Health Behaviour in School-aged Children (HBSC) survey 2001/02
HBSC Briefing Series: 6
Inequalities and Health
Nina Parry-Langdon and Chris Roberts
Research and Evaluation Branch
Health Promotion Division
Office of the Chief Medical Officer
Addressing inequalities in health is a key strategic aim of the Welsh Assembly Government,
demonstrated through the national health targets 1 and outlined in Designed for Life: Creating World
Class Health and Social Care for Wales in the 21st Century 2 and in the ‘better health’ dimension of
Wales: A Better Country. 3 In order to be able to understand more fully the relationship between
socio-economic status and adolescent health it is essential to monitor young people’s health
The Young People’s Health in Context report presents the international dissemination of findings
from the 2001/02 Health Behaviour in School-aged Children (HBSC) survey. 4 The HBSC is a cross-
national research study conducted in collaboration with the World Health Organization (WHO)
Regional Office for Europe.
This short report is the sixth in a series of HBSC briefings aimed at highlighting aspects of young
people’s health targeted in the Welsh Assembly Government’s key policies and programmes on
adolescent health. Based on chapters in Young People’s Health in Context, the report compares
Wales with selected HBSC countries with a focus on socio-economic inequality and its relation to
the health and health behaviour of young people. Data are presented for a small number of
countries participating in the study, including Wales, Scotland and England.
In health terms, childhood and adolescence are particularly important times of life. Socio-economic
status (SES) is considered to be a major social basis for inequalities and socio-economic inequality
is an extremely important predictor of health at all ages. 5,6 Given this, research into the socio-
economic circumstances of school-aged children and how this affects their health and health
behaviour is crucial for the development of evidence-based policy and practice in Wales.
The HBSC study collects cross-national data every four years to help measure and track aspects of
adolescent health and health-related behaviours and their developmental and social contexts. 7 The
study was first undertaken in 1983/84 and Wales first participated in 1986. Interim surveys have
also been conducted in Wales every two years.
The cross-national and national data provide a unique opportunity to further develop the evidence
base for policy and practice. They contribute to particular areas of adolescent health highlighted in,
for example, the Children and Young People’s Action Plan. 8 The findings will also contribute to the
wider strategic aims of the Welsh Assembly Government highlighted through Health Challenge
Wales 9 and in the health improvement recommendations of The Review of Health and Social Care
in Wales (the Wanless report).
In 2001/02, 35 countries drew national samples of 11-, 13-, and 15-year-olds in accordance with
the study protocol. 7 In the main, fieldwork took place between autumn 2001 and spring 2002.
More than 160,000 young people took part and approximately 1,500 respondents in each age
group were targeted in every country; pupils were sampled from schools and/or school classes.
Pupils who were absent on the day of the survey were not followed up.
Data were collected by self-administered questionnaire. On completion of fieldwork, national data
files were prepared using standard documentation and submitted to the HBSC International Data
Bank at the University of Bergen, Norway. Data files were checked, cleaned and returned to
countries for approval before being put in the international file. Full details of the methods used
can be found in Young People’s Health in Context. 4
The Welsh context
The main aim of this briefing is to present information on the relationship between SES and selected
health related outcomes in Wales, alongside those from young people in a small number of other
countries. Inequalities in SES have been shown to be of key importance to the health of adults and
younger children. However, the evidence is less clear for adolescent health. 11-16 In developing
health promotion and public health policies aimed at young people in Wales, it is important to
understand how these types of health behaviours are distributed according to differences in SES of
young people living in Wales.
Measuring socio-economic inequality and young people’s health
An important focus for the HBSC is to examine differences in SES and relate these to health
behaviours (e.g. smoking or exercise) and to health outcomes (e.g. injuries), as well as increasing
understanding of the relationship between SES and young people’s health. Over the years, the
HBSC study has used a number of recognised measures of adolescent SES, such as parental
occupation, family material affluence and perceived wealth.
To aid cross-national analysis, the study has developed an adolescent SES indicator which is a
measure of family wealth (or affluence) known as the Family Affluence Scale (FAS). SES is a
composite measure that incorporates economic status (income), social status (education) and work
status (occupation). Although children and young people are aware of socio-economic inequalities
and inequitable opportunities some are unable to accurately report their parents’ occupations or
educational levels, least of all their incomes. 7,18-20 Based on common indices of material deprivation
the FAS measure comprises four items which are familiar to young people: family car ownership;
bedroom occupancy; family holidays; and computer ownership. A composite score is calculated for
each young person based on his or her response to these four items. The FAS has shown a clear
relationship with occupational status, indicating the validity of the measure. The FAS therefore
provides a good proxy measure that may be used to examine socio-economic inequalities and their
relationship with young people’s health.
HBSC profile of SES and young people
The FAS analysis uses a three-point scale, where FAS 1 indicates low affluence, FAS 2 middle
affluence and FAS 3 high affluence. Figure 1 illustrates the differences in the proportions of young
people in the different FAS groups (according to the FAS composite score) for 11-15 year-olds in
Wales, Scotland and England, compared with the overall HBSC sample.
FAS 1 (Low)
50 FAS 3 (High)
30 28 29
Figure 1: Percentage of young people in FAS groups, 11-15 year olds
The proportions in each of the three FAS groups are similar in Wales and England. However, the
proportion of young people in the lowest FAS group is slightly higher in Scotland, with the proportion
in the highest FAS group being slightly lower. Across HBSC countries, Norway has the lowest
proportion of young people in the low affluence group (6 per cent) and the highest proportion in the
high affluence group (58 per cent). Ukraine has the highest proportion in the low affluence group
(73 per cent) and the lowest proportion in the high affluence group (6 per cent). The proportions of
affluent families are higher in northern and western Europe and North America. These countries
are also more likely to have low proportions of families in the low affluence group with the
exception of Israel.
Differences between SES and young people’s health
Previous HBSC research has found that the relationship between socio-economic status and health
outcomes varies depending upon the indicator used (e.g. smoking behaviour) and the outcome
measured (e.g. weekly smoking), gender and country. Studies have also shown that children and
adolescents from families of low socio-economic status have more health problems than those of
high socio-economic status. However, some studies have found a lack of evidence for health
inequalities in adolescence. The mechanisms behind social inequalities in health are complex.
Some measures of health and health behaviour are more sensitive to socio-economic
circumstances of the family than others. For example, alongside family affluence, social and
individual factors may also impact on health behaviours. HBSC research has shown that smoking
is strongly correlated to the amount of available spending money which could come from sources
other than the family. 21
In order to understand the nature of health inequalities in adolescence the HBSC data are used to
examine different health and health behavioural outcomes and their relationship to FAS. Examples
provided here include the relationship between young people’s self-rated health, subjective health
complaints, physical activity and smoking and FAS for boys and girls aged 11-15. In addition to the
three UK countries, data are also presented for those HBSC countries with the highest and lowest
levels of each outcome.
Self-rated health and FAS
Self-rated health was measured using the following question:
Would you say your health is Excellent, Good, Fair or Poor?
FAS 1 (Low) FAS 1 (Low) 45
FAS 2 FAS 2
40 40 39
FAS 3 (High) FAS 3 (High) 36
33 33 32
30 29 30 28 29
22 21 22
20 19 19 20 19 17
15 15 14
10 9 10
Figure 2: Percentage of young people who report being in fair or poor health, according to
FAS composite score, 11-15 year olds
Figure 2 shows the percentage of young people who rate their health as fair or poor by country,
gender and FAS score. Among boys and girls, there is a relatively clear gradient for all three UK
countries, with decreasing proportions of young people reporting fair or poor health as family
affluence increases. Girls are more likely to report being in poorer health and overall levels are
highest in Wales.
This relatively clear gradient can be seen across all HBSC countries. For boys, Austria shows the
lowest levels of self-reported poor health and Ukraine the highest. For girls, Greece has the lowest
levels and Lithuania the highest. As in the UK countries, girls reported higher levels of poorer self-
rated health than boys across the study.
Subjective health complaints and FAS
A standard symptom checklist was used to measure subjective health complaints:
In the last 6 months how often have you had the following: Headache, Stomach-ache, Back-ache,
Feeling low, Irritability or bad temper, Feeling nervous, Difficulties in getting to sleep, Feeling dizzy.
Response categories: About every day; More than once a week; About every week; About every
month; Rarely or never.
FAS 1 (Low) FAS 1 (Low) 54
FAS 2 FAS 2
FAS 3 (High) 46 FAS 3 (High) 44
40 40 38
32 33 32
31 30 29
30 27 30 2828
24 23 24 24
20 19 20 17
Figure 3: Percentage of young people who report at least one subjective health complaint
daily, according to FAS composite score, 11-15 year olds
Figure 3 shows the percentage of young people who reported at least one subjective health
complaint daily by country, gender and FAS score. In the three UK countries there is a gradient
showing decreasing proportions of boys and girls reporting one or more subjective health complaint
daily as family affluence increases. The proportion of girls reporting one or more subjective health
complaints in Wales is slightly lower than in England and Scotland.
The prevalence of daily health complaints is associated with low FAS in many but not all HBSC
countries. Switzerland shows the lowest level of daily health complaints for boys and girls in
families with low affluence, the highest levels being found in the USA for boys and Greece for girls.
Physical activity and FAS
Moderate-to-Vigorous Physical Activity (MVPA) is the standard measure used by HBSC to assess
young people’s levels of activity. 7 MVPA was measured using two items:
Over the past seven days, on how many days were you physically active for a total of at least 60
minutes per day?
Over a typical or usual week, on how many days are you physically active for a total of at least 60
minutes per day?
Response categories for both questions: 0 days, 2 etc. … 7 days
BOYS FAS 1 (Low) GIRLS FAS 1 (Low)
FAS 2 FAS 2
FAS 3 (High) FAS 3 (High)
80 78 80
70 70 70 71 70
70 67 70 67
64 65 65 64
60 61 63
60 59 60 58 59
50 49 50 49
40 38 40 38
Figure 4: Percentage of young people who report at 60 minutes or more of at least moderate
physical activity 4 or more days a week, according to FAS composite score, 11-15
Figure 4 shows the association between FAS and MVPA. In the UK there is a clear gradient showing
higher proportions of physical activity for boys and girls in the most affluent families. This gradient
can be found in most HBSC countries, particularly for girls. Across all three UK countries girls
reported far less physical activity compared to boys in all three FAS groups.
In most HBSC countries the proportion of young people reaching MVPA increases with increasing
FAS for both genders, particularly for girls. The highest activity levels among both sexes in the least
affluent families can be found in Ireland, the lowest in France.
Weekly smoking and FAS
Smoking frequency was measured using the following question:
How often do you smoke at present?
Response categories: I don’t smoke; Every day; At least once a week, but not every day; Less than
once a week.
FAS 1 (Low) FAS 1 (Low)
FAS 2 FAS 2
FAS 3 (High) FAS 3 (High)
20 20 18
11 11 12 12 10 12
10 9 8 9 10 9
7 6 7
6 5 6 4
Figure 5: Percentage of young people who report smoking weekly, according to FAS
composite score, 11-15 year olds
Figure 5 shows the association between FAS and weekly smoking. Across the UK, whilst there is a
gradient showing lower levels of smoking in boys and girls of less affluent families, the relationship
is not strong. The rates of weekly smoking among boys and girls from less affluent families in
Wales are similar to those in England and slightly higher than those in Scotland. In the UK countries,
girls have higher levels of weekly smoking than boys across all three FAS groups.
The association between smoking and FAS is less consistent across HBSC countries than that for
self-rated health, subjective health complaints and physical activity. For example, in Macedonia,
higher proportions of weekly smoking can be found among girls in less affluent families, with the
reverse being found for boys. The highest levels of weekly smoking can be found in Greenland for
girls and the Ukraine for boys. Conversely, the lowest levels are found in Macedonia for girls and
Sweden for boys.
The way forward
The international data from the HBSC study contribute to an understanding of socio-economic
status and its relationship to health and health behaviour in young people. The impact of these
relationships on young people’s health is an issue of concern across the United Kingdom, Europe
The health of children and young people is a priority for the Welsh Assembly Government as
demonstrated through the appointment of the Children’s Commissioner for Wales. The Welsh
Assembly Government’s commitment to the health of children and young people of Wales is outlined
in the National Service Framework for Children, Young People and Maternity Services in Wales. 22
The delivery of this commitment is laid out in Frameworks for Partnership, 23 progress towards
which is described in Children and Young People: Rights to Action. 24
These findings will contribute to collaborative initiatives which address the focus on joint
responsibility for health as set out in Health Challenge Wales. Importantly, children’s health is one
of the priority areas in the National Targets for Wales. In addition, policies and programmes targeted
at children and young people in Wales, such as the Sexual Health Strategic Framework, 25 Climbing
Higher 26 and Food and Wellbeing, 27 recognise the impact of social inequality on young people’s
The HBSC surveys will continue to track and monitor health behaviour and to inform the
development of policies and initiatives for young people. In addition to these briefings on 2001/02
data 28-32 a series of research reports based on data from the 2004 HBSC survey in Wales will follow.
We would like to thank the many young people who have taken part in the HBSC surveys and the
secondary schools that have supported our research. Without their co-operation we would not be
able to report the health issues effecting young people in Wales.
Contact for information
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