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

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

An investment case analysis for the prevention and treatment of adolescent mental disorders and suicide in England.

BACKGROUND: Adolescent mental health (AMH) needs in England have increased dramatically and needs exceed treatment availability. This study undertook a comparative assessment of the health and economic return on investment (ROI) of interventions to prevent and treat mental disorders among adolescents (10-19 years) and examined intervention affordability and readiness. METHODS: Interventions were identified following a review of published and grey literature. A Markov model followed a simulated adolescent cohort to estimate implementation costs and health, education, and economic benefits. Intervention affordability was assessed, comparing annual cost per adolescent with NHS England per capita spending, and an expert panel assessed intervention readiness using a validated framework. RESULTS: Over 10- and 80-year horizons, interventions to treat mild anxiety and mild depression were most cost-effective, with the highest individual lifetime ROI (GBP 5822 GBP 1 and GBP 257: GBP 1). Preventing anxiety and depression was most affordable and 'implementation ready' and offered the highest health and economic benefits. A priority package (anxiety and depression prevention; mild anxiety and mild depression treatment) would avert 5 million disability-adjusted life-years (DALYS) and achieve an ROI of GBP 15: GBP 1 over 10 years or 11.5 million DALYs (ROI of GBP 55: GBP 1) over 80 years. CONCLUSION: The economic benefits from preventing and treating common adolescent mental disorders equivalent to 25% of NHS England's annual spending in 2021 over 10 years and 91% over 80 years. Preventing and early treatment for anxiety and depression had the highest ROIs and strong implementation readiness.

The great decline in adolescent risk behaviours: Unitary trend, separate trends, or cascade?

In many high-income countries, the proportion of adolescents who smoke, drink, or engage in other risk behaviours has declined markedly over the past 25 years. We illustrate this behavioural shift by collating and presenting previously published data (1990-2019) on smoking, alcohol use, cannabis use, early sexual initiation and juvenile crime in Australia, England, the Netherlands, New Zealand, and the USA, also providing European averages where comparable data are available. Then we explore empirical evidence for and against hypothesised causes of these declines. Specifically, we explore whether the declines across risk behaviours can be considered 1) a 'unitary trend' caused by common underlying drivers; 2) separate trends with behaviour-specific causes; or 3) the result of a 'cascade' effect, with declines in one risk behaviour causing declines in others. We find the unitary trend hypothesis has theoretical and empirical support, and there is international evidence that decreasing unstructured face-to-face time with friends is a common underlying driver. Additionally, evidence suggests that behaviour-specific factors have played a role in the decline of tobacco smoking (e.g. decreasing adolescent approval of smoking, increasing strength of tobacco control policies) and drinking (e.g. more restrictive parental rules and attitudes toward adolescent drinking, decreasing ease of access to alcohol). Finally, declining tobacco and alcohol use may have suppressed adolescent cannabis use (and perhaps other risk behaviours), but evidence for such a cascade is equivocal. We conclude that the causal factors behind the great decline in adolescent risk behaviours are multiple. While broad contextual changes appear to have reduced the opportunities for risk behaviours in general, behaviour-specific factors have also played an important role in smoking and drinking declines, and 'knock-on' effect from these behavioural domains to others are possible. Many hypothesised explanations remain to be tested empirically.

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.

Country-Level Meritocratic Beliefs Moderate the Social Gradient in Adolescent Mental Health: A Multilevel Study in 30 European Countries.

PURPOSE: Adolescents with higher socioeconomic status (SES) report better mental health. The strength of the association-the "social gradient in adolescent mental health"-varies across countries, with stronger associations in countries with greater income inequality. Country-level meritocratic beliefs (beliefs that people get what they deserve) may also strengthen the social gradient in adolescent mental health; higher SES may be more strongly linked to adolescent's perceptions of capability and respectful treatment. METHODS: Using data from 11-15 year olds across 30 European countries participating in the 2013/2014 Health Behaviour in School-aged Children study (n = 131,101), multilevel regression models with cross-level interactions examined whether country-level meritocratic beliefs moderated the association between two individual-level indicators of SES, family affluence and perceived family wealth, and three indicators of adolescent mental health (life satisfaction, psychosomatic complaints, and aggressive behavior). RESULTS: For family affluence, in some countries, there was a social gradient in adolescent mental health, but in others the social gradient was absent or reversed. For perceived family wealth, there was a social gradient in adolescent life satisfaction and psychosomatic complaints in all countries. Country-level meritocratic beliefs moderated associations between SES and both life satisfaction and psychosomatic complaints: in countries with stronger meritocratic beliefs associations with family affluence strengthened, while associations with perceived family wealth weakened. CONCLUSIONS: Country-level meritocratic beliefs moderate the associations between SES and adolescent mental health, with contrasting results for two different SES measures. Further understanding of the mechanisms connecting meritocratic beliefs, SES, and adolescent mental health is warranted.

A bio-ecological framing of evidence on the determinants of adolescent mental health - A scoping review of the international Health Behaviour in School-Aged Children (HBSC) study 1983-2020.

This paper extracts, organises and summarises findings on adolescent mental health from a major international population study of young people using a scoping review methodology and applying a bio-ecological framework. Population data has been collected from more than 1.5 million adolescents over 37 years by the Health Behaviour in School-Aged Children: WHO Cross-National (HBSC) Study. The paper reviews the contribution that this long standing study has made to our understanding of the individual, developmental, social, economic, cultural determinants of adolescent mental health by organising the findings of 104 empirical papers that met inclusion criteria, into individual, microsystem, mesosystem and macrosystem levels of the framework. Of these selected papers, 68 were based on national data and the other 36 were based on international data, from varying numbers of countries. Each paper was allocated to a system level in the bio-ecological framework according to the level of its primary focus. The majority (51 papers) investigate individual level determinants. A further 28 concentrate primarily on the microsystem level, 6 on the mesosystem level, and 29 on the macrosystem level. The paper identifies where there is evidence on the determinants of mental health, summarises what we have learned, and highlights research gaps. Implications for the future development of this population health study are discussed in terms of how it may continue to illuminate our understanding of adolescent mental health in a changing world and where new directions are required.

Intersectionality and Adolescent Mental Well-being: A Cross-Nationally Comparative Analysis of the Interplay Between Immigration Background, Socioeconomic Status and Gender.

PURPOSE: Intersectionality theory highlights the importance of the interplay of multiple social group memberships in shaping individual mental well-being. This article investigates elements of adolescent mental well-being (life dissatisfaction and psychosomatic complaints) from an intersectional perspective. It tests mental well-being consequences of membership in combinations of multiple social groups and examines to what extent such intersectional effects depend on the national context (immigration and integration policies, national-level income, and gender equality). METHODS: Using Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy, we assessed the role of the national context in shaping the interplay between immigration background, socioeconomic status, and gender, using data from 33 countries from the 2017/2018 Health Behaviour in School-aged Children survey. RESULTS: We found no uniform intersectionality effects across all countries. However, when allowing the interplay to vary by national context, results did point toward some intersectional effects. Some aggravated negative effects were found for members of multiple disadvantaged social groups in countries with low levels of income equality and restrictive migration policies, whereas enhanced positive effects were found for members of multiple advantaged groups in these countries. Similarly, mitigated negative effects of membership in multiple disadvantaged groups were shown in countries with higher levels of income equality and more inclusive migration policies, whereas mitigated positive effects were found for multiply advantaged individuals. Although for national-level gender equality results pointed in a similar direction, girls' scores were counterintuitive. High national-level gender equality disproportionately benefitted groups of disadvantaged boys, whereas advantaged girls were doing worse than expected, and reversed effects were found for countries with low gender equality. CONCLUSIONS: To fully understand social inequalities in adolescent mental well-being, the interplay between individual-level and national-level indicators must be explored.

National-Level Wealth Inequality and Socioeconomic Inequality in Adolescent Mental Well-Being: A Time Series Analysis of 17 Countries.

PURPOSE: Although previous research has established a positive association between national income inequality and socioeconomic inequalities in adolescent health, very little is known about the extent to which national-level wealth inequalities (i.e., accumulated financial resources) are associated with these inequalities in health. Therefore, this study examined the association between national wealth inequality and income inequality and socioeconomic inequality in adolescents' mental well-being at the aggregated level. METHODS: Data were from 17 countries participating in three consecutive waves (2010, 2014, and 2018) of the cross-sectional Health Behaviour in School-aged Children study. We aggregated data on adolescents' life satisfaction, psychological and somatic symptoms, and socioeconomic status (SES) to produce a country-level slope index of inequality and combined it with country-level data on income inequality and wealth inequality (n = 244,771). Time series analyses were performed on a pooled sample of 48 country-year groups. RESULTS: Higher levels of national wealth inequality were associated with fewer average psychological and somatic symptoms, while higher levels of national income inequality were associated with more psychological and somatic symptoms. No associations between either national wealth inequality or income inequality and life satisfaction were found. Smaller differences in somatic symptoms between higher and lower SES groups were found in countries with higher levels of national wealth inequality. In contrast, larger differences in psychological symptoms and life satisfaction (but not somatic symptoms) between higher and lower SES groups were found in countries with higher levels of national income inequality. CONCLUSIONS: Although both national wealth and income inequality are associated with socioeconomic inequalities in adolescent mental well-being at the aggregated level, associations are in opposite directions. Social policies aimed at a redistribution of income resources at the national level could decrease socioeconomic inequalities in adolescent mental well-being while further research is warranted to gain a better understanding of the role of national wealth inequality in socioeconomic inequalities in adolescent health.

Family composition and age at menarche: Findings from the international Health Behaviour in School-aged Children study.

BACKGROUND: Early menarche has been associated with father absence, stepfather presence and adverse health consequences in later life. This article assesses the association of different family compositions with the age at menarche. Pathways are explored which may explain any association between family characteristics and pubertal timing. METHODS: Cross-sectional, international data on the age at menarche, family structure and covariates (age, psychosomatic complaints, media consumption, physical activity) were collected from the 2009-2010 Health Behaviour in School-aged Children (HBSC) survey. The sample focuses on 15-year old girls comprising 36,175 individuals across 40 countries in Europe and North America (N = 21,075 for age at menarche). The study examined the association of different family characteristics with age at menarche. Regression and path analyses were applied incorporating multilevel techniques to adjust for the nested nature of data within countries. RESULTS: Living with mother (Cohen's d = .12), father (d = .08), brothers (d = .04) and sisters (d = .06) are independently associated with later age at menarche. Living in a foster home (d = -.16), with 'someone else' (d = -.11), stepmother (d = -.10) or stepfather (d = -.06) was associated with earlier menarche. Path models show that up to 89% of these effects can be explained through lifestyle and psychological variables. CONCLUSIONS: Earlier menarche is reported amongst those with living conditions other than a family consisting of two biological parents. This can partly be explained by girls' higher Body Mass Index in these families which is a biological determinant of early menarche. Lower physical activity and elevated psychosomatic complaints were also more often found in girls in these family environments.

Country-Level Gender Equality and Adolescents' Contraceptive Use in Europe, Canada and Israel: Findings from 33 Countries.

CONTEXT: Although an association between gender equality and contraceptive use has been confirmed among adult samples, few studies have explored this relationship among adolescents. An examination of whether adolescents' contraceptive use is more prevalent in countries with higher levels of gender equality is needed to fill this gap. METHODS: Nationally representative data from 33 countries that participated in the 2013-2014 Health Behaviour in School-Aged Children study and country-level measures of gender equality-using the 2014 Global Gender Gap Index-were analyzed. Multilevel multinomial logistic regression analyses were employed to assess associations between gender equality and contraceptive use (condom only, pill only and dual methods) at last intercourse as reported by 4,071 females and 4,110 males aged 14-16. RESULTS: Increasing gender equality was positively associated with contraceptive use among both males and females. For every 0.1-point increase on the equality scale, the likelihood of condom use at last intercourse rose (odds ratio, 2.1 for females), as did the likelihood of pill use (6.5 and 9.6, respectively, for males and females) and dual method use (2.1 and 5.6, respectively). Associations with pill use and dual use remained significant after national wealth and income inequality were controlled for. Overall, associations were stronger for females than for males. CONCLUSIONS: More research is needed to identify potential causal pathways and mechanisms through which gender equality and adolescents' contraceptive use may influence one another.

Do Drinking Motives Mediate the Relationship between Neighborhood Characteristics and Alcohol Use among Adolescents?

Adolescents not only vary in their alcohol use behavior but also in their motivations for drinking. Young people living in different neighborhoods may drink for different reasons. The aims of this study were to determine if neighborhood characteristics were associated with adolescent drinking motives, and whether drinking motives mediate the relationship between neighborhood context and regular alcohol use. Data from the Scottish Health Behaviours in School-aged Children 2010 survey of students in their 4th year of secondary school were used. The study included 1119 participants who had data on neighborhood characteristics and had used alcohol in the past year. Students were asked questions about the local area where they lived, their alcohol use, and their motives for drinking alcohol, based on the Drinking Motives Questionnaire Revised Short Form (DMQR-SF). Multilevel multivariable models and structural equation models were used in this study. Coping motives showed significant variation across neighborhoods. Structural equation models showed coping motives mediated the relationships between neighborhood deprivation, living in an accessible small-town, and neighborhood-level disorder with regular alcohol use. Public health policies that improve neighborhood conditions and develop adaptive strategies, aimed at improving alcohol-free methods for young people to cope better with life's stresses, may be particularly effective in reducing inequalities in adolescent alcohol use if targeted at small towns and areas of increased deprivation.

Gender Inequality and Sex Differences in Physical Fighting, Physical Activity, and Injury Among Adolescents Across 36 Countries.

PURPOSE: Sex differences in adolescent health are widely documented, but social explanations for these sex differences are scarce. This study examines whether societal gender inequality (i.e., men's and women's unequal share in political participation, decision-making power, economic participation, and command over resources) relates to sex differences in adolescent physical fighting, physical activity, and injuries. METHODS: National-level data on gender inequality (i.e., the United Nations Development Program's Gender Inequality Index) were linked to health data from 71,255 15-year-olds from 36 countries in the 2009-2010 Health Behaviour in School-Aged Children study. Using multilevel logistic regression analyses, we tested the association between gender inequality and sex differences in health while controlling for country wealth (gross domestic product per capita). RESULTS: In all countries, boys reported more physical fighting, physical activity, and injuries than girls, but the magnitude of these sex differences varied greatly between countries. Societal gender inequality positively related to sex differences in all three outcomes. In more gender unequal countries, boys reported higher levels of fighting and physical activity compared with boys in more gender equal countries. In girls, scores were consistently low for these outcomes; however, injury was more common in countries with less gender inequality. CONCLUSIONS: Societal gender inequality appears to relate to sex differences in some adolescent health behaviors and may contribute to the establishment of sex differences in morbidity and mortality. To reduce inequalities in the health of future generations, public health policy should target social and cultural factors that shape perceived gender norms in young people.

The neighbourhood social environment and alcohol use among urban and rural Scottish adolescents.

OBJECTIVES: This research examined the relationship between neighbourhood social environmental characteristics and drinking outcomes among a sample of urban and rural adolescents. METHODS: From a sample of 1558 Scottish secondary schoolchildren, surveyed as part of the 2010 Health Behaviour in School-aged Children study, we modelled three drinking outcomes on a variety of neighbourhood conditions, including social cohesion, disorder, alcohol outlet density, deprivation, and urban/rurality. Nested and cross-classified multilevel logistic regressions were specified. RESULTS: An urban-to-rural gradient was found with non-urban adolescents exhibiting higher odds of having ever drank. Neighbourhood social cohesion related to having ever drank. Among drinkers, those living in accessible small towns had higher odds of weekly drinking and drunkenness compared to urban areas. Higher odds of drunkenness were also found in remote rural areas. Those residing in the least deprived areas had lower odds of weekly drinking. CONCLUSIONS: In Scotland, inequalities exist in adolescent alcohol use by urban/rurality and neighbourhood social conditions. Findings support regional targeting of public health efforts to address inequalities. Future work is needed to develop and evaluate intervention and prevention approaches for neighbourhoods at risk.

Self-reported weight and predictors of missing responses in youth.

OBJECTIVE: The aims of the present manuscript are to analyse self-reported data on weight, including the missing data, from the 2014 Scottish Health Behaviour in School-Aged Children (HBSC) Study, and to investigate whether behavioural factors related with overweight and obesity, namely dietary habits, physical activity and sedentary behaviour, are associated with weight non-response. RESEARCH METHODS & PROCEDURES: 10839 11-, 13- and 15-year-olds participated in the cross-national 2014 Scottish HBSC Study. Weight missing data was evaluated using Little's Missing Completely at Random (MCAR) test. Afterwards, a fitted multivariate logistic regression model was used to determine all possible multivariate associations between weight response and each of the behavioural factors related with obesity. RESULTS: 58.9% of self-reported weight was missing, not at random (MCAR p < 0.001). Weight was self-reported less frequently by girls (19.2%) than by boys (21.9%). Participants who reported low physical activity (OR 1.2, p < 0.001), low vegetable consumption (OR 1.24, p < 0.001) and high computer gaming on weekdays (OR 1.18, p = 0.003) were more likely to not report their weight. CONCLUSIONS: There are groups of young people in Scotland who are less likely to report their weight. Their weight status may be of the greatest concern because of their poorer health profile, based on key behaviours associated with their non-response. Furthermore, knowing the value of a healthy weight and reinforcing healthy lifestyle messages may help raise youth awareness of how diet, physical activity and sedentary behaviours can influence weight.

Trends in the perceived body size of adolescent males and females in Scotland, 1990-2014: changing associations with mental well-being.

OBJECTIVES: This paper explores trends in Scottish adolescents' body size perceptions and associated mental well-being outcomes. METHODS: Data were collected on Scottish 11-, 13-, and 15-year-olds by the Health Behaviour in School-aged Children study between 1990 and 2014 (n = 42,312). Logistic regression was used to examine changes in the prevalence of over- and underweight perceptions. Ordinal and linear regressions were used to examine changes in the association between body perception and mental well-being. RESULTS: Little change was observed in over- or underweight perceptions. However, relative to those perceiving their body as 'about right', those perceiving themselves as overweight reported decreasing confidence (all groups), decreasing happiness (11- and 13-year-old girls), and increasing psychological health symptoms (all girls and 15-year-old boys). Perceived underweight is associated with poor well-being, especially in males, but we present little evidence that this is a recent phenomenon. CONCLUSIONS: We present evidence suggesting that the association between body size perception and poor mental health in adolescence is changing over time. This may play a role in the recently observed worsening of mental well-being in Scottish adolescents.

"Boys Should Have the Courage to Ask a Girl Out": Gender Norms in Early Adolescent Romantic Relationships.

PURPOSE: The purpose of the study is to explore how gender norms emerge in romantic relationships among early adolescents (EAs) living in five poor urban areas. METHODS: Data were collected as part of the Global Early Adolescent Study. The current research analyzed data from interviews with 30 EAs (aged 11-13 years) living in five poor urban sites: Baltimore, Cuenca, Edinburgh, Ghent, and Nairobi. All interviews were recorded, transcribed, and analyzed in English using Atlas.ti, focusing on how EAs experience and perceive gender norms in romantic relationships. RESULTS: Across the five sites, only a few respondents described having been in love, the majority of whom were boys. Findings indicate that stereotypical gender norms about romantic relationships prevail across these cultural settings, depicting boys as romantically/sexually active and dominant, and girls as innocent with less (romantic) agency. In spite of the similarities, Nairobi was unique in that respondents referred to how sexual behavior and violence can occur within EA relationships. In all countries, heterosexuality was perceived to be the norm. Nevertheless, there were examples of EAs accepting homosexuality and expressing supportive attitudes toward equality between the sexes. CONCLUSIONS: While EAs across five different cultural settings seem to endorse stereotypical gender norms in romantic relationships, a few stories also illustrate more gender-equal attitudes. As stereotypical gender norms have a demonstrated negative effect on adolescent sexual and reproductive health and well-being, additional research is needed to understand which factors-at the interpersonal and structural level-contribute to the construction of these norms among EAs.

Trends in the sexual behaviour of 15-year olds in Scotland: 2002-14.

Background: Early sexual initiation and inadequate contraceptive use can place adolescents at increased risk of unplanned pregnancy and sexually transmitted infections. These behaviours are patterned by gender and may be linked to social inequalities. This paper examines trends in sexual initiation and contraceptive use by gender and family affluence for Scottish adolescents. Methods: Cross-sectional data from four nationally representative survey cycles (2002, 2004, 2010, 2014) (n = 8895) (mean age = 15.57) were analysed. Logistic regressions examined the impact of survey year on sexual initiation, condom use and birth control pill (BCP) use at last sex; as well as any changes over time in association between family affluence and the three sexual behaviours. Analyses were stratified by gender. Results: Between 2002 and 2014, adolescent males and females became less likely to report having had sex. Low family affluence females were more likely to have had sex than high family affluence females, and this relationship did not change over time. Condom use at last sex was reported less by males since 2002, and by females since 2006. Low family affluence males and females were less likely to use condoms than high family affluence participants, and these relationships did not change over time. There were no effects of time or family affluence for BCP use. Conclusion: There has been a reduction in the proportion of 15-year olds in Scotland who have ever had sex, but also a decrease in condom use for this group. Economic inequalities persist for sexual initiation and condom use.

Quality of life and adolescents' communication with their significant others (mother, father, and best friend): the mediating effect of attachment to pets.

The relationship between adolescents' communication with their significant others (mother, father, and best friend) and quality of life (KIDSCREEN) was investigated in 2262 Scottish adolescent pet owners. The variable attachment to pets was also tested and assessed as a mediator of this relationship. A positive relationship between adolescents' communication with their significant other (mother, father, and best friend) and quality of life decreased when controlling for attachment to dogs. In cat owners, a positive relationship between communication with a best friend and quality of life decreased when controlling for attachment to cats. In cat and dog owners, attachment to these pets predicted higher levels of quality of life. Higher attachment to dogs and cats was explained by good best friend (IV) and attachment to pets (DV) and best friends. Mediation effects of attachment to dogs and cats might be explained in terms of the caring activities associated with these types of pets.