Associations between adolescents' energy drink consumption frequency and several negative health indicators.

BACKGROUND: The purpose of this study was to identify how various negative health indicators are associated with energy drink consumption frequency among 13- and 15-year-old Finnish adolescents. METHODS: Data (N = 2429) from the nationally representative international Health Behaviour in School-aged Children study (2018) were analyzed via descriptive analysis and logistic regression analyses, with control for salient covariates. Relative risks (RR) were derived from the adjusted odds ratios. RESULTS: Even infrequent energy drink consumption was associated with various negative health indicators. Moreover, as compared to non-users, frequent energy drink consumers were more likely to report several health-compromising behaviors: current smoking (RR = 9.85, 95% CI: 5.68-16.02), current snus use (RR = 3.62, 95% CI: 1.80-6.85), cannabis use (RR = 3.42, 95% CI: 1.69-6.52), alcohol consumption (RR = 3.08, 95% CI: 2.49-3.71), problematic social media use (RR = 2.53, 95% CI:1.68-3.72), short sleep (RR = 2.12, 95% CI: 1.69-2.60), skipping breakfast (RR = 1.87, 95% CI: 1.51-2.29), drunkenness (RR = 1.59, 95% CI: 1.11-2.23), inadequate tooth brushing (RR = 1.28, 95% CI: 1.05-1.54). In addition, frequent energy drink consumption was associated with perceived negative health indicators: feelings of insufficient sleep (RR = 1.56, 95% CI: 1.11-2.15), low self-rated health (RR = 1.48, 95% CI: 1.15-1.87), and multiple health complaints (RR = 1.31, 95% CI: 1.07-1.56). CONCLUSIONS: Energy drink consumption, even infrequent, was associated with several negative health indicators, and the reporting of these increased with the frequency of energy drink consumption. The findings support the concerns of health authorities regarding the negative associations between energy drink consumption and health, even among persons as young as 13 years. There is evidence to support specific policy level actions, including restrictions on the sale of energy drinks to adolescents. This measure has been proposed in a Finnish government program, but implementation has yet to occur. Moreover, marketing of these beverages in platforms that are popular among adolescents (e.g., the social media) should be rigorously evaluated, and comprehensive interventions and actions implemented to ensure that adolescents, parents/guardians, and professionals working with adolescents (e.g., in schools) have a good understanding of the links between energy drink consumption and health.

Loneliness, subjective health complaints, and medicine use among Finnish adolescents 2006-2018.

AIMS: Loneliness is an important public health challenge for all ages. This study reports time trends of loneliness among adolescents over a 12-year period and analyses the strength of the associations between loneliness, health complaints, and medicine use. METHODS: Data were derived from the cross-sectional Finnish Health Behaviour in School-aged Children study conducted in 2006, 2010, 2014, and 2018. The study population is based on a random sample of schools with 20,444 participants aged 11-15 years. The trends were analysed with a Mantel-Haenszel test, and the strength of the associations was evaluated by mixed-effects logistic and linear regressions. RESULTS: An increasing prevalence in frequent loneliness (2006: 11%; 2018: 15%) was evident over the 12-year study period, especially in girls and 15-year-olds. Among all adolescents, loneliness was associated with a higher risk of recurrent health complaints and medicine use to treat the corresponding health issues, especially nervousness (odds ratio 5.8) and sleeping difficulties (odds ratio 7.6). CONCLUSIONS: Adolescence is a period of higher risk of frequent loneliness and associated health complaints. In this study, loneliness was common among adolescence and an increasing trend of loneliness was observed between 2006 and 2018. Also, psychosomatic health complaints and medicine use were strongly associated with loneliness. Persistent loneliness is a significant health risk and failure to resolve loneliness before entering adulthood may imply significant concerns for future well-being.

Energy Drink Consumption Among Finnish Adolescents: Prevalence, Associated Background Factors, Individual Resources, and Family Factors.

Objectives: Energy drink consumption among adolescents has become a notable global phenomenon, and has been associated with numerous negative health outcomes. In order to understand the popularity of energy drinks among adolescents, and to target interventions, it is important to identify the determinants underpinning consumption. Methods: The nationally representative data (cross-sectional) were drawn from the Health Behaviour in School-aged Children (HBSC) surveys, conducted in 2014 and 2018, each comprising 13- and 15-year-old Finnish adolescents (n = 7405). Results: Weekly energy drink consumption increased among Finnish adolescents between 2014 (18.2%) and 2018 (24.4%), especially among girls. In 2018, boys typically consumed more than girls, and 15-year-olds more than 13-year-olds. Moreover, in 2018, weekly energy drink consumption was more prevalent among 15-year-old adolescents with a non-academic educational aspiration (46.0%) than among adolescents with an academic aspiration (18.3%). Gender (boys more than girls), older age (only in 2018), less parental monitoring, lower school achievement, and a lower level of health literacy explained around 28% of the variance in weekly energy drink consumption in both years. Conclusion: According to the findings, interventions to decrease the energy drink consumption, should be targeted at all adolescents, but especially at those with fewer individual resources. The interventions should also pay attention to family-level factors.

The Association between Loneliness, Mental Well-Being, and Self-Esteem among Adolescents in Four Nordic Countries.

Positive mental health is central to adolescent well-being. The present study examines the prevalence of loneliness and positive mental health indicators (mental well-being and self-esteem) in four Nordic countries and associations between loneliness, mental well-being, and high self-esteem. This study is based on data from the Health Behaviour in School-aged Children (HBSC) study which was conducted in 2018 in Denmark, Finland, Iceland, and Sweden. Participants were 5883 15-year-old boys and girls. To examine the associations between loneliness, mental well-being, and self-esteem, structural equation modeling (SEM) was applied. In the comparison of Nordic countries, the prevalence of loneliness was highest among Finnish and Icelandic adolescents. High mental well-being and high self-esteem were most prevalent in Denmark and Sweden. In general, boys scored higher on positive mental health indicators and girls on loneliness. Loneliness was also a strong indicator of low mental well-being and low self-esteem in all Nordic countries. Loneliness is not only associated with mental health problems such as anxiety and depression, but it is also a risk factor for adolescents' positive mental health. Positive mental health is important for healthy maturation and there is a need to develop initiatives to reduce adolescent loneliness and so support positive development.

Does health literacy explain regional health disparities among adolescents in Finland?

Health literacy (HL)-as a broad range of health-related competencies-has been proposed to be a promising construct in understanding health disparities better, also among adolescents. Several factors have been found to explain differences in adolescents' HL levels; however, not much is known about how different regions of a country or majority/minority status is associated with HL, or whether HL is associated with regional health disparities. The aim of this study was to examine and compare HL and health levels among majority- and minority-language-speaking adolescents living in different regions of Finland, and to explore if HL explains regional health disparities, taking into account other important structural stratifying factors. The study uses Health Behaviour in School-aged Children survey data, collected among 13- and 15-year-old pupils in Finnish- and Swedish-speaking schools in Finland in 2014 (N = 3853/1123; 85/83%). Findings suggest that regional differences in HL levels and regional health disparities exist in both language groups. Health disparities were present in the Finnish-speaking sample among boys, the proportion rating their health as excellent ranging from 23 to 31% across regions, and in the Swedish-speaking sample among girls, the corresponding numbers ranging from 13 to 20%. In addition to other important structural stratifying factors, comprehensive HL explains these regional health disparities. This study adds to prior studies on the role of HL as a modifiable health resource by showing that regional health disparities among adolescents can partially be attributed to corresponding HL differences.

School Satisfaction and School Pressure in the WHO European Region and North America: An Analysis of Time Trends (2002-2018) and Patterns of Co-occurrence in 32 Countries.

PURPOSE: The purpose of the study was to examine the trends between 2002 and 2018 in school pressure and school satisfaction among 15-year-old students, across countries and by gender, in the WHO European region and North America, and explore whether there are variations between countries and by gender in the co-occurrence of school pressure and school satisfaction. METHODS: Data from the 32 countries that participated in the Health Behaviour in School-aged Children study (HBSC) study between 2002 and 2018 were used. Statistical analyses included t-tests, binary logistic regression analyses, and chi-square tests, as required by each of the study aims. RESULTS: School satisfaction tended to increase over the period 2002-2018 among boys, whereas school pressure increased among girls. Also, gender differences tended to dissipate in school satisfaction and generally increase in school pressure. The co-occurrence of school satisfaction and school pressure in 2017/2018 shows that the majority of students are found in the "not pressured-not highly satisfied" and "pressured-not highly satisfied" groups. There were more boys in the former group and more girls in the latter group. CONCLUSION: Few students in the 32 countries belonged to the "not pressured-highly satisfied" group, which from a public health perspective may be seen as the most desirable group. The increases in school pressure in girls from 2002 to 2018 and their overrepresentation in the pressured groups require further attention.

Empowerment-enabling home and school environments and self-rated health among Finnish adolescents.

Perceived health during adolescence has not only immediate consequences for individuals and for society, but also long-term. We need to understand better the health development in this period of the lifespan. Empowerment may be one pathway through which social factors and conditions translate into health effects. This study aimed to examine whether empowerment-enabling home and school environments are associated with self-rated health among adolescents, and whether the associations differ between genders, age or majority/minority language groups. Anonymous questionnaire data from respondents aged 11, 13 and 15 years were obtained from the Health Behaviour in School-aged Children study, conducted in Finland in 2014 in Finnish- and Swedish-speaking schools (n = 5925/1877). The proportion rating their health as excellent varied between 33.6 (11-year-olds) and 23.1% (15-year-olds), boys rating their health as excellent more often than girls in all age groups. Findings showed that indicators of both empowerment-enabling home and school environments were independently and positively related to adolescents' self-rated health. Whereas a respectful, accepting, kind and helpful attitude among classmates and a good home atmosphere were quite consistently associated with excellent health, there were gender and age differences with concern to the other empowerment-enabling indicators. Moreover, there were gender-, age- and language-related differences regarding adolescents' perceptions of how empowerment enabling their environments were. Home and school environments that create opportunities through encouragement and care, and through strengthening feelings of being secure, accepted and respected are potentially empowerment enabling. This study suggests that such environmental qualities are important for the perceived health of young people.

Health asset profiles and health indicators among 13- and 15-year-old adolescents.

OBJECTIVES: We examined the associations between adolescents' health assets and various health indicators (smoking, alcohol use, sleep length, physical activity, healthy eating, oral health, self-reported health, multiple health complaints). METHODS: A nationally representative sample was drawn from Finnish-speaking schools, comprising 13- and 15-year-old adolescents (n = 3833). The measures taken covered the adolescents' health assets, which were labelled Family-financial, Psychological, Family-social, Friends-social, School-social, and Human. Our analysis applied two-step cluster analysis and multilevel mixed-effects binary logistic regression. RESULTS: Six asset profiles were identified: 'Limited in most assets, despite medium affluence', 'Mostly average assets, but low affluence', 'Mostly average assets, though high affluence', 'Mostly above average assets', 'Rich in most assets', and 'Rich in all assets'. There were significant differences between the profiles in terms of risk level and desirable level health outcomes. CONCLUSIONS: Adolescents differ in their asset profiles. Having multiple health assets appears to protect adolescents from risky behaviour or poor health, and to promote positive health. There is a need for health initiatives to develop a range of health-protecting and health-promoting assets, rather than focus on only one.

Cross-country comparisons of trends in adolescent psychosomatic symptoms - a Rasch analysis of HBSC data from four Nordic countries.

BACKGROUND: To analyse the psychometric properties of the HBSC Symptom Checklist (HBSC-SCL) on psychosomatic symptoms with a focus on the operating characteristics of the items, and on the impacts of measurement distortions on the comparisons of person measures across time and between countries. METHODS: Data were collected in 1993/94, 1997/98, 2001/02, 2005/06, 2008/09, 2013/14 in Denmark, Finland, Norway and Sweden as part of the Health Behaviour in School-aged Children (HBSC) study. Data comprised 116,531 students 11, 13 and 15 years old. Rasch analysis was conducted of the HBSC-SCL consisting of eight items with a focus on Differential Item Functioning (DIF) and item threshold ordering. The impacts of DIF and threshold disordering on trend analyses were analysed in a subsample consisting of 15 years old students. RESULTS: One item shows evidence of severe DIF and the categorisation of some items does not seem to work as intended. Analyses of changes based on proportions of psychosomatic symptoms show that bad item functioning affects some comparisons between countries across time: A four percentage point difference between 15 years old girls in Finland and Sweden concerning the rate of increase of psychosomatic symptoms from 1994 to 2014 disappears when the problems with DIF and disordered item thresholds are taken into account. Although the proportions of students with psychosomatic symptoms are clearly higher 2014 than 1994 in all four countries the shape of most trends is nonlinear. CONCLUSIONS: Some of the cross-country comparisons were distorted because of DIF and problems related to disordering of the item thresholds. The comparisons among girls between Finland and Sweden were affected by the problems pertaining to the original measure of psychosomatic symptoms, while the trend patterns among boys were not much affected. In addition to confirming increasing rates of adolescent mental health problems in the Nordic countries, the substantive analyses in the current study show that Finland is joining Sweden in having the sharpest increase among older adolescents, in particular among girls. To improve the functioning of the scale the DIF item could be removed or replaced and response categories collapsed in post hoc analyses.

Does health literacy explain the link between structural stratifiers and adolescent health?

BACKGROUND: The concept of health literacy (HL) may help us to better understand the mechanisms leading to health disparities, and to focus on the factors that can be influenced. However, not much is yet known about how HL is related to health disparities, or whether the association exists among adolescents. The aim of the study was to examine the associations between structural stratifiers, HL and health indicators among adolescents. METHODS: The nationally representative Finnish Health Behaviour in School-aged Children survey data (n=3833) were collected from 13- and 15-year-old pupils in the spring of 2014. Pearson correlation coefficients were calculated, and separate path models were estimated for the perceived health and health behaviour measures. RESULTS: HL was found to be an independent factor explaining disparities in health. Higher HL was related to positive health outcomes. HL also acted as a mediator between health behaviours and structural stratifiers, except for gender. School achievement and educational aspirations were among the factors explaining the HL level, which in turn, explained the health indicators. CONCLUSION: The concept of HL is of use in understanding health disparities. In particular, HL provides a mechanism via which school achievement and educational plans affect health outcomes. Low HL places adolescents who have poor school achievement and who do not intend to continue on an academic path in an unequal position with respect to their health.

Prevalence of self-reported chronic pain among adolescents: Evidence from 42 countries and regions.

BACKGROUND: Reports of the overall chronic pain prevalence and its associated demographic characteristics among adolescents vary greatly across existing studies. Using internationally comparable data, this study investigates age, sex and country-level effects in the prevalence of chronic single-site and multi-site pain among adolescents during the last six months preceding the survey. METHODS: Data (n = 214,283) from the 2013/2014 Health Behaviour in School-aged Children (HBSC) study were used including nationally representative samples of 11-, 13- and 15-year-olds from general schools in 42 participating countries. Multilevel logistic regression analyses were used. RESULTS: The overall proportion of adolescents reporting chronic weekly pain during the last six months was high (44.2%). On average, in comparison with different specific localized types of single-site pain, the prevalence of multi-site pain was more common varying from 13.2% in Armenia to 33.8% in Israel. Adolescent age and sex were strong predictors for reporting pain, but significantly different demographic patterns were found in the cross-country analyses. The most consistent findings indicate that multi-site pain was more prevalent among girls across all countries and that the prevalence increased with age. CONCLUSIONS: Internationally comparable data suggest that self-reported chronic pain among adolescents is highly prevalent, but different age and sex patterns across countries exist. Adolescents with chronic pain are not a homogenous group. Chronic pain co-occurrence and differences in chronic pain characteristics should be addressed in both clinical and public health practice for effective adolescent chronic pain management and prevention. SIGNIFICANCE: Chronic pain co-occurrence is common during adolescence across countries, the prevalence being among girls and in older age groups. Significant cross-country variations in the chronic pain prevalence and chronic pain patterns among adolescents exist. Significant country differences emerge for specific chronic pain patterns in association with adolescent demographics.

The cross-national measurement invariance of the health literacy for school-aged children (HLSAC) instrument.

BACKGROUND: Health literacy (HL) is an important determinant of health and health behaviours, and there is a need to monitor HL levels among all population groups. It is therefore essential to develop instruments to assess HL during childhood and adolescence. The aim of this study was to examine the cross-national measurement invariance of the instrument Health Literacy for School-aged Children (HLSAC) in four European countries. METHODS: The data were collected via standardized self-administered anonymous questionnaires within classrooms in Finland, Poland, Slovakia, and Belgium. There were in total 1468 respondents (aged 13, N = 690; aged 15, N = 778). The HLSAC instrument was used to measure the subjective HL of adolescents in each country. A multigroup confirmatory factor analysis was applied to test measurement invariance. RESULTS: Configural and metric invariance was established, but scalar invariance did not hold. However, the instrument exhibited high internal consistency (α = 0.85) and showed adequate fit with the data. Moreover, the partial invariance allowed comparison of mean values across the countries in question. There were significant mean value differences between countries and age-groups. CONCLUSIONS: HL mean values (as assessed via the HLSAC instrument) can be compared across countries. The instrument has utility for large-scale international HL studies on adolescents.

Loneliness and subjective health complaints among school-aged children.

AIM: The first aim of this study was to explore the prevalence of loneliness and subjective health complaints (SHCs) among school-aged children in Finland. The second aim was to analyse to what extent perceived loneliness explains any variance in SHCs among school-aged children. METHOD: A representative sample of 5925 Finnish children and adolescents from grades 5 ( Mage=11.8 years), 7 ( Mage=13.8) and 9 ( Mage=15.8) completed the Health Behaviour in School-aged Children (HBSC) survey. Descriptive statistics were used to examine the prevalence of health complaints and loneliness. Structural equation modelling was used to test how strongly loneliness was associated with SHCs. RESULTS: The prevalence of loneliness and SHCs was higher among girls and increased with age. Loneliness was a significant predictor of health complaints, especially of psychological symptoms among girls and among ninth grade students. CONCLUSIONS: The findings indicate that loneliness is a major risk to the health and well-being of school-aged children. The strong association between loneliness and SHCs highlights the importance of active preventive actions to reduce loneliness.

Socioeconomic differences in the use of alcohol and drunkenness in adolescents: Trends in the Health Behaviour in School-aged Children study in Finland 1990-2014.

AIMS: The aims of this study were to explore time-based trends of socioeconomic differences in alcohol use and drunkenness in Finnish adolescents from 1990 to 2014 and to investigate the significance of two indicators in detecting socioeconomic differences in alcohol use and drunkenness. METHODS: Data were retrieved from seven surveys conducted as part of the Health Behaviour in School-aged Children (HBSC) study in Finland from 1990 to 2014. The alcohol use and drunkenness of 15-year-old students, as well as socioeconomic status, including educational aspiration and perceived family wealth, were assessed via a self-report questionnaire. Logistic regression models were used to investigate the relationships between alcohol use, drunkenness and indicators of socioeconomic status. RESULTS: The study showed that the alcohol use and drunkenness of Finnish 15-year-old adolescents have decreased since the late 1990s. However, the level of decrease is not consistent among different socioeconomic groups and socioeconomic differences in drinking behaviour between two educational aspiration groups have persisted over two decades. Girls from the groups with low perceived family wealth were more likely to be frequently drunk in the time period 2006-2014. CONCLUSIONS: This study suggests that students with low educational aspiration should be the target population for interventions aiming at reducing the alcohol use and drunkenness of Finnish adolescents. In future interventions aimed at reducing heavier drinking, adolescents (especially girls) from less wealthy families should be the first priority. Further studies on trends in socioeconomic differences in alcohol use and drunkenness in adolescence should be conducted using different indicators of socioeconomic status and other social context factors should also be taken into account.

Different drinking motives, different adverse consequences? Evidence among adolescents from 10 European countries.

INTRODUCTION AND AIM: This study, which builds on previous research demonstrating that drinking motives are associated with adverse consequences, investigates the associations between drinking motives and non-alcohol-attributed adverse consequences and disentangles alcohol-related and direct effects. DESIGN AND METHOD: On the basis of a sample of 22 841 alcohol-using 13- to 16-year-olds (50.6% female) from Belgium, Denmark, Estonia, Finland, Ireland, Portugal, Scotland, Slovakia, Switzerland and Wales, structural equation models were used to estimate direct and indirect effects. Additionally, differences across countries were tested in a multigroup analysis. RESULTS: The indirect effect (via alcohol use) was greater for injuries and academic problems than for more general outcomes such as life dissatisfaction and negative body image. For social, enhancement and coping motives, we found positive indirect effects (via alcohol use) on injuries and academic problems; the association was negative for conformity motives. The direct effect, that is, the effect above and beyond alcohol use, indicated more negative consequences among those who tended to drink more frequently for coping motives. More negative consequences, such as injuries and negative body image, were also found among those who drink for conformity motives. The pattern of association was largely comparable across countries. DISCUSSION AND CONCLUSION: While the actual mean level of drinking motives, alcohol use and adverse consequence varied across countries, the consistency of association patterns implies that drinking motive-inspired health promotion efforts are likely to be beneficial across Europe. This is particularly important for coping drinkers because they are especially prone to adverse consequences over and above their alcohol use. [Wicki M, Kuntsche E, Eichenberger Y, Aasvee K, Bendtsen P, Dankulincová Veselská Z, Demetrovics Z, Dzielska A, Farkas J, de Matos MG, Roberts C, Tynjälä J, Välimaa R, Vieno A. Different drinking motives, different adverse consequences? Evidence among adolescents from 10 European countries.

Semantics bias in cross-national comparative analyses: is it good or bad to have "fair" health?

The Health Behavior in School-aged Children is a cross-national study collecting data on social and health indicators on adolescents in 43 countries. The study provides comparable data on health behaviors and health outcomes through the use of a common protocol, which have been a back bone of the study sine its initiation in 1983. Recent years, researchers within the study have noticed a questionable comparability on the widely used item on self-rated health. One of the four response categories to the item "Would you say your health is….?" showed particular variation, as the response category "Fair" varied from 20 % in Latvia and Moldova to 3-4 % in Bulgaria and Macedonia. A qualitative mini-survey of the back-translations showed that the response category "Fair" had a negative slant in 25 countries, a positive slant in 10 countries and was considered neutral in 9 countries. This finding indicates that there are what may be called semantic issues affecting comparability in international studies, since the same original word (in an English original) is interpreted differently across countries and cultures. The paper test and discuss a few possible explanations to this, however, only leaving to future studies to hold a cautious approach to international comparisons if working with the self-rated health item with four response categories.

Physical Activity Trends of Finnish Adolescents With Long-Term Illnesses or Disabilities From 2002-2014.

BACKGROUND: Adolescents' physical activity level is a major source of concern. For adolescents with long-term illnesses or disabilities (LTID), being physically active can prevent secondary conditions. This is one of the first studies reporting trends in physical activity of adolescents with LTID in relation to gender, age, and sports club membership. METHODS: Data were collected from the Health Behavior in School-aged Children study in Finland during 2002, 2006, 2010, and 2014. In 13- and 15-year-olds (N = 2206), 17.1% reported having LTID. Daily physical activity recall was the dependent variable. Binary logistic regression analysis was conducted separately for sports club members (n = 936) and nonmembers (n = 1270). RESULTS: The proportion of physically active adolescents with LTID in 2014 was higher than in 2002 for girls (15.6% vs 8.7%) and boys (26.6% vs 13.0%). Girl sports club members were 2 times more likely to be physically active in 2014 than in 2002. The largest trend between 2014 and 2002 was among boy nonmembers (odds ratio: 4.62, 95% confidence interval, 2.02-10.58). CONCLUSIONS: More adolescents with LTID took part in daily moderate-to-vigorous physical activity in 2014 than in 2002; however, physical activity levels still remain low. Sports club membership was similar to that of the general population.

Teacher Competencies in Health Education: Results of a Delphi Study.

OBJECTIVE: The aim of this research study was to identify the core competencies for health education teachers in supporting the development of health literacy among their students. METHOD/RESULTS: A three round Delphi method was employed. Experts in health education were asked to identify core competencies for school health educators. Twenty six participants from the academic field were invited to participate in the study. Twenty participants completed the first round of the Delphi, while eighteen took part in round two and fifteen participated in the final round. Data were collected using an electronic questionnaire. The first round contained an open ended question in which participants were asked to name and define all the competencies they perceived were important. Thematic analysis was undertaken on these data. A list of 36 competencies was created from this round. This list was then returned to the same participants and they were asked to rate each competency on a 7 point semantic differential scale in terms of importance. The resulting data were then analysed. For the final round, participants were presented with a list of 33 competencies and were asked to rank them again, in order of importance. CONCLUSION: Twelve core competencies emerged from the analysis and these competencies comprised of a mixture of knowledge, attitude and skills. The authors suggest that how these competencies are achieved and operationalised in the school context can be quite complex and multi-faceted. While the authors do not seek to generalise from the study they suggest that these competencies are an important input for all stakeholders, in order to question national and international teacher guidelines. In addition the competencies identified may provide a useful starting point for others to undertake deeper analysis of what it means to be an effective health educator in schools.

Trends in self-rated health in European and North-American adolescents from 2002 to 2010 in 32 countries.

BACKGROUND: Self-rated health (SRH) in adolescence is known to be associated with health outcomes in later life. We carried out a trend analysis on data coming from three waves of data collected in 32 countries (mostly European) from 2002 to 2010 coming from the Health Behaviour in School-Aged Children surveys. METHODS: SRH in adolescents was assessed using a Likert scale (excellent, good, fair and poor). Responses were dichotomized into 'excellent' vs. 'rest'. Country, age and gender groups were compared based on the odds ratio of declaring excellent SRH in 2010 with respect to 2002 and 2006. RESULTS: The trend for European adolescents indicates an improvement over the last decade, although, in the majority of countries, a higher proportion of adolescents rate their health as excellent during the period 2002-06 with respect to the second half of the decade (2006-10).Girls were found to constantly rate their health as poorer, compared to their male peers, in all countries. Age has also a very stable trend towards a decreasing rating of health with increasing age. CONCLUSION: Decreased rating of health in the period 2006-10 may be a signal of the socio-economic difficulties of Europe in the last part of this decade.

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.