Understanding the Health and Well-Being of Early Adolescents Throughout the World: Findings From the 2017–2018 Survey of Health Behavior in School-Aged Children

Abstract

In the supplement accompanying this issue of the Journal of Adolescent Health, we present 10 articles from the Health Behavior in School-aged Children (HBSC)—WHO Collaborative Cross-national Study, an international research study that aims to increase understanding of adolescent health and behavior, as well as their social determinants, particularly the settings of family, peers, and school [[1]Inchley J. Currie D. Budisavljevic S. Spotlight on Adolescent Health and Well-Being. Findings from the 2017/18 Health Behaviour in School-Aged Children (HBSC) Survey in Europe and Canada. Volume 1: Summary Report. WHO Regional Office for Europe, Copenhagen2020Google Scholar]. These articles tackle many of the critical issues that emerge from comprehensive analyses of the latest HBSC 2017–2018 survey, which includes data from 45 of the 50 member countries across Europe and North America [2Kern M.R. Duinhof E.L. Walsh S.D. et al.Intersectionality and adolescent mental well-being. A cross-nationally comparative analysis of the interplay between immigration background, socio-economic status and gender.J Adolesc Health. 2020; 66: S12-20Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 3Dierckens M. Weinberg D. Huang Y. et al.National level wealth inequality and socioeconomic inequality in adolescent mental wellbeing: A time-series analysis of 17 countries.J Adolesc Health. 2020; 66 (S21–8)Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 4Heinz A. Catunda C. van Duin C. et al.Patterns of health related gender inequalities – a cluster analysis of 45 countries.J Adolesc Health. 2020; 66: S29-39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 5Walsh S.D. Sela T. De Looze M. et al.Clusters of contemporary risk and their relationship to mental well-being among 15- year old adolescents across 37 countries.J Adolesc Health. 2020; 66 (S40–9)Abstract Full Text Full Text PDF Scopus (23) Google Scholar, 6Cosma A. Stevens G. Martin G. et al.Cross-national time trends in adolescent mental well-being from 2002 to 2018 and the explanatory role of schoolwork pressure.J Adolesc Health. 2020; 66 (S50–8)Abstract Full Text Full Text PDF Scopus (59) Google Scholar, 7Löfstedt P. García-Moya I. Corell M. et al.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.J Adolesc Health. 2020; (S59-69): 66Google Scholar, 8Gariepy G. Danna S. Gobiņa I. et al.How are adolescents sleeping? Adolescent sleep patterns and sociodemographic differences in 24 European and North American countries.J Adolesc Health. 2020; 66 (S81–8)Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar, 9Dzielska A. Kelly C. Ojala K. et al.Weight reduction behaviors among European adolescents–Changes from 2001/2002 to 2017/2018.J Adolesc Health. 2020; 66: S70-80Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar, 10Boer M. van den Eijnden R.J.J.M. Boniel-Nissim M. et al.Adolescents' intense and problematic social media use and their well-Being in 29 countries.J Adolesc Health. 2020; 66: S89-99Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar, 11Craig W. Boniel-Nissim M. King N. et al.Social media use and cyber-bullying: A cross-national analysis of young people in 42 countries.J Adolesc Health. 2020; 66: S100-8Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar]. In addition, three commentaries offer, in turn, an overview of the HBSC study; a detailed description of the critical role that young people have provided in the ongoing development, implementation, and dissemination of the findings of the HBSC; and finally, a discussion of the important role that evidence-based public policy plays in improving the health and well-being of young people [12Inchley J. Stevens G.W.J.M. Samdal O. Currie D.B. Enhancing understanding of adolescent health and well-Being: The Health Behavior in School-aged Children study.J Adolesc Health. 2020; 66: S3-5Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar, 13Kelly C. Branquinho C. Dzielska A. et al.Youth participation in the Health Behavior in School-aged Children study.J Adolesc Health. 2020; 66: S6-8Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 14Budisavljevic S. Arnarsson A. Hamrik Z. et al.Improving adolescent health: Translating health behaviour in school-aged children evidence into policy.J Adolesc Health. 2020; 66: S9-11Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. In the first commentary, Inchley et al. give a comprehensive overview of the HBSC and how this ongoing survey, initiated in 1982, has developed to guide prevention and intervention programs for early adolescents (aged 11–15 years) in Europe and North America over time [[12]Inchley J. Stevens G.W.J.M. Samdal O. Currie D.B. Enhancing understanding of adolescent health and well-Being: The Health Behavior in School-aged Children study.J Adolesc Health. 2020; 66: S3-5Abstract Full Text Full Text PDF PubMed Scopus (19) Google Scholar]. The HBSC is a school-based national cross-sectional survey with data collected in representative schools and regions within member countries through self-completed questionnaires, given in the classroom every 4 years. In the second commentary, Kelly et al. explore how youth engagement has evolved in the development of the study, with specific examples of the role that young people play in questionnaire development, data analyses, preparation of manuscripts, and the development of recommendations for public policy [[13]Kelly C. Branquinho C. Dzielska A. et al.Youth participation in the Health Behavior in School-aged Children study.J Adolesc Health. 2020; 66: S6-8Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. The HBSC was far ahead of other national and international studies in its engagement with young people. Perhaps this working group has set the standard for investigators to come on board and support what is currently being advocated by many organizations: to engage youth as partners in the development of surveys and preventive interventions [[15]Patton G.G. Sawyer S.M. Santelli J. et al.Our future: A Lancet commission on adolescent health and wellbeing.Lancet. 2016; 387: 2423-2478Abstract Full Text Full Text PDF PubMed Scopus (1519) Google Scholar,[16]Ozer E.J. Afifi R. Gibbs L. Mathur R.T. Youth engagement and participation: Field-building across research and practice.J Adolesc Health. 2018; 63: 671-672Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. The final commentary by Budisavljevic et al. makes a strong case in demonstrating how the results of the HBSC work have informed the policy makers charged with investing in development programs for adolescents in their respective countries [[14]Budisavljevic S. Arnarsson A. Hamrik Z. et al.Improving adolescent health: Translating health behaviour in school-aged children evidence into policy.J Adolesc Health. 2020; 66: S9-11Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar]. In his editorial, supplement Guest Editor Dr. Jason Nagata describes how the 10 manuscripts reflect the interdisciplinary nature of the HBSC, grouping the topics into three broad areas: the social determinants of health, mental health and well-being, and social media [[17]Nagata J.M. New findings from the health behavior in school-aged children survey: Social media, social determinants, and mental health.J Adolesc Health. 2020; 66: S1-2Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar]. Here, I adopt his framework to outline the articles' contributions. The first three articles use data from 13 to 45 countries to highlight structural issues that may have an impact on adolescent health, including national wealth, family income, gender inequality, and social disadvantage [2Kern M.R. Duinhof E.L. Walsh S.D. et al.Intersectionality and adolescent mental well-being. A cross-nationally comparative analysis of the interplay between immigration background, socio-economic status and gender.J Adolesc Health. 2020; 66: S12-20Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar, 3Dierckens M. Weinberg D. Huang Y. et al.National level wealth inequality and socioeconomic inequality in adolescent mental wellbeing: A time-series analysis of 17 countries.J Adolesc Health. 2020; 66 (S21–8)Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 4Heinz A. Catunda C. van Duin C. et al.Patterns of health related gender inequalities – a cluster analysis of 45 countries.J Adolesc Health. 2020; 66: S29-39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Kern et al., using 2018 HBSC data from 43 countries, identify no uniform intersectionality effects across all countries [[2]Kern M.R. Duinhof E.L. Walsh S.D. et al.Intersectionality and adolescent mental well-being. A cross-nationally comparative analysis of the interplay between immigration background, socio-economic status and gender.J Adolesc Health. 2020; 66: S12-20Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar]. However, when carefully looking at national context, there were some important associations: adolescents belonging to multiple disadvantaged social groups benefit from policies promoting inclusivity and equality, and those adolescents from disadvantaged social groups may experience aggravated negative effects in countries with restrictive migration policies and low income equality. Dierckens et al., using data from 17 countries with three consecutive waves of HBSC data (2010–2018), present some confusingly divergent findings, with higher levels of national income inequality being associated with more mental health symptoms [[3]Dierckens M. Weinberg D. Huang Y. et al.National level wealth inequality and socioeconomic inequality in adolescent mental wellbeing: A time-series analysis of 17 countries.J Adolesc Health. 2020; 66 (S21–8)Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar]. Heinz et al., using 2018 HBSC data across 45 countries, attempt to clarify the role of gender inequality in adolescent health [[4]Heinz A. Catunda C. van Duin C. et al.Patterns of health related gender inequalities – a cluster analysis of 45 countries.J Adolesc Health. 2020; 66: S29-39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. Much to our surprise, gender equality is not necessarily associated with greater health equality. For example, the greater gender equality in a country, the higher the odds that girls feel fat, report less support from families, feel school pressure, have multiple health complaints, smoke, drink alcohol, and have low life satisfaction compared with boys [[4]Heinz A. Catunda C. van Duin C. et al.Patterns of health related gender inequalities – a cluster analysis of 45 countries.J Adolesc Health. 2020; 66: S29-39Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar]. These findings around gender equality need further investigative work to determine the mechanism of these associations. The next three papers move from the broader structural issues affecting adolescent health to examine the mental health and well-being of adolescents in the HBSC countries. Walsh et al., using 2018 HBSC data from 37 countries, examine clusters of traditional risk behaviors (e.g., substance use, early sex, bullying, problematic social media use, substance use, etc.) and risk factors (e.g., low social support) and how these relate to adolescent mental well-being. Of all these factors and risks, low social support and problematic social media use were the strongest predictors of low life satisfaction and poor mental health [[5]Walsh S.D. Sela T. De Looze M. et al.Clusters of contemporary risk and their relationship to mental well-being among 15- year old adolescents across 37 countries.J Adolesc Health. 2020; 66 (S40–9)Abstract Full Text Full Text PDF Scopus (23) Google Scholar]. Cosma et al., using HBSC data across five cohorts (2002–2018) in 36 countries, monitor trends in mental health over 16-year period, reporting no evidence for a substantial decrease in mental health and well-being over time [[6]Cosma A. Stevens G. Martin G. et al.Cross-national time trends in adolescent mental well-being from 2002 to 2018 and the explanatory role of schoolwork pressure.J Adolesc Health. 2020; 66 (S50–8)Abstract Full Text Full Text PDF Scopus (59) Google Scholar]. The small decline in mental health and well-being and increases in schoolwork pressure appears to be consistent with high-income countries. Löfstedt et al., using HBSC data across five cohorts (2002–2018) from 32 countries, further increases our understanding of the school satisfaction and school pressure by gender [[7]Löfstedt P. García-Moya I. Corell M. et al.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.J Adolesc Health. 2020; (S59-69): 66Google Scholar]. In the final analyses, boys appear to be more satisfied with school over time, whereas girls appear to feel more pressured by school. These findings raise some opportunities for the development of preventive interventions: the fewest young people of both genders were in the group that was not pressured and highly satisfied wih their lives. Two other papers in this supplement examine weight reduction and sleep patterns, which are strongly related to mental health and well-being [[8]Gariepy G. Danna S. Gobiņa I. et al.How are adolescents sleeping? Adolescent sleep patterns and sociodemographic differences in 24 European and North American countries.J Adolesc Health. 2020; 66 (S81–8)Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar,[9]Dzielska A. Kelly C. Ojala K. et al.Weight reduction behaviors among European adolescents–Changes from 2001/2002 to 2017/2018.J Adolesc Health. 2020; 66: S70-80Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. Gariepy et al., using HBSC data across two cohorts (2014, 2018) from 24 countries, examine sleep patterns of adolescents, and the findings confirm the universality of insufficient sleep for adolescents: most adolescents (32%–86%) do not meet sleep recommendations for young people [[8]Gariepy G. Danna S. Gobiņa I. et al.How are adolescents sleeping? Adolescent sleep patterns and sociodemographic differences in 24 European and North American countries.J Adolesc Health. 2020; 66 (S81–8)Abstract Full Text Full Text PDF PubMed Scopus (59) Google Scholar]. These findings lend further support to international public health efforts to change environmental issues such as school start times. Dzielska et al., using HBSC data over five cohorts (2002–2018) in 26 countries, examine the prevalence of weight reduction behaviors over the past 16 years [[9]Dzielska A. Kelly C. Ojala K. et al.Weight reduction behaviors among European adolescents–Changes from 2001/2002 to 2017/2018.J Adolesc Health. 2020; 66: S70-80Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar]. Overall, 18% of girls and 10.2% of boys reported weight reduction behaviors. Since 2002, there has been a significant increase in the prevalence of weight reduction behaviors among boys, whereas the behaviors of girls have remained stable. These results may justify more attention being given to adolescent males for the prevention of disordered eating. The final two articles in this supplement focus exclusively on social media use [[10]Boer M. van den Eijnden R.J.J.M. Boniel-Nissim M. et al.Adolescents' intense and problematic social media use and their well-Being in 29 countries.J Adolesc Health. 2020; 66: S89-99Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar,[11]Craig W. Boniel-Nissim M. King N. et al.Social media use and cyber-bullying: A cross-national analysis of young people in 42 countries.J Adolesc Health. 2020; 66: S100-8Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar]. Given the unprecedented rise of social media use among adolescents, with the majority of adolescents using social media in some context, these articles provide new prevalence data across countries. Boer et al., using 2018 HBSC data from 29 countries, find that more than one third of youth report intense social media use, defined as use almost all the time throughout the day [[10]Boer M. van den Eijnden R.J.J.M. Boniel-Nissim M. et al.Adolescents' intense and problematic social media use and their well-Being in 29 countries.J Adolesc Health. 2020; 66: S89-99Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. The problem, however, with this definition of intense social media use is that it may be normative in many countries. Seven percent of young people report that they meet the criteria for problematic social media use, indicated by symptoms of addiction to social media. Problematic social media use is associated with poorer well-being across all domains, including life satisfaction, mental health, school, and families [[10]Boer M. van den Eijnden R.J.J.M. Boniel-Nissim M. et al.Adolescents' intense and problematic social media use and their well-Being in 29 countries.J Adolesc Health. 2020; 66: S89-99Abstract Full Text Full Text PDF PubMed Scopus (79) Google Scholar]. Craig et al., using 2018 HBSC data from 42 countries, explore social media and cyberbullying versus cybervictimization for both girls and boys. The message of this article is clear: pervasive access to social medial allows new opportunities for aggression, and the problematic use of social media poses the strongest and most consistent risk for young people. Given that young people are using social media at increased rates in all venues, we need to develop public health messaging that speaks to young people about the positive and negative aspects of social media. For good or ill, social media are the dominant milieu for today's young people, and at its best, it offers them unprecedented opportunities to be global citizens. The HBSC is a model of how consistently used data gathered over almost three decades can be used both to drive the development of country-/region-specific preventive interventions and also to inform relevant global programs of cross-national trends. The articles in the supplement use a variety of metrics, some grouping countries to focus on trends over decades, and others offer a deep dive into data specific for 2018. This supplement tackles many of the critical issues affecting young people: mental health, risk behaviors, social support, social media, gender, bullying, weight, and sleep. A limitation of this supplement, although, is that some significant issues related to morbidity and mortality in the second and third decade of life—including road traffic accidents, violence, major depressive disorders, and suicide—were not addressed. This omission may be attributed to the age range of the study being 11–15 years, but increasingly, there is a need to focus on the impact of early adolescence on late adolescence and young adulthood. In spite of these limitations, the HBSC has played a major role in informing national and international policy related to adolescent health for over three decades. In their commentary, Budisavljevic et al. highlight how data from the HBSC have made a strong case for countries investing resources in supporting the second decade of life [[13]Kelly C. Branquinho C. Dzielska A. et al.Youth participation in the Health Behavior in School-aged Children study.J Adolesc Health. 2020; 66: S6-8Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. A recent supplement in the Journal of Adolescent Health entitled, “An Investment Case for the Rights of Adolescents,” provides additional evidence-based support for investing resources in adolescent health and well-being, matching well with the HBSC's mission to drive investment with data [[18]Malhotra J. Charting a pathway to multisectoral investments in adolescent health in low- and middle-income countries.J Adolesc Health. 2019; 65: S1-S2Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar].