two subgroups with relatively high levels of problematic SMU over time: One showed high (24.7%) and one showed average SMU frequency (15.8%). Also, two subgroups with persistently low levels of problematic SMU were identified: One reported low (22.4%) and one reported high SMU frequency (37.1%). Although both subgroups with high levels of problematic SMU reported low subjective well-being, the group with high SMU frequency showed low self-control, whereas the group with average SMU frequency reported poor social competencies.

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.

Mental Health in Adolescents with a Migration Background in 29 European Countries: The Buffering Role of Social Capital.

Previous research is inconclusive as to whether having an immigration background acts as a risk factor for poor mental health in adolescents, and furthermore, what contribution the social context in which adolescents grow up may make. To address these questions, the current study uses an integrative resilience framework to investigate the association between immigration background and adolescent mental health, and the moderating role of social capital at the individual, the school, and the national level. The study uses data gathered from nationally representative samples of adolescents aged 11, 13, and 15 years (Ngirls = 63,425 (52.1%); Mage = 13.57, SD = 1.64) from 29 countries participating in the 2017/18 Health Behaviour in School-aged Children (HBSC) study. Data analysis reveals that first- and second-generation immigrants reported higher levels of life dissatisfaction and psychosomatic symptoms than their native peers, and that this association varied across schools and countries. In addition, social capital was found to moderate the association between immigration background and adolescent mental health. Individual-level social support from peers and family and national-level trust protected against poor mental health in adolescents with an immigration background, while the opposite was true for individual-level teacher support. Supportive teacher-student relationships were found to provide more protection against poor mental health for native adolescents than for immigrant adolescents. Our findings indicate the importance of taking an ecological approach to design interventions to reduce the negative effects of having an immigration background on adolescent mental health.

Perceived Social Support from Different Sources and Adolescent Life Satisfaction Across 42 Countries/Regions: The Moderating Role of National-Level Generalized Trust.

Although previous research established a positive association between perceived social support and adolescent life satisfaction, little is known about the relative importance of different sources of support for adolescent life satisfaction and cross-country variations in this respect. Using large-scale representative samples from the 2017/18 Health Behaviour in School-aged Children (HBSC) study, this study examined to what extent the association between social support and life satisfaction in early adolescence varied across different social sources and countries. Also, it examined whether cross-country variations are explained by national-level generalized trust, a sociocultural factor that shapes adolescent socialization. National-level data were linked to data from 183,918 early adolescents (Mage = 13.56, SD = 1.63, 52% girls) from 42 European and North American countries/regions obtained from HBSC. Multilevel regression analyses yielded a positive association between support from different sources and life satisfaction. The strongest associations were found for support from families, followed by teachers and classmates, and weakest for support from friends. Associations varied across different countries/regions. National-level trust amplified the association between perceived classmate support and adolescent life satisfaction. The revealed cross-country differences open avenues for future cross-cultural research on explanations for cross-cultural differences in the association between social support from different sources and life satisfaction in early adolescence.

Attention Deficit Hyperactivity Disorder-Symptoms, Social Media Use Intensity, and Social Media Use Problems in Adolescents: Investigating Directionality.

Cross-sectional research shows that adolescents' social media use (SMU) and attention deficit hyperactivity disorder (ADHD)-symptoms are related, but it is unclear whether this relation is explained by SMU intensity or by addiction-like SMU problems. Also, due to the lack of longitudinal studies, the direction of this relation remains unknown. This study aims to disentangle which type of SMU is related to ADHD-symptoms, and in which direction, using a three-wave longitudinal study among Dutch adolescents aged 11-15 years (n = 543). Findings suggest a unidirectional relation: SMU problems increased ADHD-symptoms over time, SMU intensity did not. This implies that problematic use, rather than the intensity of use harmfully affects adolescents' ADHD-symptoms.

Associations between Ethnic Minority Status and Popularity in Adolescence: the role of Ethnic Classroom Composition and Aggression.

Although there are theoretical reasons to expect an association between ethnic minority status and popularity, research on this topic is scarce. Therefore, this association was investigated including the moderating role of the ethnic classroom composition and the mediating role of aggression. Data from the longitudinal Dutch SNARE (Social Network Analysis of Risk behavior in Early adolescence) project were used among first-year students (comparable to 5th grade) (N = 1134, Nclassrooms = 51, M = 12.5 years, 137 non-Western ethnic minority students). Popularity and aggression were assessed with peer nominations. Multi-level Structural Equation Models showed that ethnic minority status was indirectly associated with higher popularity, through higher aggression. Moreover, with increasing numbers of ethnic minority students in the classroom, popularity levels of both ethnic majority and ethnic minority students decreased. Only when differences in aggression between ethnic minority and majority students were included in the analyses, while the ethnic classroom composition was not included, lower popularity levels were found for ethnic minority than ethnic majority students. Scientific and practical implications of this study were addressed in the discussion.

Does the density of the health workforce predict adolescent health? A cross-sectional, multilevel study of 38 countries.

BACKGROUND: Scant evidence exists on the relation between the availability of health professionals and adolescent health, and whether the size of the health workforce equally benefits adolescents across socioeconomic strata. METHODS: We conducted a cross-sectional analysis of adolescent health in 38 countries. Data from 218 790 adolescents were drawn from the 2013/2014 Health Behavior in School-aged Children survey. We used multilevel regression analyses to examine the association between the density of the health workforce and psychosomatic and mental health symptoms with differences in country wealth and income inequality controlled. RESULTS: A higher density of psychologists was associated with better self-reported mental health in adolescents (P = 0.047); however, this finding was not robust to sensitivity analyses. The densities of physicians and psychiatrists were not significantly associated with better adolescent psychosomatic or mental health. Cross-level interactions between the health workforce and socioeconomic status did not relate to health, indicating that larger health workforces did not reduce socioeconomic differences in adolescent health. CONCLUSIONS: This study found that adolescents in countries with a higher density of health providers do not report better psychosomatic or mental health. Other social or structural factors may play larger roles in adolescent health.

Do country-level environmental factors explain cross-national variation in adolescent physical activity? A multilevel study in 29 European countries.

BACKGROUND: Worldwide, roughly 80% of adolescents fail to meet World Health Organization (WHO) recommendations regarding physical activity, though there is substantial variation in adolescent physical activity prevalence across countries. This study explored whether country-level environmental differences explained cross-national variation in adolescent moderate- to vigorous-intensity physical activity (MVPA) and vigorous-intensity activity (VPA). METHOD: Using the data of 138,014 11- to 15-year-olds from 29 European countries in the 2013/2014 Health Behaviour in School-aged Children (HBSC) study, multilevel regression models examined the influence of four types of country-level environmental factors (physical, socio-cultural, economic, and political) on self-reported individual-level physical activity (MVPA and VPA). RESULTS: The environmental variables explained 38% of country-level variance in MVPA and 81% of country-level variance in VPA. Lower annual average national temperature, higher community safety, lower average national household income and a weaker physical education policy were significantly associated with more MVPA. Greater urbanisation, lower annual average national temperature, higher adult physical activity and higher average national household income were significantly associated with more VPA. CONCLUSIONS: The findings showed that national differences in the physical, socio-cultural and economic environment were related to adolescent physical activity. They point to potential avenues for future research looking at interactions between individual and environmental factors.

The interplay between national and parental unemployment in relation to adolescent life satisfaction in 27 countries: analyses of repeated cross-sectional school surveys.

BACKGROUND: Previous research shows that parental unemployment is associated with low life satisfaction in adolescents. It is unclear whether this translates to an association between national unemployment and adolescent life satisfaction, and whether such a contextual association is entirely explained by parental unemployment, or if it changes as a function thereof. For adults, associations have been shown between unemployment and mental health, including that national unemployment can affect mental health and life satisfaction of both the employed and the unemployed, but to different degrees. The aim of this paper is to analyse how national unemployment levels are related to adolescent life satisfaction, across countries as well as over time within a country, and to what extent and in what ways such an association depends on whether the individual's own parents are unemployed or not. METHODS: Repeated cross-sectional data on adolescents' (aged 11, 13 and 15 years, n = 386,402) life satisfaction and parental unemployment were collected in the Health Behaviour in School-aged Children (HBSC) survey, in 27 countries and 74 country-years, across 2001/02, 2005/06 and 2009/10 survey cycles. We linked this data to national harmonised unemployment rates provided by OECD and tested their associations using multilevel linear regression, including interaction terms between national and parental unemployment. RESULTS: Higher national unemployment rates were related to lower adolescent life satisfaction, cross-sectionally between countries but not over time within countries. The verified association was significant for adolescents with and without unemployed parents, but stronger so in adolescents with unemployed fathers or both parents unemployed. Having an unemployed father, mother och both parents was in itself related to lower life satisfaction. CONCLUSION: Living in a country with higher national unemployment seems to be related to lower adolescent life satisfaction, whether parents are unemployed or not, although stronger among adolescents where the father or both parents are unemployed. However, variation in unemployment over the years did not show an association with adolescent life satisfaction.

International trends in 'bottom-end' inequality in adolescent physical activity and nutrition: HBSC study 2002-2014.

Background: In spite of many positive trends that have emerged in the health of young people, adolescents from more affluent groups continue to experience more favourable health outcomes. There are no groups that are more vulnerable than those who report very poor ('bottom-end') indicators of health behaviour. The present study investigated the role of socio-economic factors as potential determinants of bottom-end health behaviours pertaining to physical activity and diet. Methods: Our analysis incorporated health data for some 700 000 15-year-old adolescents in 34 countries. The data source was four cycles of the Health Behaviour in School-aged Children (HBSC) study (2001/2002, 2005/2006, 2009/2010 and 2013/2014). As per UNICEF precedents, adolescents whose health behaviour scores were below the mean of the lower half of the distribution fell into the 'bottom-end' on this indicator. Results: Adolescents from less affluent families were much more likely to report being in the bottom-end of the distribution of these health indicators. Large, persistent and widespread socio-economic gradients existed for physical activity and healthy eating, while the findings were mixed for unhealthy eating. Such socio-economic inequalities were largely stable or widened for physical activity and healthy eating, while inequalities in unhealthy eating narrowed. Conclusion: Although it is important to continue monitoring average levels of adolescent health, national and international policies need to pay attention to the concentration of poor health outcomes among adolescents from less affluent families and to redress social inequalities in adolescent health behaviour.