A focus on adolescent peer violence and bullying in Europe, central Asia and Canada. Health Behaviour in School-aged Children international report from the 2021/2022 survey

The Health Behaviour in School-aged Children (HBSC) study is a large school-based survey carried out every four years in collaboration with the WHO Regional Office for Europe. HBSC data are used at national/regional and international levels to gain new insights into adolescent health and well-being, understand the social determinants of health and inform policy and practice to improve young people’s lives. The 2021/2022 HBSC survey data are accompanied by a series of volumes that summarize the key findings around specific health topics. This report, Volume 2 in the series, focuses on adolescent peer violence and bullying, using the unique HBSC evidence on adolescents aged 11, 13 and 15 years across 44 countries and regions in Europe, central Asia and Canada. It describes the status of adolescent peer violence (bullying, cyberbullying and fighting), the role of gender, age and social inequality, and how adolescent bullying and fighting behaviour has changed over time. Findings from the 2021/2022 HBSC survey provide an important evidence benchmark for current research, intervention and policy-planning.

Life satisfaction in the context of the COVID-19 pandemic among middle school adolescents in France: findings from a repeated cross-sectional survey (EnCLASS, 2012-2021).

Background and aims: Since the COVID-19 pandemic, several studies have reported a decrease in adolescents' well-being. We aim to describe life satisfaction over the last decade and examine the factors associated with its variations between 2020 and 2021 among French students in their last year of middle school (around 14-15 years old). Methods: Data were drawn from a repeated biennial cross-sectional national survey conducted in French schools over the last decade (EnCLASS study), using a self-administered questionnaire. After describing life satisfaction trends between 2012 and 2021 using the Cantril ladder, we examined individual changes in life satisfaction between 2020 and 2021 and their associations with housing and studying conditions during the COVID-19 lockdown, using multinomial logistic regression analysis (decrease, increase, no change as reference). Results: Among the 17,686 survey respondents, an overall slight decrease in the prevalence of adolescents reporting high life satisfaction (i.e., Cantril score ≥6) was observed since 2012 with the lowest proportion reported in 2021 (77.4%). Between 2020 and 2021, 16.3% of French adolescents experienced an improvement in life satisfaction, while 17.7% experienced the opposite. Decrease in life satisfaction between 2020 and 2021 was more likely experienced by adolescents living in reconstructed families [aOR 2.09 (95%CI, 1.58-2.77)], those who did not have their own room [aOR 1.58 (1.16-2.15)], nor access to the Internet to interact with their friends during the lockdown [aOR 1.47 (1.09-1.98)]. Interestingly, more girls than boys were represented in both those reporting increase and decrease in life satisfaction [aOR 1.82 (1.40-2.37) and 1.43 (1.14-1.79), respectively]. Conclusions: This study shows that the way adolescents experienced the first 2020 lockdown in France was not uniform, and that one must consider sex as well as housing and studying conditions when interpreting adolescents' life satisfaction decrease during the COVID-19 pandemic.

Perceived Discrimination Among Adolescents in Ireland.

Adolescents belonging to minority or marginalized groups often experience discrimination, which may negatively affect their mental and physical health. Using the dataset of the 2018 Health Behaviour in School-Aged Children (HBSC) study, we analyzed perceived discrimination based on various grounds in four minority groups of schoolchildren in Ireland: sexual minority youth, youth living with a disability or chronic condition, immigrant youth, and youth belonging to the Traveller community. To minimize the potential confounding effect of psycho-social contextual factors, we used a case-control matching approach, comparing minority groups with their non-minority peers matched by gender, age group, and social class. Minority groups were significantly more likely than their matched non-minority counterparts to report discrimination, not only on the basis of their minority status but also on other grounds. These associations varied in their effect size. We discuss educational and policy implications of the findings for reducing discrimination and structural stigma in school settings.

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.

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

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

Bullying, Mental Health, and the Moderating Role of Supportive Adults: A Cross-National Analysis of Adolescents in 45 Countries.

Objectives: Relationships with supportive adults during adolescence may be a protective factor that lowers the risks associated with bullying. The current study aimed to examine the moderating role of supportive adults in the associations between bullying involvement (in-person and cyber) and mental health problems (psychological symptoms and low life satisfaction). Methods: Data from 45 countries and regions taking part in the 2017/18 Health Behaviour in School-Aged Children study (N = 230,757) were used. Multivariable Poisson regression models were used to estimate relative risks of bullying on mental health. Effect estimates were compared across the number of supportive adults to examine a possible cumulative protective effect of relationships with supportive adults. Results: Bullying involvement was consistently associated with poor mental health across the 45 countries. Risk of mental health problems associated with bullying involvement was greatest among students reporting relationships with multiple supportive adults. This was true for all indicators of bullying involvement. Conclusion: Bullying remains a prevalent and harmful experience for youth worldwide. Merely having supportive adults is not sufficient in protecting youth from experiencing the mental health risks associated with bullying.

Social inequalities in treatment receipt for childhood cancers in Ireland: A population-based analysis.

Treatment advances over the past five decades have resulted in significant improvements in survival from childhood cancer. Although survival rates are relatively high, social disparities in outcomes have been sometimes observed. In a population-based study, we investigated social inequalities by sex and deprivation in treatment receipt in childhood cancer in Ireland. Cancers incident in people aged 0 to 19 during 1994 to 2012 and treatments received were abstracted from the National Cancer Registry Ireland. Multivariable modified Poisson regression with robust error variance (adjusting for age, and year) was used to assess associations between sex and deprivation category of area of residence at diagnosis and receipt of cancer-directed surgery, chemotherapy or radiotherapy. Three thousand seven hundred and four childhood cancers were included. Girls were significantly less likely than boys to receive radiotherapy for leukemia overall (relative risk [RR] = 0.70; 95% confidence interval [CI] = 0.50-0.98), and acute lymphoblastic leukemia specifically (RR = 0.54; 95% CI = 0.36-0.79), and surgery for central nervous system (CNS) overall (RR = 0.83; 95% CI = 0.74-0.93) and other CNS (RR = 0.76; 95% CI = 0.60-0.96). Girls were slightly less likely to receive chemotherapy for non-Hodgkin lymphoma and surgery for Hodgkin lymphoma (HL), but these results were not statistically significant. Children residing in more deprived areas were significantly less likely to receive chemotherapy for acute myeloid leukemia or surgery for lymphoma overall and HL, but more likely to receive chemotherapy for medulloblastoma. These results may suggest social inequalities in treatment receipt for childhood cancers. Further research is warranted to explore whether similar patterns are evident in other childhood cancer populations and to better understand the reasons for the findings.

Levels of Physical Activity and Mental Health in Adolescents in Ireland.

The benefits of physical activity for the physical health of individuals are well documented. Less is known about the benefits of physical activity for mental health. This paper explores the associations between physical activity and positive mental health and mental health problems. The paper utilises data collected from a representative sample of 10-17-year-old adolescents in Ireland. Physical activity in the study is measured using moderate-to-vigorous physical activity (MVPA) and vigorous physical activity (VPA). Mental health was measured using the Cantril Leader of Life Satisfaction, the WHO-5 index, Mental Health Inventory (MHI-5) and the Health Behaviour in School-Aged Children (HBSC) Symptom Checklist (HBSC-SCL). Data were analysed using bivariate (Pearson Correlation, t-test, one-way ANOVA) and multivariate (two-way ANOVA, ordinary least squares (OLS) regressions) analyses. In total, 8636 adolescents were included in this analysis. Higher participation in physical activity was associated with higher scores on the positive mental health indicators and lower scores on the mental health problems indicators. When modelled together, VPA was a stronger predictor of mental health than MVPA, especially in girls. For example, standardised beta coefficients for predicting MHI-5 were -0.09 for MVPA (p < 0.001) and -0.13 for VPA (p < 0.001) To our knowledge, this is the first study that looks at levels of physical activity as well as both positive mental health and mental health problems. The study highlights the need to encourage and enable adolescents, and especially girls, to participate in vigorous exercising as way of promoting positive mental health.

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

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

Social Media Use and Cyber-Bullying: A Cross-National Analysis of Young People in 42 Countries.

PURPOSE: Social media use (SMU) has become an intrinsic part of adolescent life. Negative consequences of SMU for adolescent health could include exposures to online forms of aggression. We explored age, gender, and cross-national differences in adolescents' engagement in SMU, then relationships between SMU and victimization and the perpetration of cyber-bullying. METHODS: We used data on young people aged 11-15 years (weighted n = 180,919 in 42 countries) who participated in the 2017-2018 Health Behaviour in School-aged Childrenstudy to describe engagement in the three types of SMU (intense, problematic, and talking with strangers online) by age and gender and then in the perpetration and victimization of cyber-bullying. Relationships between SMU and cyber-bullying outcomes were estimated using Poisson regression (weighted n = 166,647 from 42 countries). RESULTS: Variations in SMU and cyber-bullying follow developmental and gender-based patterns across countries. In pooled analyses, engagement in SMU related to cyber-bullying victimization (adjusted relative risks = 1.14 [95% confidence interval (CI): 1.10-1.19] to 1.48 [95% CI: 1.42-1.55]) and perpetration (adjusted relative risk = 1.31 [95% CI: 1.26-1.36] to 1.84 [95% CI: 1.74-1.95]). These associations were stronger for cyber-perpetration versus cyber-victimization and for girls versus boys. Problematic SMU was most strongly and consistently associated with cyber-bullying, both for victimization and perpetration. Stratified analyses showed that SMU related to cyber-victimization in 19%-45% of countries and to cyber-perpetration in 38%-86% of countries. CONCLUSIONS: Accessibility to social media and its pervasive use has led to new opportunities for online aggression. The time adolescents spend on social media, engage in problematic use, and talk to strangers online each relate to cyber-bullying and merit public health intervention. Problematic use of social media poses the strongest and most consistent risk.

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.

Clusters of Contemporary Risk and Their Relationship to Mental Well-Being Among 15-Year-Old Adolescents Across 37 Countries.

PURPOSE: Adolescents' mental well-being has become a growing public health concern. Adolescents' daily lives and their engagement in risks have changed dramatically in the course of the 21st century, leading to a need to update traditional models of risk to include new exposures and behaviors. To date, studies have examined the relationship between (mainly traditional) risk behaviors and adolescent mental well-being or looked at risk factors that jeopardize mental well-being such as lack of social support but have not combined them together to highlight the most significant risks for adolescent mental well-being today. The present study included new and traditional risk behaviors and risk factors, robustly derived an empirically based model of clusters of risk, and examined the relative association of these clusters to adolescent mental well-being. METHODS: Data from the 2017-2018 Health Behaviours in School-aged Children study were used. The sample included 32,884 adolescents (51.7% girls) aged 15 years from 37 countries and regions. The principal component analysis was used to determine the existence of clusters of risk, using 21 items related to adolescent mental well-being that included both risk behaviors (e.g., substance use) and risk factors (e.g., peer support). Analysis was conducted in both a randomly split training and test set and in gender separate models. Mixed-effects logistic regressions examined the association between clusters of risk and mental well-being indices (low life satisfaction and psychosomatic complaints). RESULTS: Seven clusters of risk were identified: substance use and early sex, low social support, insufficient nutrition, bullying, sugary foods and drinks, physical health risk, and problematic social media use (SMU). Low social support and SMU were the strongest predictors of low life satisfaction (odds ratios = 2.167 and 1.330, respectively) and psychosomatic complaints (odds ratio = 1.687 and 1.386, respectively). Few gender differences in predictors were found. Exposure to bullying was somewhat more associated with psychosomatic complaints for girls, whereas physical health risk was associated with reduced relative odds of low life satisfaction among boys. Split-sample validation and out-of-sample prediction confirmed the robustness of the results. CONCLUSIONS: The results highlight the importance of contemporary clusters of risk, such as low social support and SMU in the mental well-being of young people and the need to focus on these as targets for prevention. We propose that future studies should use composite risk measures that take into account both risk behaviors and risk factors to explain adolescents' mental well-being.

Bullying victimization: time trends and the overlap between traditional and cyberbullying across countries in Europe and North America.

OBJECTIVES: This study explores recent cross-national trends over time (2002-2014) in the occurrence of victimization by bullying; then it documents the overlap between cybervictimization and traditional bullying in 2014 among adolescents in 37 countries. METHODS: Data from four cycles (2002, 2006, 2010, and 2014) of the cross-national Health Behavior in School-Aged Children study were included (N = 764,518). Trends in traditional victimization were evaluated using logistic regression models in 37 countries. Prevalence of cybervictimization and the overlap between cybervictimization and traditional victimization were estimated. RESULTS: Linear decreases in bullying victimization were observed in 21 countries among boys, and in 12 countries among girls. The prevalence of cybervictimization was systematically lower than traditional victimization. Overall across all countries, 45.8% of those who reported cybervictimization also reported traditional victimization (46.5% for boys and 45.3% for girls), but wide country variations were observed. CONCLUSIONS: These indicate the need for a more holistic perspective to intervention and prevention that considers all expressions of bullying, traditional or online. Public health programs and policies could focus on addressing bullying more broadly, rather than focusing on behaviors that happen in a particular context.

Association of Early-Life Exposure to Income Inequality With Bullying in Adolescence in 40 Countries.

Importance: While the association between income inequality and interpersonal violence has been attributed to the psychosocial effects of inequality (eg, increased class anxiety, reduced social capital), longitudinal evidence for this pathway is limited by a reliance on small ecological studies and cross-sectional data. The developmental consequences of early-life inequality for subsequent involvement in violence have not been investigated. Objective: To examine the association between income inequality during infancy and early childhood and adolescents' involvement in bullying others, experiences of being bullied, or both. Design, Setting, and Participants: The Health Behavior in School-aged Children survey study was conducted in European and North American schools. This analysis used individual data on bullying (being bullied, bullying others, or both) from 6 consecutive school-based surveys of 11-year-old to 15-year-old students carried out in 40 countries between February 1994 to March 2014. Data analysis occurred from March 2018 to January 2019. Exposure: National Gini indices of income inequality for every year of life spanning a 35-year period (1979 to 2014). Main Outcomes and Measures: Being bullied, bullying others, and both outcomes were measured using a common definition and questions adapted from the Bully-Victim Questionnaire and translated to many languages. Results: The sample included 425 938 male students and 448 265 female students from 162 country-survey year groups in 29 196 schools. Linear regression coefficients indicated that early-life income inequality from birth to 4 years was positively associated with being bullied (male students: linear regression coefficient, 18.26 [95% CI, 11.04-25.47]; P < .001; female students: linear regression coefficient, 15.67 [95% CI, 10.02-21.33]; P < .001), and dual involvement in being bullied and bullying others (male students: linear regression coefficient, 5.55 [95% CI, 2.67-8.44]; P < .001; female students: linear regression coefficient, 2.45 [95% CI, 0.93-3.97]; P < .001), after differences in lifetime mean income inequality (from birth to when bullying was measured), national per capita income, family socioeconomic position, age, and cohort were controlled. No such association was found with bullying others after differences in being bullied were controlled. Conclusions and Relevance: Being bullied is associated with early-life exposure to income inequality. Although further research on the underlying pathways is needed to guide intervention, these results suggest temporality in the association between inequality and violence and suggest that growing up in areas of high income inequality is associated with victimization in adolescence.

Educational attainment of childhood cancer survivors: A systematic review.

BACKGROUND: Advances in treatment mean that most children diagnosed with cancer during childhood survive. Therefore, it is increasingly important to examine the long-term consequences of childhood cancer, including educational attainment. This systematic review investigated whether the educational attainment of childhood cancer survivors differ from the cancer-free population. DESIGN/METHODS: We searched seven databases for articles published from January 2005 to August 2018. We identified full papers in English, reporting primary data on academic attainment of adult survivors of childhood cancer, compared to a control group. Quality appraisal was conducted using the Newcastle-Ottawa Scale. RESULTS: Fourteen studies met the inclusion criteria. Nine papers included patients with various types of cancers, four focused on a single type of cancer, and one on patients who underwent stem cell transplantation. Of the 14 papers, 2 studies were considered good quality, 10 were considered adequate quality, and 2 were considered poor quality. Four studies reported more favorable educational attainment among survivors while six did not report significant differences. Less favorable attainment was consistently reported for CNS survivors in four studies. CONCLUSION: The literature does not provide a clear pattern of the long-term consequences of childhood cancer on education attainment. While this may suggest that there is no consistent difference between the education attainment of cancer survivors and controls, it may also be the result of limitations in the existing research. To better assess the education attainment of survivors, there is a need for high-quality studies, with appropriate comparators, and standardized measures of education attainment across countries.

Bullying and bystander behaviour and health outcomes among adolescents in Ireland.

BACKGROUND: Little is known about the impact of being a bystander to bullying. This study compared health outcomes among bullies, victims and bystanders, and investigated actions taken by bystanders when they saw bullying. METHOD: Participants included 7522 students aged 12-18 years that completed self-report questionnaires in the 2013/2014 Health Behaviour in School-aged Children survey. Binary logistic regression models (controlled for bully, victim, bystander status and demographic variables) were used to investigate the associations between participation in bullying as a bully, victim and bystander and health outcomes. RESULTS: Overall, 13.3% of adolescents reported being a bully, 25.1% reported being a victim and 30.5% reported that they saw bullying, in the last couple of months. Bystanders were significantly more likely to experience psychological symptoms (OR 1.355), somatic symptoms (OR 1.392) and low life satisfaction (OR 1.268) than those who were not bystanders. Helping the victim was significantly associated with experiencing psychological symptoms (OR 1.240), somatic symptoms (OR 1.251) and low life satisfaction (OR 1.198). Being a bully was significantly associated with experiencing psychological symptoms (OR 1.382) and not having excellent health (OR 1.252). Victims were significantly more likely to experience psychological symptoms (OR 2.437), somatic symptoms (OR 2.364), low life satisfaction (OR 2.564) and not having excellent health (OR 1.559). CONCLUSION: In Ireland, being a bystander to bullying is more prevalent in schools than bullying perpetration or victimisation. The impact of being a bystander to bullying needs to be highlighted and included in intervention development.

What do coaches want to know about sports-related concussion? A needs assessment study.

PURPOSE: This study aims to identify the concussion-related training and education needs of Gaelic Athletic Association (GAA) coaches in Ireland, as well as the preferred method of concussion education delivery. METHODS: We used a self-report questionnaire to collect data from a convenience sample of 108 GAA coaches in Ireland. Data were captured on (1) informational needs and desires, (2) preferred methods of delivery, and (3) concussion practices and procedures. Questionnaires were completed electronically from June 3rd-September 29th, 2015. RESULTS: Coaches indicated that they were most interested in receiving information about the (1) signs and symptoms of concussion, (2) assessment of concussion, and (3) return-to-play guidelines. Over two-thirds of participants indicated that in-person training would be the most effective mode of delivery of concussion education for this population. Additionally, only 10% coaches reported that before the start of the season they talked to their athletes about concussion management and safety, and this was more common among coaches who reported being formally educated about concussion. CONCLUSION: Our findings reveal a disconnect between the concussion education needs and the education that is currently provided to GAA coaches, in terms of content and delivery modality. Our results suggest a need for a multifaceted approach to concussion education, tailored to the needs and learning preferences of the target population.