Abstract

Background

Changing morbidity patterns and the growing importance of mental health and chronic conditions on the international public health agenda have both contributed to a widespread interest in subjective health outcomes. In particular research in children and adolescents has witnessed an increase in activity over the past years. Although subjective health in children and adolescents has been extensively studied, comparative research across countries and cultures as well as across time is rare. The study of factors at macro level and their association with subjective health at individual level are poorly investigated areas in this population group.

Research aims

One of the main aims of this Thesis was to explore cross-national differences in subjective health and well-being of children and adolescents in Europe, North America, and Israel, and to describe the trend of subjective health and well-being in children and adolescents in Germany. A secondary aim included the investigation of the role of individual and national level determinants of subjective health in a cross-national sample. Another central aim of this Thesis was to assess the burden/prevalence of mental health problems and overweight in children and adolescents and their impact on subjective well-being.

Methods

The Thesis comprises six papers, which are based on data from the international Health Behaviour in School-aged Children (HBSC) Survey and the European KIDSCREEN Study. In the Thesis, two different HBSC data sets were used: The first three papers used the international HBSC Data from the 2005/06 survey which took place in 41 countries in Europe, North America, and Israel and included N=204,534 schoolchildren ages 11, 13, and 15 years. The analyses in paper four and five were based on the German HBSC trend data from the survey years 2002 (N=5,650), 2006 (N=7,274), and 2010 (N=5,005). Paper 6 used the KIDSCREEN Survey data collected in 13 European countries in 2003. A total of N=22,827 children and adolescents ages 8 through 18 years were surveyed.

Results

In general, the majority of children and adolescents in Europe, North America, and Israel report good subjective health (Paper 1) and German trends indicate a positive development over the past eight years (Paper 4). Trend analyses further showed that girls report worse health and with increasing age this gender difference becomes larger (Paper 4). Detailed analyses revealed that girls, older children, and low affluent groups report the worst health including lowest mental health and well-being (Paper 1, 2, 4 and 5). The prevalence of subjective health outcomes (self-rated health, life satisfaction, and health complaints) varied across countries and revealed distinct patterns (Paper 1). Psychometric analyses performed on KIDSCREEN-10 confirmed it as a suitable screening tool for low mental well-being in national and cross-national samples (Paper 2). Multi-level analyses on social determinants of health showed that stress-inducing factors, such as poor social relationships, school-related problems (schoolwork pressure, bullying), but also national level factors, such as the Human Development Index (HDI), were related to worse health (Paper 3). A negative attitude towards school and having difficulty talking with one’s parents were strongly associated with low well-being and mental health problems (Paper 5). Well-being was also lower in overweight boys and girls as compared to their normal weight peers. Overweight children and adolescents were particularly affected on their physical well-being and self-perception, but also in areas of social life (“social acceptance/bullying”) (Paper 6).

Conclusions

The results portray a comprehensive picture of children’s and adolescents’ subjective health and well-being cross-nationally and over time. The large data sets deliver robust evidence with important implications for research, policy, and practice, but also highlight under researched areas. First of all, future research needs to concentrate on providing clarity in terms of the conceptualization of subjective health and well-being. Secondly, measurement tools need to be developed which are developmentally, cross-culturally, and gender-appropriate. Strengthening of monitoring and consideration of cultural factors constitute a third important area for development. Given the lack of sufficient knowledge on the role of macro level factors in subjective health of children and adolescents, more research is needed to explore associations, in particular for cultural aspects. These can provide further insight on the identified cross-national differences in subjective health that became apparent in the papers of this Thesis.