Establishing spirituality as an intermediary determinant of health among 42,843 children from eight countries.

The World Health Organization (WHO) Commission on the Social Determinants of Health (CSDH) conceptual framework identifies socio-economic position as a structural determinant of health. Recognized intermediary determinants include biological, behavioural, and psychosocial factors. We examined whether connections afforded by a healthy spirituality potentially act as unrecognized intermediary determinants in adolescent populations, contributing to inequities in mental health. Reports from 42,843 children (21,007 boys, 21,836 girls) from eight countries who participated in the 2017-2018 Health Behaviour in School-aged Children (HBSC) study were used to describe correlations between family affluence and positive levels of mental health, using a cross-sectional design. Based on the CSDH conceptual framework and multivariable regression analyses, we then examined whether these associations were mediated by spiritual health. Connections afforded by a high level of spiritual health were universally correlated with positive mental health status. In three Western European nations (England, Scotland, and Wales) and Canada affluence was correlated with better mental health and this was partially mediated by spiritual health. Among the four Eastern European countries (Latvia, Lithuania, Moldova, Poland), our findings did not support aspects of the CSDH framework that focus on affluence as a direct determinant of health. Spiritual health potentially is an intermediary determinant of children's health in some Western countries, but not in Eastern countries. The universality of social determinants of health models and the measures used in their evaluation require careful assessment across cultures, political contexts, and health outcomes.

Do sociodemographic risk profiles for adolescents engaging in weekly e-cigarette, cigarette, and dual product use differ?

BACKGROUND: E-cigarette use represents a contemporary mode of nicotine product use that may be changing the risk profile of participating adolescents. Understanding differences in sociodemographic characteristics of adolescents engaging in contemporary e-cigarette use and traditional cigarette use is important for effectively developing and targeting public health intervention programs. The objective of this study was to identify and compare sociodemographic risk profiles for exclusive e-cigarette use and dual-product use among a large sample of Canadian youth. METHODS: A survey of 46,666 secondary school students in the 2021-22 wave of the COMPASS study measured frequency of past month e-cigarette and cigarette use as well as age, sex, gender, racial or ethnic background, spending money, relative family affluence, and having one's own bedroom. Rates of cigarette-only, e-cigarette-only, and dual product use were calculated, and separate classification trees were run using the CART algorithm to identify sociodemographic risk profiles for weekly dual-product use and weekly e-cigarette-only use. RESULTS: Over 13% of adolescents used only e-cigarettes at least weekly, 3% engaged in weekly dual e-cigarette and cigarette use, and less than 0.5% used only cigarettes. Available spending money was a common predictor of dual-product and e-cigarette-only use. Gender diverse youth and youth with lower perceived family affluence were at higher risk for dual-product use, while white and multiethnic adolescents were at greater risk of e-cigarette-only use. Two high-risk profiles were identified for e-cigarette-only use and four high-risk profiles were identified for dual product use. CONCLUSIONS: This study used a novel modelling approach (CART) to identify combinations of sociodemographic characteristics that profile high-risk groups for exclusive e-cigarette and dual-product use. Unique risk profiles were identified, suggesting that e-cigarettes are attracting new demographics of adolescents who have not previously been considered as high-risk for traditional cigarette use.

School learning modes during the COVID-19 response and pre- to during pandemic mental health changes in a prospective cohort of Canadian adolescents.

PURPOSE: Considerable debate centered on the impact of school closures and shifts to virtual learning on adolescent mental health during the COVID-19 pandemic. We evaluated whether mental health changes differed by school learning modes during the pandemic response among Canadian adolescents and whether associations varied by gender and perceived home life. METHODS: We used prospective survey data from 7270 adolescents attending 41 Canadian secondary schools. Conditional change linear mixed effects models were used to examine learning mode (virtual optional, virtual mandated, in-person, and blended) as a predictor of change in mental health scores (depression [Centre for Epidemiologic Studies - Depression], anxiety [Generalized Anxiety Disorder-7], and psychosocial well-being [Flourishing scale]), adjusting for baseline mental health and covariates. Gender and home life happiness were tested as moderators. Least square means were calculated across interaction groups. RESULTS: Students learning in a blended learning mode had greater anxiety increases relative to their peers in other learning modes. Females learning fully in-person and males learning virtually when optional reported less of an increase in depression scores relative to their gender counterparts in other learning modes. Learning virtually when optional was associated with greater declines in psychosocial well-being in students without happy home lives relative to other learning modes. CONCLUSION: Findings demonstrate the importance of considering gender and home environments as determinants of mental health over the pandemic response and when considering alternative learning modes. Further research is advised before implementing virtual and blended learning modes. Potential risks and benefits must be weighed in the context of a pandemic.

Physical environment features that predict outdoor active play can be measured using Google Street View images.

BACKGROUND: Childrens' outdoor active play is an important part of their development. Play behaviour can be predicted by a variety of physical and social environmental features. Some of these features are difficult to measure with traditional data sources. METHODS: This study investigated the viability of a machine learning method using Google Street View images for measurement of these environmental features. Models to measure natural features, pedestrian traffic, vehicle traffic, bicycle traffic, traffic signals, and sidewalks were developed in one city and tested in another. RESULTS: The models performed well for features that are time invariant, but poorly for features that change over time, especially when tested outside of the context where they were initially trained. CONCLUSION: This method provides a potential automated data source for the development of prediction models for a variety of physical and social environment features using publicly accessible street view images.

The Impact of the COVID-19 Pandemic on the Mental Health of First-Year Undergraduate Students Studying at a Major Canadian University: A Successive Cohort Study.

OBJECTIVE: To examine the impact of the COVID-19 pandemic on first year undergraduate student mental health. METHODS: As part of the Queen's University U-Flourish Student Well-Being and Academic Success study, three successive cohorts of students entering undergraduate studies in 2018 (pre-pandemic), 2019 (transitional), and 2020 (during pandemic) completed electronic surveys at entry and completion of first year. Validated self-report measures were used to assess mental health status including symptom levels of anxiety, depression, and insomnia, self-harm and frequency of substance use. Propensity matching and multivariable log-binomial regression were used in comparisons of mental health indicators across the cohorts. RESULTS: Clinically significant symptoms of depression, anxiety, insomnia, and self-harm were reported more frequently in the 2020-2021 cohort, coincident with remote learning and pandemic restrictions. In female students, screen positive rates for anxiety and depression, and suicidal ideation increased from about one-third to just under one-half in association with the pandemic (χ2, p < .01), while increases in mental health concerns were less pronounced among males. Among females, increases in clinically significant symptoms over first year appeared greatest during the pandemic year, while striking decreases in alcohol consumption in both females and males were reported in that same year. Studying under pandemic conditions had a negative impact on student well-being, social relationships and school connectedness, quality of learning experience, leisure activities, and optimism about future prospects. CONCLUSIONS: Mental health concerns including anxiety, depression and sleep problems increased in first year students during the pandemic, especially among females, while alcohol use declined. These findings highlight the negative mental health impact associated with studying under pandemic restrictions involving remote learning and social distancing.

Access to medical care and its association with physical injury in adolescents: a cross-national analysis.

BACKGROUND: Strong variations in injury rates have been documented cross-nationally. Historically, these have been attributed to contextual determinants, both social and physical. We explored an alternative, yet understudied, explanation for variations in adolescent injury reporting-that varying access to medical care is, in part, responsible for cross-national differences. METHODS: Age-specific and gender-specific rates of medically treated injury (any, serious, by type) were estimated by country using the 2013/2014 Health Behaviour in School-aged Children study (n=209 223). Available indicators of access to medical care included: (1) the Healthcare Access and Quality Index (HAQ; 39 countries); (2) the Universal Health Service Coverage Index (UHC; 37 countries) and (3) hospitals per 100 000 (30 countries) then physicians per 100 000 (36 countries). Ecological analyses were used to relate injury rates and indicators of access to medical care, and the proportion of between-country variation in reported injuries attributable to each indicator. RESULTS: Adolescent injury risks were substantial and varied by country and sociodemographically. There was little correlation observed between national level injury rates and the HAQ and UHC indices, but modest associations between serious injury and physicians and hospitals per 100 000. Individual indicators explained up to 9.1% of the total intercountry variation in medically treated injuries and 24.6% of the variation in serious injuries. CONCLUSIONS: Cross-national variations in reported adolescent serious injury may, in part, be attributable to national differences in access to healthcare services. Interpretation of cross-national patterns of injury and their potential aetiology should therefore consider access to medical care as a plausible explanation.

Connections associated with a healthy spirituality: are these unrecognized intermediary determinants that shape health inequities in Canadian young people?

BACKGROUND: The health of adolescents is determined by structural and intermediary factors. Such factors operate through pathways that foster different opportunities to achieve health and wellbeing, contributing to inequities. Past analyses of cross-national adolescent health data show that measures of child spirituality, conceptualized as the strength of the connections in our lives, may operate as intermediary determinants in some Western countries. Inspired by this idea, the current analysis provides an in-depth exploration of such pathways among Canadian adolescents. Our objectives were to confirm the existence of relationships between economic position and seven indicators of adolescent health status, then explore whether any observed inequities could be explained by the strength of connections afforded by a healthy spirituality. METHODS: Cycle 8 of the Canadian Health Behaviour in School-aged Children (HBSC) study was conducted in 2017-18. A school-based sample (n = 18,962) of adolescents was obtained from across Canada following a standard cross-national protocol. Eligible participants completed a general survey about their health, health behaviours and their determinants. Survey data were used to model the potential effect of perceived levels of relative affluence on each of seven health indicators. Comparison of crude and adjusted relative risks estimates from weighted log-binomial regression models provided evidence of indirect mediating effects attributable to each of four domains of spirituality. RESULTS: As perceived levels of family affluence increased, the percentages of young people who reported each (7/7) of the negative health outcomes decreased. The spiritual health domain "connections to self" (i.e., the importance of meaning, purpose, joy and happiness in life) mediated the strength of relationships between relative affluence and each (7/7) of the outcomes in boys and girls. "Connections to others" (the importance of kindness, respect and forgiveness) mediated the strength of relationships between relative affluence and each (7/7) of the outcomes among girls. Inconsistent evidence of possible mediation was identified for connections to others in boys, as well as the other two domains of spirituality (connections to nature, then connections to the transcendent) in boys and girls. CONCLUSION: Specific connections afforded by a healthy spirituality could be intermediary determinants of health in Canadian adolescent populations.

Stronger together: Coping behaviours and mental health changes of Canadian adolescents in early phases of the COVID-19 pandemic.

BACKGROUND: The impact of the COVID-19 pandemic and consequent public health restrictions on the mental health of adolescents is of global concern. The purpose of this study was to examine how Canadian adolescents coped during the early pandemic and whether different coping methods were associated with changes in mental health from before the pandemic to the early lockdown response. METHODS: Using two-year linked survey data (2018-2020) from a prospective cohort of secondary school students (n = 3,577), linear regression models were used to examine whether changes in mental health (anxiety [Generalized Anxiety Disorder-7 scale], depression [Center for Epidemiologic Studies Depression 10-item scale Revised], emotion regulation [Difficulties in Emotion Regulation Scale], psychosocial well-being [Flourishing scale]) were related to each coping behaviour. RESULTS: The most common reported coping behaviours included staying connected with friends online (78.8%), playing video games, watching TV/movies, and/or surfing the internet/social media (76.2%), studying or working on schoolwork (71.0%), and getting exercise (65.2%). The use of positive coping mechanisms during the early pandemic period (e.g., keeping a regular schedule, time with family, time with friends online) was associated with less adverse mental health changes from before to during the early lockdown; whereas, negative coping mechanisms (e.g., spending time alone, eating junk food) were consistently associated with more adverse mental health changes. CONCLUSION: This study demonstrates the importance of social support and connections with both friends and family, as well as keeping and maintaining a routine, over the pandemic. Interventions supporting positive relationships and engagement in these coping behaviours may be protective for adolescent mental health during disruptive events.

Item response theory and differential test functioning analysis of the HBSC-Symptom-Checklist across 46 countries.

BACKGROUND: The Symptom Checklist (SCL) developed by the Health Behaviour in School-aged Children (HBSC) study is a non-clinical measure of psychosomatic complaints (e.g., headache and feeling low) that has been used in numerous studies. Several studies have investigated the psychometric characteristics of this scale; however, some psychometric properties remain unclear, among them especially a) dimensionality, b) adequacy of the Graded Response Model (GRM), and c) measurement invariance across countries. METHODS: Data from 229,906 adolescents aged 11, 13 and 15 from 46 countries that participated in the 2018 HBSC survey were analyzed. Adolescents were selected using representative sampling and surveyed by questionnaire in the classroom. Dimensionality was investigated using exploratory graph analysis. In addition, we investigated whether the GRM provided an adequate description of the data. Reliability over the latent variable continuum and differential test functioning across countries were also examined. RESULTS: Exploratory graph analyses showed that SCL can be considered as one-dimensional in 16 countries. However, a comparison of the unidimensional with a post-hoc bifactor GRM showed that deviation from a hypothesized one-dimensional structure was negligible in most countries. Multigroup invariance analyses supported configural and metric invariance, but not scalar invariance across 32 countries. Alignment analysis showed non-invariance especially for the items irritability, feeling nervous/bad temper and feeling low. CONCLUSION: HBSC-SCL appears to represent a consistent and reliable unidimensional instrument across most countries. This bodes well for population health analyses that rely on this scale as an early indicator of mental health status.

Adolescent social media use and its association with relationships and connections: Canadian Health Behaviour in School-aged Children, 2017/2018.

Background: The development of healthy relationships and connections is of fundamental importance to adolescent well-being. The use of social media plays a vital role in the lives of young Canadians, yet the association between different types of social media use and the quality of relationships and connections remains unknown, and most existing analyses on this topic are based on modest and non-representative samples. Data and methods: Using 2017/2018 reports from the nationally representative Health Behaviour in School-aged Children study (n=17,149; ages 11 to 15 years), the strength, consistency and significance of associations was examined between intensive (frequent use to connect with other people) and problematic (use that depicts addictive qualities) social media use and available measures of adolescent relationships and connections. Results: Overall, intensive use (online communication with others almost all of the time) and problematic use (potential addiction to social media) were more common in girls than boys (38% of girls versus 30% of boys and 7.7% of girls versus 5.2% of boys, respectively), with prevalence levels that rose with age. Intensive use was associated with more positive social relationships with friends, especially among girls (relative risk [RR] = 1.40 [95% confidence interval (CI) 1.28 - 1.54]), while problematic use was consistently and negatively associated with strong relationships and connections in all groups in the study. Notably, problematic use was negatively associated with strong family relationships in boys (RR = 0.58 [95% CI 0.42 to 0.79]) and girls (RR=0.48 [95% CI 0.36 to 0.63]). Interpretation: Intensive use of social media has the potential to strengthen relationships and connections in adolescents. However, when social media use becomes addictive or "problematic", it is highly correlated with weaker relationships and a sense of social disconnection. Public health initiatives related to social media use should consider how different types of social media use have the potential to impact on different aspects of health.

Distinguishing between spiritual health and religious involvement as determinants of adolescent health in Canada and the Czech Republic.

Spiritual health is a topic of emergent interest; however, lack of a clear distinction between spiritual health and religious involvement makes it difficult to understand the potential role of spiritual health as a determinant of health. Analyses of such relationships that cross countries and cultures are rare. We therefore assessed whether differences exist between spiritual health and religious involvement and their respective associations with general indicators adolescent health. The study was based on the 2013/2014 Health Behaviour in School-aged Children study conducted in Canada (n = 10 761) and the Czech Republic (n = 4411). In both countries, we failed to identify strong or statistically significant associations between self-reported religiosity and adolescent health. In contrast, adolescents with higher spiritual health scores consistently reported enhanced levels of general health status. Study findings point to the importance of a strong sense of spiritual health as a protective determinant of adolescent health, and raise questions about religious involvement as protective to adolescent health outcomes.

Low risks for spiritual highs: Risk-taking behaviours and the protective benefits of spiritual health among Saskatchewan adolescents.

Objectives: Adolescent risk-taking behaviours, such as substance use and early sexual activity, can adversely impact physical health and psychosocial development. A connection to spiritual health may buffer against the negative health impacts of several risk-taking behaviours. The aim of this study was to determine if higher spiritual health was associated with lower risk-taking behaviours among school-attending adolescents in Saskatchewan, Canada. Methods: A representative sample of 4,751 adolescents in the Canadian province of Saskatchewan completed the Health Behaviour of School-aged Children (HBSC) questionnaire during the 2014 to 2015 school year. The main risk-taking behavioural outcomes were self-reported: smoking; alcohol; and cannabis use; as well as sexual intercourse. The main exposures related to spiritual health included four factors: connectedness to (1) one's self; (2) others; (3) nature; and (4) notions of the transcendent. Multivariable logistic regression analyses were used to test for associations between exposures and outcome measures. Results: The sample was balanced across gender, primarily Caucasian (71%), and primarily ages 11 to 15 years (48%). Adolescents indicated a high prevalence of spiritual health. Across all adjusted models, the results demonstrated that adolescents who value the various components of spiritual health showed a decreased likelihood of engaging in cigarette smoking, alcohol and marijuana use, and sexual intercourse. Conclusion: The findings indicate the potential for spiritual health to be considered as the basis for public- and community-health interventions, pending further evidence from experimental studies.

Fatal farm injuries to Canadian children.

Children on Canadian farms are at high risk for fatal injury. Ongoing surveillance of these deaths is required to affirm recurrent patterns of injury, and to determine whether historical approaches to prevention have resulted in declines in the occurrence of these traumatic events. We analyzed epidemiological patterns and trends in the occurrence of fatal pediatric farm injuries over 23 years. Records of deaths were obtained from the Canadian Agricultural Injury Reporting system. To contrast more recent data with injury patterns described historically, cases were compared between two time periods. An intentional consensus process was used to finalize key patterns and their clinical or social importance. 374 fatal farm injuries to children in Canada were identified over the 23 years of study; 253 in period 1 and 121 in period 2. While machinery and non-machinery causes of death varied between the two study periods, mean annual rates of fatal injury (approximately 4 per 100,000 children) remained similar. Notably emergent types of injury in recent years included those caused by all-terrain vehicles, skid steer loaders, and drownings. Observed declines in the numbers of fatal farm injuries are most likely attributable to analogous declines in the number of registered farms in Canada. Our findings call into question the effectiveness of pediatric farm safety initiatives that primarily focus on education. Second, while CAIR fatality data are maintained, surveillance of hospitalized injuries has been disbanded and the fatality records require updating. Only by doing so will such surveillance findings provide comprehensive information to inform prevention.

Domains of spirituality and their associations with positive mental health: a study of adolescents in Canada, England and Scotland.

Spirituality is a concept with ancient roots yet contemporary relevance to mental health. Its assessment in populations of young people, however, remains an immense challenge. Efforts to perform such assessments typically involve use of unidimensional scales incorporating items related to four domains (connections to "self", "others", "nature", and the "transcendent"). For adolescents, it remains unclear whether these domains equally influence mental health, or if one domain is particularly important. Here we analyzed reports from adolescents who participated in the 2014 Health Behaviour in School-aged Children (HBSC) study conducted in Canada (n = 21,173), England (n = 4339) and Scotland (n = 5603). Reports of positive mental health were modelled as a function of ordinal scores describing each spiritual health domain, controlling for age, the other domains, and potential confounders. Subsequent analyses focused on the centrality of connections to "self" in these relationships. We identified strong and consistent associations between positive mental health and higher scores for each of the four spiritual health domains. In fully adjusted models, these effects were diminished or changed direction for connections to "others", "nature", and the "transcendent", while the positive association with "connections to self" remained. While associations exist between each of the four domains of spiritual health and positive mental health, it appears that associations with connections to "others", "nature", and the "transcendent" are sometimes mediated by connections to "self". Implications for assessment, models and related interventions and health promotion strategies, based on the idea that inner connections may be central to the protective effects of spiritual health, are considered.

Sex, drugs, risk and resilience: analysis of data from the Canadian Health Behaviour in School-aged Children (HBSC) study.

Background: Risk-taking behaviour among adolescents, particularly those experiencing childhood adversities, can predispose to injury, unwanted pregnancy, long-term morbidity and death. Resilience, i.e. adapting to threats and thriving, has rarely been examined as a protective factor for adolescent risk-taking. We studied whether the malleable traits of empathy, confidence, self-control and optimism, all markers of resilience, align with decreased risk-taking despite adversity, among 11-15 year olds. Methods: From responses of 22 643 Canadian youth to the Health Behaviour in School-aged Children (2014) survey we validated a five-item resilience scale. Using regression analyses, this scale and a single measure of self-control were considered as potential protective factors for a composite measure of risk-taking behaviour and of initiation of sexual activity before age 14. Results: There was a dose-dependent association between greater resilience and diminished risk-taking for boys and, even more so, among girls. This relationship remained significant after controlling for family and social support, implying that greater resilience may override the detrimental impact of childhood adversity on risk-taking. The least resilient youth were most likely to report early sexual activity, although this relationship was not linear. Generally, the impact of self-control on risk-taking was not statistically significant, perhaps because of shortcomings of the self-control indicator. Conclusion: Brief screening protocols can identify assets that protect against risk-taking behaviours among adolescents. The malleable nature of these traits offers primary care providers and public health personnel a novel and effective route to decreasing adolescent risk-taking and fostering future health.

Determinants of injury among older Saskatchewan farm operators: A prospective cohort study.

SIGNIFICANCE: The agricultural industry differs from other businesses in the composition of its workforce. Often farm owner-operators work beyond what society would expect to be a normal retirement age. Older farmers may be less receptive to behavioral changes designed to improve worksite safety and are at increased risk for experiencing a work-related injury. We had a unique opportunity to evaluate the relative influence of specific occupational conditions and practices reported by older farm operators (age ≥55 years) on the occurrence of injury using a longitudinal approach. MATERIALS AND METHODS: Baseline data were provided by eligible and consenting farm members in the first quarter of 2013. These farms were then followed longitudinally by mail surveys over 24 months to document injury experiences. For each survey, mailed questionnaires were sent to participating farms and completed by a single respondent. Cox proportional hazard models were used to determine which characteristics of the farm work environment were protective. RESULTS: A total of 96 farm injuries were reported by 73 of 566 farm operators. Medium (hazard ratio [HR] = 0.58; confidence interval [CI], 0.35-0.96) or high (HR = 0.53; CI, 0.30-0.94) worksite physical safety and high economic security (HR = 0.41; CI, 0.24-0.71) were protective in reducing injury among older farmers. CONCLUSION: Safety features in the physical environment and economic security are important protective factors for injury among older farmers. This supports injury prevention theory that suggests that engineering controls are superior to changes in work practices or the use of personal protective equipment in reducing injuries among older farmers.

The history and promise of holism in health promotion.

Holism is an ancient theme concept that has resurfaced in recent literature, and that requires informed and intentional use in order to preserve its utility. This paper provides a historical and conceptual reintroduction of the notion of holism as it relates to health, with the hopes of informing the term's use in public health discourse. It also addresses the challenges that a lack of conceptual clarity about holistic health imposes on public health and health promotion discussions. It describes how the use and conceptualizations of holism are shifting in health promotion and argues that failing to accurately define and delineate its scope risks diluting its utility for future health promotion applications. We address these two problems, and build an argument for a rediscovery of the theory of holism in public health and health promotion, globally.

Outdoor play and nature connectedness as potential correlates of internalized mental health symptoms among Canadian adolescents.

Exposures to outdoor environments have great potential to be protective factors for the mental health of young people. In a national analysis of Canadian adolescents, we explored how such exposures, as well as self-perceptions of connectedness with nature, each related to the prevalence of recurrent psychosomatic symptoms. The data source for this cross-sectional study, consisting of a weighted sample of 29,784 students aged 11-15 years from 377 schools, was the 2013/2014 cycle of the Health Behaviour in School-aged Children (HBSC) study. We modeled reports of exposure to the outdoors and then perceived connection(s) to nature as correlates of reduced psychosomatic symptoms. Associations varied by sex. Among girls, spending on average >0.5 h/week outdoors was associated with a 24% (95% CI: 5%, 40%) lower prevalence of high psychosomatic symptoms, compared to those who averaged no time playing outdoors. No such relationship was observed among boys. Perception of connection to nature as 'important' was similarly associated with a 25% (95% CI: 9%, 38%) reduction in the prevalence of high psychosomatic symptoms; this association did not differ by sex or age. Our analysis highlights the potential importance of adolescent engagement with nature as protective for their psychological well-being. It also emphasizes the importance of accounting for differences between boys and girls when researching, planning, and implementing public mental health initiatives that consider exposure to the outdoors.

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.

Exposure to agricultural hazards among children who visit farms.

BACKGROUND: Children are commonly injured on farms, yet no studies provide evidence about exposures that leave rural children visiting farms at risk. OBJECTIVES: The objectives of this study were to study (a) how frequently rural nonfarm children are exposed to farms, farm work and associated activities; and (b) the safety conditions and practices on farms being visited. METHODS: A cross-sectional survey was administered in Saskatchewan, Canada to rural parents during 2014. Participation included reports on 458 farms visited by rural children, and then 549 children from 312 families who had been exposed to a farm in the past year. Child-level indicators included age, sex, farm safety education and training, engagement in farm work and play activities and exposure to specific farm safety hazards. Farm-level indicators included self-perceived safety conditions, and child supervision practices. RESULTS: One-third of the children sampled (n=549) had been exposed to a farm in the past year. Safety conditions, practices and supervision varied by demographic subgroup. Farm safety education and agriculture training were most common in the oldest age group (13 to 17 years; 24.7% and 9.2%, respectively) of which 40.8% had worked on a farm previously, averaging 10 hours/week (interquartile range 3 to 20) during summer months. Mechanized and nonmechanized work was observed for children of both sexes and rose with age. Physical hazards were reported both proximally (≤100 yards) and distally (>300 yards) to farm homes. CONCLUSIONS: Children who visit farms are potentially exposed to risk, and these risks increase with age as children take on formal work roles, leaving them vulnerable to farm injury.