Timo-Kolja Pförtner

Decreases in adolescent weekly alcohol use in Europe and North America: evidence from 28 countries from 2002 to 2010

BACKGROUND This study examined trends in adolescent weekly alcohol use between 2002 and 2010 in 28 European and North American countries. METHODS Analyses were based on data from 11-, 13- and 15-year-old adolescents who participated in the Health Behaviour in School-Aged Children (HBSC) study in 2002, 2006 and 2010. RESULTS Weekly alcohol use declined in 20 of 28 countries and in all geographic regions, from 12.1 to 6.1% in Anglo-Saxon countries, 11.4 to 7.8% in Western Europe, 9.3 to 4.1% in Northern Europe and 16.3 to 9.9% in Southern Europe. Even in Eastern Europe, where a stable trend was observed between 2002 and 2006, weekly alcohol use declined between 2006 and 2010 from 12.3 to 10.1%. The decline was evident in all gender and age subgroups. CONCLUSIONS These consistent trends may be attributable to increased awareness of the harmful effects of alcohol for adolescent development and the implementation of associated prevention efforts, or changes in social norms and conditions. Although the declining trend was remarkably similar across countries, prevalence rates still differed considerably across countries.

The association between family affluence and smoking among 15‐year‐old adolescents in 33 European countries, Israel and Canada: the role of national wealth

AIMS To examine the role of national wealth in the association between family affluence and adolescent weekly smoking, early smoking behaviour and weekly smoking among former experimenters. DESIGN AND PARTICIPANTS Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2005/2006 in 35 countries from Europe and North America that comprises 60 490 students aged 15 years. Multi-level logistic regression was conducted using Markov chain Monte Carlo methods (MCMC) to explore whether associations between family affluence and smoking outcomes were dependent upon national wealth. MEASUREMENT Family Affluence Scale (FAS) as an indicator for the socio-economic position of students. Current weekly smoking behaviour is defined as at least weekly smoking (dichotomous). Early smoking behaviour is measured by smoking more than a first puff before age 13 years (dichotomous). Weekly smoking among former experimenters is restricted to those who had tried a first puff in the past. FINDINGS The logistic multi-level models indicated an association of family affluence with current weekly smoking [odds ratio (OR) = 1.088; 95% credible interval (CrI) = 1.055-1.121, P < 0.001], early smoking behaviour (OR = 1.066; CrI = 1.028-1.104, P < 0.001) and smoking among former experimenters (OR = 1.100; CrI = 1.071-1.130; P < 0.001). Gross domestic product (GDP) per capita was associated positively and significantly with the relationship between family affluence and current weekly smoking (OR = 1.005; CrI = 1.003-1.007; P < 0.001), early smoking behaviour (OR = 1.003; CrI = 1.000-1.005; P = 0.012) and smoking among former experimenters (OR = 1.004; CrI = 1.002-1.006; P < 0.001). The association of family affluence and smoking outcomes was significantly stronger for girls. CONCLUSIONS The difference in smoking prevalence between rich and poor is greater in more affluent countries.

Trends in socioeconomic inequalities in adolescent alcohol use in Germany between 1994 and 2006

ObjectivesTo examine socioeconomic differences in adolescent alcohol use in Germany as well as their changes between 1994 and 2006.MethodsData were obtained from the “Health Behaviour in School-aged Children” study conducted in North Rhine-Westphalia, Germany in 1994, 1998, 2002 and 2006. The analysis is based on 5.074 15-year-old students. Prevalence and trends were analysed for each category of family affluence and educational track separately using log-binominal regression models.ResultsAn increase in weekly alcohol use between 1994 and 2002 was followed by a strong decrease from 2002 to 2006. Family affluence only had a weak effect on weekly drinking with a tendency for lower-affluent students reporting less alcohol use. Educational track showed almost no relationship with weekly alcohol use. Trend analyses within the subgroups revealed that the overall trend in alcohol use was similar in all socioeconomic and educational groups.ConclusionsSocioeconomic patterns in drinking behaviour are not yet developed in 15-year-old adolescents. Adolescence could therefore be an important time frame for tackling inequalities in alcohol use later in life.

Relative deprivation and risk factors for obesity in Canadian adolescents

Research on socioeconomic differences in overweight and obesity and on the ecological association between income inequality and obesity prevalence suggests that relative deprivation may contribute to lifestyle risk factors for obesity independently of absolute affluence. We tested this hypothesis using data on 25,980 adolescents (11–15 years) in the 2010 Canadian Health Behaviour in School-aged Children (HBSC) study. The Yitzhaki index of relative deprivation was applied to the HBSC Family Affluence Scale, an index of common material assets, with more affluent schoolmates representing the comparative reference group. Regression analysis tested the associations between relative deprivation and four obesity risk factors (skipping breakfasts, physical activity, and healthful and unhealthful food choices) plus dietary restraint. Relative deprivation uniquely related to skipping breakfasts, less physical activity, fewer healthful food choices (e.g., fruits, vegetables, whole grain breads), and a lower likelihood of dieting to lose weight. Consistent with Runcimans (1966) theory of relative deprivation and with psychosocial interpretations of the health consequences of income inequality, the results indicate that having mostly better off schoolmates can contribute to poorer health behaviours independently of school-level affluence and subjective social status. We discuss the implications of these findings for understanding the social origins of obesity and targeting health interventions.

Socioeconomic inequalities in the impact of tobacco control policies on adolescent smoking. A multilevel study in 29 European countries

INTRODUCTION There are concerns that tobacco control policies may be less effective in reducing smoking among disadvantaged socioeconomic groups and thus may contribute to inequalities in adolescent smoking. This study examines how the association between tobacco control policies and smoking of 15-year-old boys and girls among 29 European countries varies according to socioeconomic group. METHODS Data were used from the Health Behaviour in School-aged Children (HBSC) study conducted in 2005/2006 comprising 50,338 adolescents aged 15 years from 29 European countries. Multilevel logistic regression analyses were conducted to assess the association of weekly smoking with components of the Tobacco Control Scale (TCS), and to assess whether this association varied according to family affluence (FAS). Analyses were carried out per gender and adjusted for national wealth and general smoking rate. RESULTS For boys, tobacco price was negatively associated with weekly smoking rates. This association did not significantly differ between low and high FAS. Levels of tobacco-dependence treatment were significantly associated with weekly smoking. This association varied between low and high FAS, with higher treatment levels associated with higher probability of smoking only for low FAS boys. For girls, no tobacco policy was significantly associated with weekly smoking, irrespective of the FAS. CONCLUSIONS Results indicated that most tobacco control policies are not clearly related to adolescent weekly smoking across European countries. Only tobacco price seemed to be adequate decreasing smoking prevalence among boys, irrespective of their socioeconomic status.

The use of parental occupation in adolescent health surveys. An application of ISCO-based measures of occupational status

Background Recent research has emphasised that the challenge in researching socioeconomic differences in adolescent health cross-nationally lies in providing valid and comparable measures of socioeconomic position (SEP) across regions. This study aims to examine measures of occupational status derived from the International Standard Classification of Occupations (ISCO), alongside commonly used affluence measures in association with adolescent self-rated health (SRH). Methods Data were from the 2005/2006 ‘Health Behaviour in School-aged Children study’ (HBSC); 27 649 individuals aged 11, 13 and 15 years from Germany, Macedonia, Norway, Turkey, Wales and Scotland. Three occupational scales were compared: the International Socioeconomic Index of Occupational Status (ISEI), the Standard International Occupational Prestige Scale (SIOPS) and the Erikson–Goldthorpe–Portocarero class categories (EGP). Correlation analyses compared these occupational scales with the family affluence scale (FAS) and a family well-off measure, while logistic regression assessed the association between occupational scales and poor SRH. Multiple imputation techniques investigated possible bias arising from parental occupation missingness. Results Moderate correlations existed between occupational scales and FAS and family well-off. Socioeconomic inequalities in poor SRH were found for ISEI, SIOPS and EGP in all regions, independent of FAS and family well-off. Models of imputed data sets did not alter the results. The relationship between SEP and SRH was therefore not biased by high levels of missing values for ISCO. Conclusions ISCO-based indicators of occupational status in cross-national self-administered adolescent health surveys were found to be robust measures of SEP in adolescence. These measure different aspects of SEP independent of FAS and family well-off.

Getting social: Public Health’s increasing awareness of the social determinants of health

Even though the media and industry continue to tell us thatlifestyle choices are both a threat to and the salvation of ourhealth,thereisagrowingconsensusinPublicHealthresearchthathealthandlongevityaresubstantiallydeterminedbynon-medical and non-behavioural factors (Raphael 2006,Richter&Hurrelmann2009). Most of todays health problems canbe traced back to the social conditions in which we live andwork. The report of the WHO Commission on SocialDeterminants of Health is a new milestone in documentingthis shift in perspectives (CSDH 2008). Accordingly, healthand health inequalities are increasingly understood as theresult of an interdependent process of contextual conditions(such as governance and policy), socioeconomic position,health care systems and life circumstances (Starfield 2007).These social determinants influence a broad set of anindividual’s resources as well as biological, psychologicaland behavioural reactions that further shape health. Each ofthese factors contributes to the explanation of health andillness, and constitutes a complex dialogue between structureand agency that is increasingly being rewritten by PublicHealth research. The contributions in the current issue of theJournal of Public Health exemplify the increasing awarenessof Public Health researchers by focussing on welfare stateregimes, social inequalities, psychosocial resources andvarious aspects of health care.Several papers in this issue deal explicitly with the widerdeterminants of health: The first article from Hurrelmann etal. takes a broad perspective and introduces an analysis ofthe impact of different welfare state regimes on populationhealth and health inequalities. The authors present anencompassing overview of the existing social policy andpublic health literature, and provide a framework thatoutlines potential pathways linking welfare policy, livingconditions and population health. The proposed theoreticalapproach on the association between welfare state regimesund health facilitates the understanding of health inequal-ities within and between countries. Using a macro-levelapproach, Chan analyses the impact of demographicchange, economic conditions and health care supply oninfant mortality in Singapore. He shows that the level ofinfant mortally is directly reduced by health care provision,which, in turn, is affected by the level of economic hardship(income per capita and inflation rate) and demographicchanges (marriage level, female education level, birth rate).Stroebele et al. take a closer look at contextual conditionsof individual health by assessing variety and pricing ofselected foods in different socioeconomic districts in Berlin,Germany. Interestingly, when directly comparing thenumber of grocery stores, the variety of fresh fruits andvegetables being offered, and food prices in low vs. highsocioeconomic districts, the authors found no differencesthat would account for health inequalities. Baiden et al.study the association between satisfaction with housing andthe ability to cope with daily demands in Accara, Ghana.Their findings indicate that satisfaction with housing islower among higher age groups, crowded and compoundhouseholds, and less educated people. Taking these andother indicators of housing and socioeconomic conditionsinto account, the ability to cope with daily demands issignificantly reduced for people who are dissatisfied with

Widening inequalities in self-rated health by material deprivation? A trend analysis between 2001 and 2011 in Germany

Background Research on inequalities in health has shown a strong association between the lack of standard of living (defined as material deprivation) and self-rated health (SRH). In this study, we sought to further examine this association in a trend analysis of relative and absolute inequalities in SRH as defined by material deprivation in Germany. Methods Data were obtained from the German Socio-Economic Panel (GSOEP) between 2001 and 2011. Material deprivation was measured on the basis of 11 living standard items missing due to financial reasons. We used the relative index of inequality (RII) and slope index of inequality (SII) to measure inequalities in SRH by material deprivation, calculating pooled interval logistic regression with robust SEs. Stepwise models were estimated, including demographic and socioeconomic variables, to assess their inter-relation with inequalities in SRH by material deprivation. Results The results showed a steady increase in poor SRH over the 10-year duration of the study. A quadratic (inverted U-shaped) trend was observed in material deprivation in the standards of living, which rose from 2001 to 2005, and then declined in 2011. A similar but non-significant trend was found in relative and absolute inequalities in SRH by material deprivation, which increased from 2001 to 2005 and then declined. Conclusions Inequality in SRH by material deprivation was relatively stable; however, an observed quadratic trend coincided with active and passive labour market reforms in Germany in early 2005.

Der Beitrag der Versorgungsforschung zur Chancengerechtigkeit in der Gesundheit und in der Versorgung

Social inequalities in health and health care services represent issues of major concern. Findings in this area reveal inequalities in health and health care indicating disadvantages for individuals with a low socioeconomic background. Although the health care system plays a marginal role in the explanation of inequalities in health, health services research can be an important part in the development of equal health opportunities. The current article describes the causal associations between social inequalities, health inequalities and the health care service. Health services research can make a contribution to increasing equal opportunities in health and health care service. Against this background, we discuss the existing potential and need of research in the area of health services.

Gesundheitssystemgestaltung, Versorgungsgestaltung und Versorgungsentwicklung

Wie ist das deutsche Gesundheitssystem strukturiert? Welche Bedeutung hat die Strukturierung des Gesundheitssystems fur die Versorgungsgestaltung? Was sind die Grundelemente der Versorgungsentwicklung und wie hangen sie zusammen?