ArticlesSocioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study
Introduction
Adolescence is a formative life stage for adult health, but is often neglected in health policy.1 Health and health behaviours track strongly from early adolescence to adulthood, and inequalities in health are typically established early in life.2 Socioeconomic status (SES) is a major determinant of these inequalities.2 To grow up in impoverished and marginalised socioeconomic conditions shortens the lifespan and contributes to poor mental and physical health.3, 4 Some research has suggested that socioeconomic differences in health emerge in early childhood and then diminish in early adolescence, only to re-emerge in adulthood.5 However, most of the evidence in this area shows social class gradients in health at every stage of the life course, including adolescence.4, 6, 7
An understanding of trends in health inequalities and their social determinants is crucial so that policy can be developed to redress them.2, 8 The available evidence in this area relies heavily on local and national samples of young children.6, 7, 9 International studies of social inequalities in adolescent health are scarce and, as a result, predictions about future inequalities in adult health are not based on robust information. Findings from the Health Behaviour in School-aged Children (HBSC) study,4, 8, 10 which surveys the health of adolescents in North America and Europe, have shown SES differences in health in most countries and health domains, including self-rated health, psychological and physical symptoms, and life satisfaction. However, this research has not focused on trends in health inequalities in adolescence, nor on structural determinants of adolescent health, such as national wealth or income inequality.1, 11, 12
Income inequality is rising13 and health inequalities are widening14, 15 in adults, suggesting that socioeconomic differences in adolescent health might have increased in recent years. Since the 1970s, real wages for the bottom half of the workforce have fallen in many countries, while incomes of the top 1% have quadrupled.12 Income inequality has risen steadily during the past four decades, thus increasing relative deprivation, depleting the social capacity of nations to support health, and contributing to poor health in terms of mental illness, obesity, mortality, and reduced child wellbeing.16 Thus, rising income inequality might have both worsened adolescent health in general and widened social inequality in adolescent health over time.12 In a Series on adolescent health, Viner and colleagues1 concluded that the strongest determinants of adolescent health worldwide are structural factors, such as national wealth, access to education, and income inequality.
We had two goals for this study. Our first objective was to examine secular trends in health inequalities in different domains of adolescent health: physical activity, bodyweight, psychological and physical symptoms, and life satisfaction. We chose these domains to broadly represent mental and physical health and wellbeing. Because adolescent health relates to SES, and SES differences might have widened because of increasing income inequality, we hypothesised that adolescent health inequalities in all health domains grew from 2002 to 2010. Our second objective was to explore whether national wealth and income inequality relate to international differences in adolescent health and health inequalities between SES groups.
Section snippets
Study design and participants
Data for SES and health used in this time-series analysis were collected in a series of cross-sectional surveys of adolescents in 34 North American and European countries or regions in the 2002, 2006, and 2010 cycles of the HBSC study: Austria, Belgium (French region), Belgium (Flanders region), Canada, Croatia, Czech Republic, Denmark, England, Estonia, Finland, France, Germany, Greece, Greenland, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Macedonia, Netherlands, Norway, Poland,
Results
Survey data were available for a pooled sample of 492 788 adolescents. School response rates varied by country (47–90%, but more than 70% for 21 of 34 countries). Student participant response rates varied by country, but were higher than 70% for almost all national surveys. In our sample, per person income ranged from US$730 (Ukraine, 2002) to $37 530 (Norway, 2010), and rose from an average of $17 165 in 2002 to $32 593 in 2010 (table 1). Income inequality ranged from 0·225 (Denmark, 2002) to
Discussion
From 2002 to 2010, average body-mass indices and physical symptoms slightly increased and became more unequal between socioeconomic groups. We also noted progressively larger SES differences over successive surveys of physical activity and psychological symptoms. These trends run in parallel to those previously reported in health inequalities in adult and child mortality,14, 29, 30, 31 and this study extends this evidence base to many health domains in an international sample of adolescents (
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