Health Behaviour in School-Aged Children

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About HBSC

Health Behaviour in School-aged Children (HBSC), a World Health Organization collaborative cross-national study, collects data on 11-, 13- and 15-year-old boys’ and girls’ health and well-being, social environments and health behaviours every four years. Full contact details can be found on the HBSC web site.

HBSC uses findings at national and international levels:

  • to gain new insight into young people’s health and well-being
  • to understand the social determinants of health
  • inform policy and practice to improve young people’s lives

The first HBSC survey was conducted in 1983/1984 in five countries. The study has grown to include 44 countries and regions across Europe and North America.

The HBSC network

The number of researchers working on HBSC across the 44 countries and regions now exceeds 450. Information on each national team is available on the HBSC web site.

The study is supported by four specialist centres:

  • International Coordinating Centre, based at the Child and Adolescent Health Research Unit, School of Medicine, University of St Andrews, Scotland, United Kingdom
  • Data Management Centre, based at the Department of Health Promotion and Development, University of Bergen, Norway
  • Support Centre for Publications, based at the University of Southern Denmark, Odense
  • Study Protocol Production Group, based at the Ludwig Boltzmann Institute for Health Promotion, University of Vienna, Austria

It is led by the International Coordinator, Professor Candace Currie, and the Databank Manager is Professor Oddrun Samdal. The study is funded at national level in each of its member countries.

Research approach

HBSC focuses on understanding young people’s health in their social context – at home, at school, with family and friends. Researchers in the HBSC network are interested in understanding how these factors, individually and together, influence young people’s health as they move into young adulthood. Data are collected in all participating countries and regions through school-based surveys using a standard methodology detailed in the HBSC 2009/2010 international study protocol [1]. Each country uses random sampling to select a proportion of young people aged 11, 13 and 15 years, ensuring that the sample is representative of all living in the country within the age range.

This research collaboration brings in individuals with a wide range of expertise in areas such as clinical medicine, epidemiology, human biology, paediatrics, pedagogy, psychology, public health, public policy, and sociology. The approach to study development has therefore involved cross-fertilization of a range of perspectives. As such, the HBSC study is the product of topic-focused groups that collaborate to develop the conceptual foundations of the study, identify research questions, decide the methods and measurements to be employed, and work on data analyses and the dissemination of findings.

Importance of young people’s health

Young people aged between 11 and 15 years face many pressures and challenges, including growing academic expectations, changing social relationships with family and peers and the physical and emotional changes associated with maturation. These years mark a period of increased autonomy in which independent decision-making that may influence their health and health-related behaviour develops [2].

Behaviours established during this transition period can continue into adulthood, affecting issues such as mental health, the development of health complaints, tobacco use, diet, physical activity level and alcohol use. HBSC’s findings show how young people’s health changes as they move from childhood through adolescence and into adulthood. They can be used to monitor young people’s health and determine effective health improvement interventions [2].

The social determinants of health and well-being among young people

Evidence gathered over the last two decades shows that disadvantaged social circumstances are associated with increased health risks [3] [4] [5]. As a result, health inequalities are now embedded in contemporary international policy development. The WHO Commission on Social Determinants of Health claims that the vast majority of inequalities in health between and within countries are avoidable [6], yet they continue to be experienced by young people across Europe and North America.

Young people are often neglected as a population group in health statistics, being either aggregated with younger children or with young adults. Little attention has been paid to inequalities related to socioeconomic status (SES), age and gender among this group. HBSC seeks to identify and explore the extent of these inequalities, and highlight the need for preventive action to “turn this vulnerable age into an age of opportunity” [7].

In general, young people in the WHO European Region and North America enjoy better health and development than ever before, but are failing to achieve their full health potential. This results in significant social, economic and human costs and wide variations in health for all countries. Health experience during this critical period has short- and long-term implications for individuals and society. Graham & Power’s work on life-course approaches to health interventions [8] highlights adolescence as critical in determining adult behaviour in relation to issues such as tobacco and alcohol use, dietary behaviour and physical activity. Health inequalities in adult life are partly determined by early-life circumstances.

Dimensions of inequalities

Social inequalities in health are traditionally measured by examining differences in SES as defined by individuals’ (or, in the case of young people, their parents’) position in the labour market, education status or income. Gender, ethnicity, age, place of residence and disability are also important dimensions of social difference: these have been under-researched in relation to young people’s health outcomes.

It has been argued that these determinants need to be researched in their own right to enable fully developed explanations of health inequalities to emerge [9]. This is very important in policy terms, as evidence suggests that segments of the population respond differently to identical public health interventions. Researchers can therefore play an important role in advancing understanding of the individual influences of each of the dimensions of health inequalities and how they interact to affect health.

The role of HBSC

Attempts to address health inequalities must include examination of differences in health status and their causes. The HBSC study has collected data on the health and health behaviours of young people since 1983, enabling it to describe how health varies across countries and through time, and increase understanding of inequalities due to age, gender and SES. HBSC recognizes the importance of the relationships that comprise the immediate social context of young people’s lives and shows how family, peers and school can provide supportive environments for healthy development. Importantly, the study has shown that it is not only health outcomes that are differentiated by age, gender and SES, but also the social environments in which young people grow up.

Overview of previous HBSC findings

The end goal of the HBSC study is to improve the health and well-being of young people. To achieve this goal, research findings are disseminated to a wide range of users, including, but not limited to: academia, policy-makers, practitioners, the voluntary/non-governmental sectors, the public, and the media. HBSC findings are used to: influence or gauge the effectiveness of policy; develop programmes and practices; raise public awareness; and promote scientific development.

HBSC findings are disseminated in a range of ways including: international and national reports, international scientific publications, conference presentations, videos, factsheets and workshops, press articles, and websites. HBSC have contributed to: WHO/HBSC International Reports, book chapters; national reports, numerous journal articles and policy briefings.

Age differences

Young people’s health choices, including eating habits, physical activity and substance use, change during adolescence. Health inequalities emerge or worsen during this developmental phase and translate into continuing health problems and inequalities in the adult years [10] [11]. These findings have important implications for the timing of health interventions and reinforce the idea that investment in young people must be sustained to consolidate the achievements of early childhood interventions [12]. This is vital for individuals as they grow but is also important as a means of maximizing return on programmes focused on investment in the early years and reducing the economic effects of health problems.

Gender differences

Previous HBSC reports have presented findings for boys and girls separately, providing clear evidence of gender differences in health that have persisted or changed over time. Boys in general engage more in externalizing or expressive forms of health behaviours, such as drinking or fighting, while girls tend to deal with health issues in a more emotional or internalizing way, often manifesting as psychosomatic symptoms or mental health problems [13].

Gender differences for some health behaviours and indicators, such as current attempts to lose weight [14] and psychosomatic complaints [15] [16] [17] [18] [19] [20] [13], tend to increase over adolescence, indicating that this is a crucial period for the development of health differentials that may track into adulthood. Targeting young people’s health from a gender perspective has considerable potential to reduce gender health differentials in adulthood.

The magnitude of gender differences varies considerably cross-nationally. Gender difference in psychological and physical symptoms, for example, is stronger in countries with a low gender development index score [15] . Similarly, the gender difference in drunkenness is greater in eastern European countries [13]. These findings underscore the need to incorporate macro-level sociocontextual factors in the study of gender health inequalities among young people [16].

Socioeconomic differences

The HBSC study has found family affluence to be an important predictor of young people’s health. In general, cost may restrict families’ opportunities to adopt healthy behaviours such as eating fruit and vegetables [21] [22] [23] and participating in fee-based physical activity [24] [25]. Young people living in low-affluence households are less likely to have adequate access to health resources [26] and are more likely to be exposed to psychosocial stress, which underpin health inequalities in self-rated health and well-being [27]. A better understanding of these effects may enable the origins of socioeconomic differences in adult health to be identified and offers opportunities to define possible pathways through which adult health inequalities are produced and reproduced.

The distribution of wealth within countries also significantly affects young people’s health. In general, young people in countries with large differences in wealth distribution are more vulnerable to poorer health outcomes, independent of their individual family wealth [19] [28] [29] [30] [31] [32].

Cross-national differences in health

Variations in patterns of health and its social determinants are also seen between countries. Over the 30 years of the HBSC study, it has been possible to monitor how young people’s health and lifestyle patterns have developed in the context of political and economic change. Between the 1997/1998 and 2005/2006 HBSC surveys, for instance, the frequency of drunkenness increased by an average of 40% in all participating eastern European countries; at the same time, drunkenness declined by an average of 25% in 13 of 16 western European and North American countries. These trends may be attributed to policies that, respectively, either liberalized or restricted the alcohol industry [33] and to changes in social norms and economic factors. These findings underline the importance of the wider societal context and the effect it can have – both positive and negative – on young people’s health.


  1. Currie C et al., eds. Health Behaviour in School-aged Children (HBSC) study protocol: background, methodology and mandatory items for the 2009/2010 survey. Edinburgh, CAHRU, 2011.
  2. 2.0 2.1 Zanotti, C., Morgan, A., Currie, D., Looze, M. D., Roberts, C., Samdal, O., Smith, R., & Barnekow, V. (2012). Social determinants of health and well-being among young people. World Health Organization Regional Office for Europe.
  3. Acheson D. Independent inquiry into inequalities in health report. London, The Stationery Office, 1998.
  4. Mackenbach J, Bakker M, eds. Reducing inequalities in health: a European perspective. London, Routledge, 2002.
  5. Equity in health and health care: a WHO/SIDA initiative. Geneva, World Health Organization, 2006.
  6. Commission on Social Determinants of Health. Closing the gap in a generation – health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva, World Health Organization, 2008 (, accessed 28 February 2012).
  7. The state of the world’s children 2011. Adolescence: an age of opportunity. New York, UNICEF, 2011.
  8. Graham H, Power C. Childhood disadvantage and adult health: a lifecourse framework. London, Health Development Agency, 2004
  9. Kelly M et al. The social determinants of health: developing an evidence base for political action. Final report to the WHO Commission on the Social Determinants of Health. London, Universidad del Desarrollo/Nice, 2007.
  10. Brener ND et al. Youth risk behavior surveillance – selected steps communities, 2005. Morbidity and Mortality Weekly Report, 2007, 56(2):1–16.
  11. Woodward M et al. Contribution of contemporaneous risk factors to social inequality in coronary heart disease and all causes mortality. Preventive Medicine, 2003, 36(5):561–568.
  12. The state of the world’s children 2011. Adolescence: an age of opportunity. New York, UNICEF, 2011.
  13. 13.0 13.1 13.2 Hurrelmann K, Richter M. Risk behaviour in adolescence: the relationship between developmental and health problems. Journal of Public Health, 2006, 14:20–28.
  14. Ojala K et al. Attempts to lose weight among overweight and non-overweight adolescents: a cross-national survey. The International Journal of Behavioral Nutrition and Physical Activity, 2007, 4(1):50–60.
  15. 15.0 15.1 Haugland S et al. Subjective health complaints in adolescence. A cross-national comparison of prevalence and dimensionality. European Journal of Public Health, 2001, 11(1):4–10.
  16. 16.0 16.1 Torsheim T et al. Cross-national variation of gender differences in adolescent subjective health in Europe and North America. Social Science & Medicine, 2006, 62(4):815–827.
  17. Cavallo F et al. Girls growing through adolescence have a higher risk of poor health. Quality of Life Research, 2006, 15(10):1577–1585.
  18. Ravens-Sieberer U et al., HBSC Positive Health Focus Group. Subjective health, symptom load and quality of life of children and adolescents in Europe. International Journal of Public Health, 2009, 54(Suppl. 2):151–159.
  19. 19.0 19.1 Holstein BE et al., HBSC Social Inequalities Focus Group. Socio-economic inequality in multiple health complaints among adolescents: international comparative study in 37 countries. International Journal of Public Health, 2009, 54(Suppl. 2):260–270.
  20. Moreno C et al., HBSC Peer Culture Focus Group. Cross-national associations between parent and peer communication and psychological complaints. International Journal of Public Health, 2009, 54(Suppl. 2):235–242.
  21. Richter M et al. Parental occupation, family affluence and adolescent health behaviour in 28 countries. International Journal of Public Health, 2009, 54(4):203–212.
  22. Vereecken CA et al. The relative influence of individual and contextual socio-economic status on consumption of fruit and soft drinks among adolescents in Europe. European Journal of Public Health, 2005, 15(3):224–232.
  23. Vereecken C et al. Breakfast consumption and its socio-demographic and lifestyle correlates in schoolchildren in 41 countries participating in the HBSC study. International Journal of Public Health, 2009, 54(Suppl. 2):180–190.
  24. Borraccino A et al. Socio-economic effects on meeting PA guidelines: comparisons among 32 countries. Medicine & Science in Sports & Exercise, 2009, 41(4):749–756.
  25. Zambon A et al. Do welfare regimes mediate the effect of socioeconomic position on health in adolescence? A cross-national comparison in Europe, North America, and Israel. International Journal of Health Services, 2006, 36(2):309–329.
  26. Nic Gabhainn S et al. How well protected are sexually active 15-year-olds? Cross-national patterns in condom and contraceptive pill use 2002–2006. International Journal of Public Health, 2009, 54:S209–S215.
  27. Kuusela S et al. Frequent use of sugar products by schoolchildren in 20 European countries, Israel and Canada in 1993/1994. International Dental Journal, 1999, 49(2):105–114.
  28. Torsheim T et al. Cross-national variation of gender differences in adolescent subjective health in Europe and North America. Social Science & Medicine, 2006, 62(4):815–827.
  29. Elgar FJ et al. Income inequality and alcohol use: a multilevel analysis of drinking and drunkenness in adolescents in 34 countries. European Journal of Public Health, 2005, 15(3):245–250.
  30. Torsheim T et al. Material deprivation and self-rated health: a multilevel study of adolescents from 22 European and North American countries. Social Science & Medicine, 2004, 59(1):1–12.
  31. Due P et al., HBSC Obesity Writing Group. Socioeconomic position, macroeconomic environment and overweight among adolescents in 35 countries. International Journal of Obesity, 2009, 33(10):1084–1093.
  32. Elgar FJ et al. Income inequality and school bullying: multilevel study of adolescents in 37 countries. Journal of Adolescent Health, 2009, 45(4):351–359.
  33. Kuntsche E et al. Cultural and gender convergence in adolescent drunkenness: evidence from 23 European and North American countries. Archives of Pediatrics & Adolescent Medicine, 2011, 165(2):152–158

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