Household transmission of Omicron variant of SARS-CoV-2 under conditions of hybrid immunity-a prospective study in Germany.

PURPOSE: We investigated the protection offered by vaccinations and previous infections for the household transmission of Omicron variant of SARS-CoV-2. METHODS: 34,666 participants of the German DigiHero cohort study with two or more household members were invited to a prospective household transmission study between June and December 2022. In case of a positive SARS-CoV-2 test in a household, symptom diaries were completed for at least 14 days. Dry blood spots (DBS) were taken from all household members at the beginning and six to eight weeks later. DBS were analyzed for SARS-CoV-2 antibodies. RESULTS: 1191 individuals from 457 households participated. The risk of acquiring a SARS-CoV-2 infection decreased with higher S-titer levels at the time of exposure (from 80% at titer of 0 binding antibody units (BAU)/ml to 20% at titer of 3000 BAU/ml) and increased linearly with the time since vaccination/previous infection (20% for less than one month to 80% at one year). Transmission probability was also reduced when the symptoms of the primary case were mild and if preventive measures were implemented. CONCLUSION: Vaccinations/previous infections offer a high protection against infection with the Omicron variant for a few months only, supporting the notion of seasonal circulation of the virus.

The role of mesolevel characteristics of the health care system and socioeconomic factors on health care use - results of a scoping review.

BACKGROUND: Besides macrolevel characteristics of a health care system, mesolevel access characteristics can exert influence on socioeconomic inequalities in healthcare use. These reflect access to healthcare, which is shaped on a smaller scale than the national level, by the institutions and establishments of a health system that individuals interact with on a regular basis. This scoping review maps the existing evidence about the influence of mesolevel access characteristics and socioeconomic position on healthcare use. Furthermore, it summarizes the evidence on the interaction between mesolevel access characteristics and socioeconomic inequalities in healthcare use. METHODS: We used the databases MEDLINE (PubMed), Web of Science, Scopus, and PsycINFO and followed the 'Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols extension for scoping reviews (PRISMA-ScR)' recommendations. The included quantitative studies used a measure of socioeconomic position, a mesolevel access characteristic, and a measure of individual healthcare utilisation. Studies published between 2000 and 2020 in high income countries were considered. RESULTS: Of the 9501 potentially eligible manuscripts, 158 studies were included after a two-stage screening process. The included studies contained a wide spectrum of outcomes and were thus summarised to the overarching categories: use of preventive services, use of curative services, and potentially avoidable service use. Exemplary outcomes were screening uptake, physician visits and avoidable hospitalisations. Access variables included healthcare system characteristics such as physician density or distance to physician. The effects of socioeconomic position on healthcare use as well as of mesolevel access characteristics were investigated by most studies. The results show that socioeconomic and access factors play a crucial role in healthcare use. However, the interaction between socioeconomic position and mesolevel access characteristics is addressed in only few studies. CONCLUSIONS: Socioeconomic position and mesolevel access characteristics are important when examining variation in healthcare use. Additionally, studies provide initial evidence that moderation effects exist between the two factors, although research on this topic is sparse. Further research is needed to investigate whether adapting access characteristics at the mesolevel can reduce socioeconomic inequity in health care use.

Trends in material and non-material inequalities in adolescent health and health behaviours: A 12-year study in 23 European countries.

Information on trends in adolescent health inequalities is scarce but the available evidence suggests that inequalities are increasing. Prior studies describe associations between material resources of socioeconomic status (SES) and health, while information on non-material SES resources and inequalities in health behaviours is lacking. To improve current understandings of evolutions in adolescent health inequalities, we examined how material and non-material SES resources were associated with changes in selected health outcomes (life satisfaction, physical and psychological symptoms) and health behaviours (physical activity, screen time, breakfast, fruit, vegetables, sweets and soft drinks consumption and alcohol and tobacco use) over a 12-year period. Repeated cross-sectional data came from the 2002, 2006, 2010 and 2014 waves of the Health Behaviour in School-aged Children (HBSC) survey from 23 European countries (n = 480,386). Measures of family affluence and occupational social class were used as indicators of material and non-material SES resources respectively. Regression-based slope indices of inequality indicated that absolute material and non-material inequalities remained stable from 2002 to 2014 in all health outcomes, except for life satisfaction for which a decrease in material inequalities was found between the highest and lowest affluence group (0.81 to 0.68 difference; p < 0.001). In terms of health behaviours, material inequalities decreased in screen time between highest and lowest affluence groups (0.53 to 0.34 h/day difference; p < 0.001), fruit (odds ratio [OR] 1.89 to 1.72 lower odds; p = 0.0088) and soft drinks consumption (OR 1.36 to 1.13 lower odds; p < 0.001) and remained stable in all others. Non-material inequalities increased in all health behaviours (except for sweets consumption) between highest and lowest occupational social class groups: physical activity (0.16 to 0.24 h/day difference; p = 0.0071), screen time (-0.41 to -0.58 h/day difference; p < 0.001), breakfast (0.21 to 0.51 day/week difference; p < 0.001), fruit (OR 1.23 to 1.48 higher odds; p < 0.001), vegetables (OR 1.39 to 1.74 higher odds; p < 0.001) and soft drinks consumption (OR 0.59 to 0.43 lower odds; p < 0.001) and alcohol (OR 0.99 to 0.85 lower odds; p = 0.0420) and tobacco use (OR 0.71 to 0.59 lower odds; p = 0.0183). In summary, non-material inequalities in most health behaviours increased, whereas material inequalities in adolescent health and health behaviours remain stable or decreased. Policies and interventions may consider non-material SES components as these can help in reducing future health inequalities.

[The role of health promoting schools for increasing health equity]. / Die Bedeutung schulischer Gesundheitsförderung für die Erhöhung gesundheitlicher Chancengleichheit.

Socioeconomic health inequalities are a major field of action in public health and tackling them is one of its main goals. However, there has been little success in reducing these health inequalities. This points to a large research deficit. Inequalities in health are already evident in childhood and adolescence, showing that those with a low socioeconomic background have more risk factors and at the same time fewer resources than their socially more privileged peers. Although health promotion aims at achieving equity in health, interventions rarely consider the socioeconomic status and can therefore provide only little evidence regarding socioeconomically differentiated intervention effects. How can we ensure that all children and young people have equal chances to grow up healthy?In order to come closer to answering this question, it is the aim of this article to give an overview of health inequalities in childhood and adolescence and to highlight the contribution of school and school-based health promotion interventions for tackling health inequalities and increasing equity in health. School is not only a place where adolescents can always be reached, regardless of their socioeconomic background, it has the potential to both exacerbate and reduce health inequalities.

[The Good, the Bad and the Ugly: The Relationship between social Media Use, Subjective Health and Risk Behavior Among Children and Adolescents]. / The Good, the Bad and the Ugly: Die Beziehung zwischen sozialer Mediennutzung, subjektiver Gesundheit und Risikoverhalten im Kindes- und Jugendalter.

BACKGROUND: The current generation of young people spends more time using social media than any other age group. So far, not much is known about the consequences of social media use in terms of health and well-being among teenagers in Germany. The aim of the study was to investigate the association between social media use, health and risk behavior using data from a large representative sample for Germany. METHODS: Data were obtained from the German part of the WHO collaborative study "Health Behavior in School-aged Children (HBSC)" conducted in 2013/14. The analysis is based on 5.094 students aged 11, 13 and 15 years. Social media use was measured with an index based on 5 items. Outcomes were different measures of health and well-being as well as risk behavior. Analyses were conducted using cross tabulations and log-binomial regression models, separately for girls and boys. RESULTS: The results show that a frequent use of social media among girls was linked with poorer self-rated health (OR=1.58, 95%-CI=1.17-2.15) as well as repeated multiple psychosomatic complaints (OR=1.56, 95%-CI=1.22-1.98). For boys, multiple psychosomatic complaints (OR=1.36, 95%-CI=1.03-1.80) and low school satisfaction (OR=1.39, 95%-CI=1.06-1.83) were associated with high social media use. In terms of risk behavior, there was a clear and consistent link between frequent social media use and regular tobacco and alcohol consumption, drunkenness and bullying of classmates, irrespective of gender. The results remained stable after adjusting for age, school type and migration background. CONCLUSIONS: A clear association between social media use and various indicators of health and risk-behavior in childhood and adolescence in Germany could be identified. The results provide first indications of possible health-damaging effects of heavy social media use; these need to be confirmed using longitudinal data.

[The association between school tobacco policies and the perceived smoking prevalence of adolescents]. / Der Zusammenhang zwischen schulischer Tabakkontrolle und der wahrgenommenen Raucherprävalenz Jugendlicher.

BACKGROUND: In the German context, there is hardly any quantitative data about the implementation of school tobacco polices that include the perspective of both teachers and students. The aim of the study is to investigate the associations between implemented school tobacco policies and the perceived prevalence of smoking at the level of school staff and adolescents. METHODS: The repeated cross-sectional study (2013 and 2017) is based on pooled responses of 13- to 17-year-old adolescents (N = 2393) and school staff (N = 85) from 25 schools located in the West German metropolitan region of Hanover. In linear regression models, average marginal effects (AMEs) with 95% confidence intervals (CI95%) and robust standard errors for perceived tobacco prevalence are reported separately for school tobacco policies assessed by teachers and students (scale 0-6). All models were controlled for sociodemographic, school-, and smoking-specific covariates. RESULTS: On average, adolescents perceive a smoking prevalence of 30% ([Formula: see text]; s: 24.0) for their school. A comprehensive school tobacco policy is consistently associated with lower school smoking prevalence both from the point of view of teachers (AME: -3.54 CI95% -6.49 to -0.58) and students (AME: -1.69 CI95% -2.52 to -0.86). The number of smoking friends (e.g., "most of them are smokers" +14%: AME: 14.13 CI95% 10.46 to 17.80) and the type of school are the most relevant determinants of a high school smoking prevalence. School types with a nonacademic track report a 15% (AME: 15.03 CI95% 10.13 to 19.93) higher prevalence compared to grammar schools. DISCUSSION: Progressive school tobacco control policies should focus more on school types with nonacademic tracks, certain groups at risk, and those schools that do not strictly enforce school tobacco policies.

Social mobility, accumulation of disadvantages and health. An analysis with retrospective data from the GSOEP (2002-14).

BACKGROUND: Socioeconomic position (SEP) in different life stages is related to health-related quality of life (HRQoL). Yet, research on the relevance of life course processes is scarce. This study aims to analyse the association between accumulation of disadvantages, social mobility and HRQoL. METHODS: Analyses were conducted using population-averaged panel-data models and are based on data from the German Socio-Economic Panel 2002-14, including retrospective biographical information, comprising 25 473 observations from 8666 persons. Intergenerational and intragenerational mobility included the occupational positions in childhood (parental position), first job and middle age. Accumulation of disadvantages was measured using an accumulation index. HRQoL was assessed using the Mental and Physical Component Summary Scores of the SF12v2. RESULTS: Accumulation of disadvantages was the main predictor for the Physical Component Summary in mid-age. Men and women in a stable low SEP or with a steep downward mobility showed the least favourable physical HRQoL. This holds for intergenerational and intragenerational mobility. Mental HRQoL did not seem to be associated with accumulation or social mobility. CONCLUSION: The results show that physical HRQoL is related to social mobility and accumulation of (dis-)advantages. Further research is needed thoroughly analysing this association.

Explaining Mechanisms That Influence Smoke-Free Implementation at the Local Level: A Realist Review of Smoking Bans.

INTRODUCTION: While studies have been undertaken to understand the adoption of outdoor and indoor smoking bans, not much is known about why implementation of smoke-free (SF) environments differs at local levels. As most European countries remain at the level of indoor bans, we aim to translate existing evidence into practical recommendations on how to improve SF (outdoor) implementation within European municipalities. METHODS: We applied six methodological steps of a realist review consistent with the RAMESES publication standards for realist syntheses. Literature search was conducted in PubMed/MEDLINE and Web of Science. In total, 3829 references were screened, of which 43 were synthesized. Studies dating from 2004 to 2015 with rigor evidence of SF implementation at the local level were selected. Implementation outcomes were SF enforcement, monitoring, nonsmoking compliance, and public support in cities. RESULTS: The explanatory realist framework links four innovation stages with three context-mechanism-outcome (CMO)configurations. We identified "triggering trust," "increasing priorities," and "limiting opposing interests" as underlying mechanisms, when (1) establishing, (2) developing, (3) contesting, and (4) implementing local smoking bans. The CMO propositions (CMOs) support practical recommendations, such as (1) providing authorities with local data when establishing and developing bans, (2) developing long-term strategies and implementing state-funded SF programs to prioritize sustained enforcement, and (3) limiting opposing interests through the use of the child protection frame. CONCLUSIONS: This is the first realist review on the implementation of SF enviroments at the local level. The process-oriented theory explains how and why CMOs determine SF development in cities and municipalities from planning until implementation. IMPLICATIONS: In 2015, only 16% of the world's population lived under the jurisdiction of comprehensive SF laws. The findings of this realist review are useful to implement WHO goals of the Framework Convention on Tobacco Control (FCTC) and specifically SF environments at more local levels and to adjust them to specific contextual circumstances. This paper unpacks three mechanisms that could be triggered by SF strategies developed at local levels and that can result in improved policy implementation. Such evidence is needed to enhance SF strategies at the level of cities and municipalities and to achieve WHO "Healthy Cities Network" objectives.

[Intragenerational Mobility and Subjective Health: Findings of the Socio-Economic Panel (GSOEP) 1992-2012]. / Intragenerationale Mobilität und subjektive Gesundheit ­ Ergebnisse des Sozio-oekonomischen Panels (SOEP) von 1992­2012.

AIM OF THE STUDY: International research suggests that mobility plays an important role in determining health in later life. The aim of this study was to analyze the relationship between intragenerational mobility and subjective health on the basis of data from Germany, taking different periods from 1992 to 2012 into account. DATA AND METHODS: Data is derived from the Socio-economic Panel (GSOEP), taking three time periods into account (1992-1995, 2000-2003 and 2008-2012). Intragenerational mobility was measured by comparing first occupational position and current job. Logistic regressions were used in order to analyze the relationship between health and mobility. RESULTS: Men and women who were downwardly mobile in unemployment or stable low reported the worst health. Up- and downwardly mobile people were located between the stable-up and stable-low groups. The relationship was not affected by origin (East/West Germany). Yet, upward mobility was more common in West Germany and downward mobility was more frequent in East Germany. In general, men and women showed similar patterns. The relationship between intragenerational mobility and health remained stable over time. CONCLUSION: Occupational development showed a strong relationship with health in later life. Especially downward mobility into unemployment or staying in lower positions had strong influence on health. Socio-political measures should be taken to prevent a further divergence of health opportunities.

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.

[Intergenerational mobility and health inequalities in East and West Germany : A trend analysis from 1992 to 2012]. / Intergenerationale Mobilität und gesundheitliche Ungleichheiten in Ost- und Westdeutschland : Eine Trendanalyse von 1992 bis 2012.

BACKGROUND: Social mobility processes, i. e. the movement of a person from one social position to another, are central mechanisms for explaining health inequalities. Social differences in health status or behaviour may also change with changes in social status. This article examines the importance of intergenerational mobility, i. e. the rise and fall of social status in relation to parental social position, for subjective health in East and West Germany and whether this relationship has changed over 20 years. MATERIAL AND METHODS: The data basis is the socio-economic panel from 1992-2012. Employees aged between 25 and 59 were taken into account. Different mobility paths were determined by comparing their current occupational positions with those of their parents. For these, prevalence and logistic regression of subjective health were calculated. RESULTS: Those in low occupational positions rated their health more often as being worse in all periods. Upwardly mobile individuals had a lower risk of poorer health (OR 0.72) compared to those who remained in their original position. Persons affected by downward mobility had a similarly worse self-rated health (OR 1.55 or OR 1.86). Significant differences in gender or region of origin (East-West Germany) could not be determined. Education and income contribute to explaining the relationship. CONCLUSION: The results suggest that social advancement has a positive effect on health, whereas social decline is negative - regardless of gender, region of origin or time. It is therefore important to reinforce political efforts aimed at increasing the mobility opportunities of all social groups in a positive sense and thus reducing social inequalities.

[Trends in educational inequalities in smoking among adolescents in Germany : Evidence from four population-based studies]. / Zeitliche Entwicklung von Bildungsunterschieden im Rauchverhalten von Jugendlichen in Deutschland : Ergebnisse aus vier bevölkerungsweiten Studien.

BACKGROUND: In Germany, smoking prevalence among adolescents has significantly declined since the early 2000s. However, data show that adolescent smoking rates considerably differ between different types of secondary schools. The aim of our study was to examine how educational inequalities in adolescent smoking behaviour have developed over time. METHODS: Data were used from four population-based studies (each consisting of repeated cross-sectional surveys from 2001-2015): the representative surveys of the Federal Centre for Health Education, the German Health Interview and Examination Survey for Children and Adolescents, the Health Behaviour in School-aged Children Study, and the European School Survey Project on Alcohol and Other Drugs. Each study comprised different age groups (within the age range of 11-17 years) and used different smoking measures. Adolescents' educational status was based on the attended type of secondary school. Absolute and relative educational inequalities were presented as prevalence differences and prevalence ratios, respectively. RESULTS: Despite methodical differences, all four studies similarly reveal that adolescent smoking rates have significantly declined in all educational groups. However, lower smoking rates among secondary school students attending higher educational tracks could be observed. While absolute educational inequalities tended to decrease over time, relative inequalities between educational groups remained rather stable or even increased. DISCUSSION: Declining adolescent smoking rates suggest that smoking may have lost some of its attractiveness for young people. Our findings further emphasize the importance of tobacco control measures such as raising cigarette taxes, smoking bans, and increasing minimum legal age for tobacco purchase. As relative educational inequalities in adolescent smoking rates did not diminish over time, setting- and target group-specific interventions should focus more on students in middle and lower secondary school tracks.

Social inequality in adolescents' healthy food intake: the interplay between economic, social and cultural capital.

Background: Current explanations of health inequalities in adolescents focus on behavourial and economic determinants and rarely include more meaningful forms of economic, cultural, and social capital. The aim of the study was to investigate how the interplay between capitals constitutes social inequalities in adolescent healthy food intake. Methods: Data were collected in the 2013/14 Flemish Health Behavior among School-aged Children (HBSC) survey, which is part of the international WHO HBSC survey. The total sample included 7266 adolescents aged 12-18. A comprehensive set of 58 capital indicators was used to measure economic, cultural and social capital and a healthy food index was computed from a 17-item food frequency questionnaire (FFQ) to assess the consumption frequency of healthy food within the overall food intake. Results: The different forms of capital were unequally distributed in accordance with the subdivisions within the education system. Only half of the capital indicators positively related to healthy food intake, and instead 17 interactions were found that both increased or reduced inequalities. Cultural capital was a crucial component for explaining inequalities such that social gradients in healthy food intake increased when adolescents participated in elite cultural practices ( P < 0.05), and were consequently reduced when adolescents reported to have a high number of books at home ( P < 0.05). Conclusion: A combination of selected resources in the form of economic, cultural and social capital may both increase or reduce healthy food intake inequalities in adolescents. Policy action needs to take into account the unequal distribution of these resources within the education system.

[How does the Social Gets under the Skin? A Mediator Analysis with Data from the German Socioeconomic Panel 2011]. / Wie kommt die Gesellschaft unter die Haut? Eine Mediatoranalyse gesundheitlicher Ungleichheit mit den Daten des Sozioökonomischen Panels 2011.

Background: The relationship between socioeconomic status and health is explained by the unequal distribution of material, psychosocial and behavioral factors. The aim of this study is to analyze the relative contribution of these factors for the association between income and different indicators of health and diseases. Method: Analyses were based on data from the "German Socioeconomic Panel (GSOEP)" in 2011. We estimated the relative contribution of material, psychosocial and behavioral factors in income-related inequalities in health by logistic mediator analyses focusing on following outcomes: self-rated health, diabetes, cardiac disease, sleep disorder, joint diseases, depression and chronical back trouble. Results: The material, psychosocial and behavioral factors mediate between 45.2 and 97.7% of the association between income and health, depending on the health outcome. The material factors contributed most to health inequalities, separately (28.6-59.8%) and together with the psychosocial factors (39.8-87.4%). Health behavior plays a prominent role in diabetes and contributed separately 32.5% to the inequalities. Material deprivation and economic worries were the most significant indicators contributing to inequalities in health. Conclusions: The results indicate the high relevance of material, psychosocial and behavioral factors for explaining income-related inequalities in health. The identified patterns across multiple health outcomes illustrate the relevance of psychosocial and material factors and the need for health policy to increase the awareness about these mechanisms in the medical education and practice as well as in prevention.

Socioeconomic inequalities in adolescent health 2002-2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study.

BACKGROUND: Information about trends in adolescent health inequalities is scarce, especially at an international level. We examined secular trends in socioeconomic inequality in five domains of adolescent health and the association of socioeconomic inequality with national wealth and income inequality. METHODS: We undertook a time-series analysis of data from the Health Behaviour in School-aged Children study, in which cross-sectional surveys were done in 34 North American and European countries in 2002, 2006, and 2010 (pooled n 492,788). We used individual data for socioeconomic status (Health Behaviour in School-aged Children Family Affluence Scale) and health (days of physical activity per week, body-mass index Z score [zBMI], frequency of psychological and physical symptoms on 0-5 scale, and life satisfaction scored 0-10 on the Cantril ladder) to examine trends in health and socioeconomic inequalities in health. We also investigated whether international differences in health and health inequalities were associated with per person income and income inequality. FINDINGS: From 2002 to 2010, average levels of physical activity (3·90 to 4·08 days per week; p<0·0001), body mass (zBMI -0·08 to 0·03; p<0·0001), and physical symptoms (3·06 to 3·20, p<0·0001), and life satisfaction (7·58 to 7·61; p=0·0034) slightly increased. Inequalities between socioeconomic groups increased in physical activity (-0·79 to -0·83 days per week difference between most and least affluent groups; p=0·0008), zBMI (0·15 to 0·18; p<0·0001), and psychological (0·58 to 0·67; p=0·0360) and physical (0·21 to 0·26; p=0·0018) symptoms. Only in life satisfaction did health inequality fall during this period (-0·98 to -0·95; p=0·0198). Internationally, the higher the per person income, the better and more equal health was in terms of physical activity (0·06 days per SD increase in income; p<0·0001), psychological symptoms (-0·09; p<0·0001), and life satisfaction (0·08; p<0·0001). However, higher income inequality uniquely related to fewer days of physical activity (-0·05 days; p=0·0295), higher zBMI (0·06; p<0·0001), more psychological (0·18; p<0·0001) and physical (0·16; p<0·0001) symptoms, and larger health inequalities between socioeconomic groups in psychological (0·13; p=0·0080) and physical (0·07; p=0·0022) symptoms, and life satisfaction (-0·10; p=0·0092). INTERPRETATION: Socioeconomic inequality has increased in many domains of adolescent health. These trends coincide with unequal distribution of income between rich and poor people. Widening gaps in adolescent health could predict future inequalities in adult health and need urgent policy action. FUNDING: Canadian Institutes of Health Research.

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

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

[Social inequalities in adolescent smoking: A cross-national perspective of the role of individual and macro-structural factors]. / Sozioökonomische Unterschiede im Rauchverhalten bei Jugendlichen : Eine ländervergleichende Perspektive zum Stellenwert individueller und makrostruktureller Faktoren.

BACKGROUND: In an EU-funded project, we examined on the basis of international comparative analyses which factors were associated with and contributed to socioeconomic inequalities in adolescent smoking. This paper presents the results obtained and discusses their implications for policy and research. METHODS: Analyses were based on the "Health Behaviour in School-aged Children (HBSC)" study in 2006 and included more than 50,000 adolescents from 37 countries. The focus was on the association between family affluence and weekly smoking (regularly, at least once a week) among adolescents. Explanatory variables at the individual level refer to psychosocial resources and burdens of school, family, and peers. At the country level, national income, various tobacco control policies, and an index of external differentiation of the educational system were used. RESULTS: The psychosocial factors of school and family explained many of the inequalities in the smoking behavior of adolescents. In an international comparison, socioeconomic inequalities in smoking were stronger in richer countries. Absolute smoking rates were lower and inequalities in smoking smaller for boys in countries with higher tobacco prices. On the other hand, educational systems with higher degrees of external differentiation showed lower inequalities in smoking beahviour by girls, and relatively higher rates of smoking (for boys and girls). Stronger inequalities in smoking behaviour were demonstrated in countries with a greater range of preventative measures for tobacco dependence (for boys) and with higher levels of government spending on tobacco control (for girls). CONCLUSION: Experiences in richer countries revealed that tobacco control needs to be strengthened for socially disadvantaged adolescents. The reduction of smoking prevalence and socioeconomic inequalities in smoking behavior should be based not only on a strengthening of psychosocial resources in the family and at school, but also on an increase in tobacco prices.

Trends in social inequalities in adolescent health complaints from 1994 to 2010 in Europe, North America and Israel: The HBSC study.

BACKGROUND: Studies have shown constant or increasing health inequalities in adulthood in the last decades, but less is known about trends in health inequalities among adolescents. The aim is to analyse changes in socioeconomic differences in subjective health complaints from 1994 to 2010 among 11- to 15-year-olds in Europe, North America and Israel. METHODS: Data were obtained from the international 'Health Behaviour in School-aged Children' (HBSC) survey. Analyses were based on the HBSC surveys conducted in 1994 (19 countries), 1998 (25 countries), 2002 (32 countries), 2006 (37 countries) and 2010 (36 countries) covering a time period of up to 16 years. Log binomial regression models were used to assess inequalities in multiple health complaints. Socioeconomic position was measured using perceived family wealth. RESULTS: Inequalities in multiple health complaints emerged in almost all countries, in particular since 2002 (RR 1.1-1.7). Trend analyses showed stable (29 countries), increased (5 countries), decreased (one country) and no social inequalities (2 countries) in adolescent health complaints. CONCLUSION: In almost all countries, social inequalities in health complaints remained constant over a period of up to 16 years. Our findings suggest a need to intensify efforts in social and health policy to tackle existing inequalities.

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

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

Trends in multiple recurrent health complaints in 15-year-olds in 35 countries in Europe, North America and Israel from 1994 to 2010.

BACKGROUND: Health complaints are a good indicator of an individual's psychosocial health and well-being. Studies have shown that children and adolescents report health complaints which can cause significant individual burden. METHODS: Using data from the international Health Behaviour in School-aged Children study, this article describes trends in multiple recurrent health complaints (MHC) in 35 countries among N = 237 136 fifteen-year-olds from 1994 to 2010. MHC was defined as the presence of two or more health complaints at least once a week. Logistic regression analysis was performed to evaluate trends across the five survey cycles for each country. RESULTS: Lowest prevalence throughout the period 1994-2010 was 16.9% in 1998 in Austria and highest in 2006 in Israel (54.7%). Overall, six different trend patterns could be identified: No linear or quadratic trend (9 countries), linear decrease (7 countries), linear increase (5 countries), U-shape (4 countries), inverted U-shape (6 countries) and unstable (4 countries). CONCLUSION: Trend analyses are valuable in providing hints about developments in populations as well as for benchmarking and evaluation purposes. The high variation in health complaints between the countries requires further investigation, but may also reflect the subjective nature of health complaints.