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Candace Currie and Aixa Y. Alemán-Díaz, *WHO Collaborating Centre for International Child and Adolescent Health Policy; **Child and Adolescent Health Research Unit (CAHRU); School of Medicine | University of St Andrews
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Impactful policies in the area of adolescent health require data that provide an accurate and representative picture of how young people live and how their health and well-being are shaped by the social, economic and cultural context in which they live. Robust, large-scale surveys are able to supply powerful and sustained information on the health of different demographic groups that can illuminate health inequity. Such data have been pivotal in uncovering and highlighting gender and socioeconomic inequalities in adolescent health.

World-wide there are a number of different large-scale data collection programmes and international surveys which gather information on adolescent health and well-being.1 We will largely focus on three longstanding surveys – Health Behaviour in School-Aged Children Study (HBSC), Global Student Health Survey (GSHS) and Global Youth Tobacco Survey (GYTS) – that gather the most comprehensive data internationally from schoolchildren in early to middle adolescence. There are two household-based surveys – the Demographic and Health Surveys (DHS) and the Multiple Indicator Cluster Surveys (MICS) that collect some data on adolescents’ (aged 10-14) health but primarily focus on older adolescents or young children, which is why we will not focus on them in this commentary.

HBSC, GHSH and GYTS surveys have been supported by the World Health Organization (WHO) independently and in partnership with leading organisations to establish surveillance systems that track the health of young people globally. These data collection systems all monitor health risks and problems, but particularly in HBSC and GSHS there are also indicators measuring protective health-related behaviours or measures of positive youth development and health.2 HBSC is conducted on a quadrennial cycle across countries in Europe and North America surveying young people aged 11, 13 and 15 years on health and well-being, health behaviours and their social determinants;3 42 countries participated in the 2013/2014 round. GSHS has gathered data in a large number of mainly low- and middle-income countries on measures of risk and protective factors among young people aged 13 to 17 years.4 The GYTS was specifically designed to monitor tobacco use and the implementation of tobacco prevention programmes among youth aged 13-15 years old.5

These surveys have been developed with separate but complimentary goals that advance our knowledge of this key period in the lifecourse. They were key to WHO’s report ‘Health for the World’s Adolescents’, which presents a global overview of adolescents’ health and health-related behaviours,6 Together they form a patchwork picture of the health of adolescents globally, highlighting the need for an overarching, integrated large data system that can provide a comprehensive view; a system that capitalises on successful structures to advance our knowledge in this area.  We will attempt to demonstrate how they can be used together and where further coordination could help illuminate our understanding of adolescent health.

Young people’s health is a key asset for society, and is a vital element of achieving national and international policy and economic targets for growth. Fostering positive well-being in young people is of critical importance and adverse experience, and poor well-being in childhood can have long lasting and profound consequences, affecting not only individual adult outcomes but also future generations. McDaid et al7 argue that in order to understand factors that contribute to well-being in childhood and thus inform actions that promote and protect well-being, access to good epidemiological and sociological data is vital. The authors utilise large-scale survey data from the HBSC to make an economic argument for intervention during childhood and adolescence because it has been carried out simultaneously among nationally representative samples since 1983.8-9 HBSC’s breadth makes it a unique source with the capacity to chart growing and new challenges to adolescent health, including influences of changing family structures,10 reduced family resources,11 electronic communication,12 and the impact of the global economic recession on young people’s health.11,13 One of its most valuable characteristics is its sustained nature, which enables the growing number of regularly participating countries to report on trends over time in wide-ranging aspects of health and health behaviour9 including overweight and obesity,14 physical activity,15 and bullying.16

School-based surveys are a critical source of health information on adolescents,17-18 especially to illuminate gender vulnerabilities seen in many dimensions of health. For example, with respect to mental health it is found that in Europe and the Americas, adolescent girls are nearly twice as likely to attempt suicide as boys, but among countries participating in the GSHS in the Africa, Eastern Mediterranean, and Western Pacific regions, no gender differences are seen. HBSC data show that on a range of well-being measures, girls in Europe and North America fare worse than boys across all countries with the gender gap widening between 11 years and 15 years;8 while, GSHS does not include questions on self-rated health.2 And like HBSC, GSHS has detected consistent gender differences in physical activity, disadvantaging girls. For example, Guthold et al19 find that across all WHO regions fewer girls are meeting physical activity recommendations for health.

With respect to gender differences in tobacco use we can exploit the complementarity of surveys like HBSC, GSHS and GYTS to establish reliable tobacco surveillance systems with a distinct youth component;20 together, these surveys give a worldwide picture of girls’ vulnerabilities to this health risk behaviour.8, 21 The 2009/10 HBSC survey found that girls have higher rates of weekly smoking than boys in Spain, Czech Republic, England and Wales. While between 2003 and 2007 the GYTS found the prevalence of girls' smoking exceeded that of boys in Uruguay, Chile, and Republic of Macedonia. The GYTS provides the most comprehensive geographic and content related picture of tobacco use globally. In Europe and North America, HBSC can provide regular information on prevalence over time and relate tobacco use to a wide range of health and social indicators as well as other health behaviours. GSHS provides similar data to HBSC and GYTS, with a geographic footprint beyond that of HBSC, covering many low- and middle-income countries; but in some cases sub-national populations are sampled which may not accurately reflect the national picture.22 Different operational definitions applied by these surveys, in this case between GSHS and GTYS, can also complicate data comparisons.20 In addition, GSHS and GYTS decisions are made at a national level so surveys occur in different years and at varying intervals. Nevertheless, while limitations and incompatibilities exist, used synergistically these surveys can together provide information that helps governments to develop policies and programmes that support the prevention of smoking initiation and improving current cessation programmes20 in young people.

In a drive for better global information systems on adolescent health championed by the Lancet series, Patton et al call for future work that harnesses the potential of large scale surveys through better coordination including: “…greater harmonisation of school-based surveys, further development of strategies for socially marginalised youth, targeted research into the validity and use of these health indicators, advocating for adolescent-health information within new global health initiatives, and a recommendation that every country produce a regular report on the health of its adolescents.”17

The WHO is seeking to establish an agreed set of global adolescent indicators that can be recommended to assist countries in understanding the health situation of adolescents and take appropriate policy and programme action to address it.23 Indicators included HBSC, GSHS and the GYTS; household surveys, MICS and DHS; and administrative data systems throughout the world. This exercise will be even more powerful if it promotes and enables benchmarking and tracking change over time, two essential elements of national data intelligence that can inform policy and programme needs. Nonetheless, this effort is a prime example of how collaboration can enhance our collective ability to understand young people’s health.

While surveillance of health risk behaviours is valuable, greater insights into adolescent health are gained when social determinants of health as well as health indicators are measured.1, 24 It is particularly important for governments to be informed about inequalities in health as these may be overlooked among adolescents who are often considered a generally healthy sector of the population. Large-scale surveys that report on gender and socioeconomic differences in determinants and outcomes and show how countries vary in the extent of such inequalities are therefore especially valuable in terms of providing evidence for programme development and are especially critical to evaluating programme effectiveness. For example, HBSC data has been used to develop the WHO European child and adolescent health strategy25 and at a country level it has informed national strategy to reduce social and economic inequalities.26-28 When combined, gender and socioeconomic status can illuminate even greater inequalities that result in worse outcomes for specific demographic groups, as is the case amongst 15-year old girls in relation to self-rated health.8 In addition, there are also evident inequalities in the social determinants of health. We know for example that assets that positively support well-being stemming from the family, school and peer group are unequally distributed and favour young people growing up in more affluent circumstances.8, 29 It is due to existing valid and reliable survey data that we can confidently make these associations.

Methodologically rigorous, large-scale, regularly conducted surveys providing sound data on adolescent health are vitally important because they: create an opportunity for the empowerment of young people in decision-making and advocacy; help policymakers identify priorities for strategies, policies and programmes; allow researchers to monitor change over time and evaluate programmes; and provide a platform to better understand the drivers of inequality. Ultimately, such data enables better responses to the health disparities among young people that persist within countries and across regions. While existing surveys do provide a valuable resource, there is still a need to better harmonise our data production efforts to avoid duplication and reduce survey fatigue amongst stakeholders. We encourage all those interested and working on adolescent health surveys to work together to find synergies and exploit them for the benefit for children all over the world.

References

1- Richardson, D. and Ali, N. An Evaluation of International Surveys of Children. OECD Social, Employment and Migration Working Papers, 2014:No. 146. OECD Publishing, Paris.

DOI: http://dx.doi.org/10.1787/5jxzmjrqvntf-en. 

2- World Health Organization. Section 4: Adolescents’ health related behaviours. Health-related behaviours cluster sub-section. Health for the world's adolescents: a second chance in the second decade. 2014. From: http://apps.who.int/adolescent/second-decade/section4/page9/Behaviours-cluster.html. Accessed 18 May 2015.

3- Health Behaviour in School-aged Children (HBSC), a WHO Collaborative Study. Further information can be found: www.hbsc.org. Accessed 23 April 2015.

4- Global Student Health Survey (GSHS). Further information can be found: http://www.who.int/chp/gshs/en/. Accessed 23 April 2015.

5- Global Youth Tobacco Survey (GYTS). Further information can be found: http://www.who.int/tobacco/surveillance/gyts/en/. Accessed 23 April 2015.

6- World Health Organization. Health for the world's adolescents: a second chance in the second decade: summary (2014). Full report: http://www.who.int/maternal_child_adolescent/topics/adolescence/second-decade/en/ Accessed 27 April 2015. 

7- McDaid D, Park A, Currie C, et al. Investing in the well-being of young people: making the economic case. In: McDaid D, Cooper C, editors. Economics of Well-being. Well-being: A Complete Reference Guide (Vol. 5). Oxford: Wiley-Blackwell, 120 2014: 181–214.

8- Currie C, Zannotti C, Morgan A, et al., editors. Social determinants of health and well-being among young people. Health Behaviour in School-aged Children (HBSC) 125 study: international report from the 2009/2010 survey. Copenhagen (DNK): WHO Regional Office for Europe; 2012. Health Policy for Children and Adolescents. No.: 6. 

9- Kuntsche, E. and Ravens-Sieberer, U. Monitoring adolescent health behaviours and social determinants cross-nationally over more than a decade: introducing the Health Behaviour in School-aged Children (HBSC) study supplement on trends. The European Journal of Public Health, 2015:25(suppl 2), 1-3.

10- Bjarnason T, Bendtsen P, Arnarsson AM, et al. Life satisfaction among children in different family structures: A comparative study of 36 western societies. Children & Society, 2012: 26(1), 51-62.

11- Pförtner TK, Rathmann K, Elgar FJ, et al. Adolescents’ psychological health complaints and the economic recession in late 2007: a multilevel study in 31 countries. The European Journal of Public Health, 2014. DOI: 10.1093/eurpub/cku056

12- Boniel-Nissim, M., Lenzi, M., Zsiros, et al. International trends in electronic media communication among 11-to 15-year-olds in 30 countries from 2002 to 2010: association with ease of communication with friends of the opposite sex. The European Journal of Public Health, 2015:25(suppl 2), 41-45

13- Elgar, F. J., Pförtner, T. K., Moor, I., et al. Socioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study. The Lancet. 2015. DOI: 10.1016/S0140-6736(14)61460-4

14- Ahluwalia, N., Dalmasso, P., Rasmussen, M., et al. Trends in overweight prevalence among 11-, 13-and 15-year-olds in 25 countries in Europe, Canada and USA from 2002 to 2010. The European Journal of Public Health, 2015:25(suppl 2), 28-32.

15- Kalman, M., Inchley, J., Sigmundova, D., et al. Secular trends in moderate-to-vigorous physical activity in 32 countries from 2002 to 2010: a cross-national perspective. The European Journal of Public Health, 2015:25(suppl 2), 37-40.

16- Chester, K. L., Callaghan, M., Cosma, A., et al. Cross-national time trends in bullying victimization in 33 countries among children aged 11, 13 and 15 from 2002 to 2010. The European Journal of Public Health, 2015:25(suppl 2), 61-64.

17- Patton, GC., et al. "Health of the world's adolescents: a synthesis of internationally comparable data." The Lancet 379.9826 (2012): 1665-1675.

18- Currie, C and Aleman-Diaz, AY. Building knowledge on adolescent health: reflections on the contribution of the Health Behaviour in School-aged Children (HBSC) study. Eur J Public Health. 2015;25 Suppl 2:4-6. doi: 10.1093/eurpub/ckv017.

19- Guthold, Regina, et al. "Physical activity and sedentary behavior among schoolchildren: a 34-country comparison." The Journal of Pediatrics 157.1 (2010): 43-49.

20- Pant, Ichhya, "Comparison and Analysis of Youth Tobacco Surveillance Systems: Lessons Learned and Future Implications." Thesis, Georgia State University, 2012. http://scholarworks.gsu.edu/iph_theses/248. Accessed 18 May 2015.

21- Page, R. M., & Danielson, M. (2011). Multi-country, cross-national comparison of youth tobacco use: findings from global school-based health surveys. Addictive behaviors, 36(5), 470-478.

22- Prevention of current tobacco use in adolescents (13-15 years old). Page 71. http://www.who.int/whosis/whostat2006TobaccoAdolescents.pdf. Accessed 18 May 2015.

23- World Health Organization. Report from Technical Consultation on Health Indicators for Adolescent Health (30 September - 1 October 2014). WHO Geneva, Switzerland. 2015.

24- Viner RM, Ozer EM, Denny S, et al. Adolescence and the social determinants of health. The Lancet 2012;379:1641–52

25- Investing in children: the European child and adolescent health strategy 2015–2020. Copenhagen: WHO Regional Office for Europe; 2014. http://www.euro.who.int/en/health-topics/Life-stages/child-and-adolescent-health/news/news/2014/10/the-right-to-a-safe,-healthy-and-meaningful-adolescence. Accessed 27 April 2015.

26- Addressing the socioeconomic determinants of healthy eating habits and physical activity levels among adolescents. Copenhagen (DNK): WHO Regional Office for Europe; 2006.

27- Social cohesion for mental well-being among adolescents: Report from the 2007 WHO/HBSC Forum. Copenhagen (DNK): WHO Regional Office for Europe; 65 2008.

28- Socio-environmentally determined health inequities among children and adolescents. Copenhagen (DNK): WHO Regional Office for Europe; 2010.

29- Doku, DT. Socioeconomic Differences in Tobacco Use among Ghanaian and Finnish Adolescents

Thesis, Tampere University, 2011. https://tampub.uta.fi/bitstream/handle/10024/66749/978-951-44-8450-6.pdf?sequence=1. Accessed 18 May 2015