Bullying at School, Cyberbullying, and Loneliness: National Representative Study of Adolescents in Denmark.

AIMS: The aim was to examine how loneliness was associated with bullying victimization at school and online. METHODS: We used data from the Danish arm of the international Health Behavior in School-aged Children (HBSC) study from 2022. The study population was a nationally representative sample of 11-15-year-olds who completed the internationally standardized HBSC questionnaire at school, n = 5382. Multilevel logistic regression was applied to study the associations between bullying victimization and loneliness. RESULTS: The prevalence of reporting loneliness often or very often was 9.0%; 6.3% of the sample experienced habitual bullying victimization at school, and 4.8% incurred cyberbullying. There was a strong and graded association between loneliness and bullying victimization at school and cyberbullying. The associations were significant for boys and girls, and the association between exposure to bullying at school and loneliness was steeper for boys than girls. The gradients were steeper for physical bullying than for cyberbullying. Students exposed to habitual bullying in both contexts had an adjusted OR (95% CI) of 11.21 (6.99-17.98) for loneliness. CONCLUSION: Exposure to bullying at school and cyberbullying are strongly associated with loneliness. It is important to reduce bullying at school and on the internet and to promote effective interventions to reduce continuing loneliness.

Chronic backpain among adolescents in Denmark: trends 1991-2018 and association with socioeconomic status.

Chronic backpain among adolescents is important because the prevalence is high, above 10%, and more than 10% of all adolescents experience impacts on important day-to-day activities. Chronic backpain tracks into adulthood and is associated with several health problems. The objective was to study trends in the prevalence of chronic backpain among adolescents 1991-2018, to examine the association with socioeconomic status (SES), and whether this association changed over time. The study used data from eight comparable cross-sectional school surveys of nationally representative samples of 11-15-year-olds in 1991, 1994, 1998, 2002, 2006, 2010, 2014, and 2018, which constitute the Danish arm of the international Health Behaviour in School-aged Children (HBSC) study. The participation rate was 74.6% of the eligible study population, n = 29,952. Chronic backpain was defined as self-reported backpain daily or several days a week during the last 6 months. The prevalence of chronic backpain was 11.1%, significantly increasing from 8.9% in 1991 to 11.7% in 2018. The OR for chronic backpain was 1.20 (95% CI: 1.10-1.31) in middle, and 1.56 (95% CI: 1.41-1.73) in low compared to high SES. Sensitivity analyses with two other cut-points for backpain frequency showed similar associations.Conclusion: Chronic backpain is common among adolescents and the prevalence increased from 1991 to 2018. The prevalence was highest in lower SES families. We recommend increased efforts to prevent chronic backpain. What is Known: • Chronic backpain among adolescents is common, has a high burden of disability, is associated with several health problems, and tracks into adulthood. What is New: • The prevalence of chronic backpain among adolescents in Denmark increased from 8.9% in 1991 to 11.7% in 2018. • The prevalence was highest among adolescents from lower SES families.

Underweight among adolescents in Denmark: prevalence, trends (1998-2018), and association of underweight with socioeconomic status.

BACKGROUND: Underweight among adolescents is an important clinical and public health issue. It is associated with adverse health outcomes throughout the life-span and may reflect food poverty, unhealthy eating habits, or some underlying health conditions. OBJECTIVE: To study prevalence and trends in underweight among adolescents 1998-2018, to examine social inequality in underweight, and whether social inequality changed over time. METHODS: Data were derived from 6 cross-sectional school surveys from The Health Behaviour in School-aged Children study in Denmark. The study included 11-, 13-, and 15-year-old schoolchildren in random samples of schools in 1998, 2002, 2006, 2010, 2014, and 2018 (n = 22,177). Underweight was determined by body mass index-for-age thinness grade 2-3 (the Cole and Lobstein method). Socioeconomic status was determined using occupational social class (the Danish OSC Measurement). RESULTS: The overall prevalence of underweight was 3.1% among boys and 5.3% among girls (P < 0.0001) and decreased by age (P < 0.0001) among both boys and girls. The prevalence of underweight was almost stable from 1998 to 2018. There was no observed absolute or relative social inequality in the prevalence of underweight among boys or girls. CONCLUSION: The prevalence of underweight in 11- to 15-year-olds was significantly higher among girls than boys. The prevalence remained stable from 1998 to 2018. There was no significant association between SES and prevalence of underweight. It is important to elucidate the underlying causes of underweight such as malnutrition, eating disorders, eating problems, loss of appetite, chronic diseases, insufficient knowledge of nutrients effects on bodily functions, and persistent pain.

Underweight among adolescents is an important clinical and public health issue as it may reflect food poverty, unhealthy eating habits, or some underlying health problem. The aim was to study prevalence and trends in underweight among adolescents 1998­2018 and to examine social inequality in underweight. We used data from 6 cross-sectional school surveys from Denmark. Across all surveys, the number of participants was 22,177 11-, 13-, and 15-year-old students. The prevalence of thinness grades 2 and 3 were taken as indicators of underweight and were 3.1% among boys and 5.3% among girls. This prevalence was almost stable from 1998 to 2018. Contrary to overweight, which is usually more prevalent in lower socioeconomic groups, underweight was not associated with socioeconomic status. There were 2 exceptions: the prevalence of underweight among girls was highest in those from high socioeconomic groups in1998, while the prevalence among boys was highest in those from low socioeconomic groups in 2018. Underweight conditions in adolescents need careful medical examinations to elucidate the underlying causes of underweight, for example, malnutrition, eating disorders, eating problems, loss of appetite, voluntary uptake of fad diets, chronic disease, insufficient knowledge of nutrients that impact their bodily functions, mental health problems, and persistent pain.

Assessing Differences in the Implementation of Smoke-Free Contracts-A Cross-Sectional Analysis from the School Randomized Controlled Trial X:IT.

OBJECTIVE: The X:IT study is a school-based smoking preventive intervention that has previously been evaluated in a large randomized controlled trial (RCT) with good effects. However, the actual effect for participating students depends on the individual implementation. The aim of this study was to examine the implementation of smoke-free contract, which is one of the three main intervention components. Specifically, we examined whether it was implemented equally across family occupational social class (OSC), separately for boys and girls, the joint effect of OSC and gender, and the participants' own reasons for not signing a contract. RESULTS: Overall, the smoke-free contract was well implemented; 81.8% of pupils (total N = 2.015) signed a contract (girls 85.1, boys 78.6%). We found a social gradient among girls; more than 90% were in OSC group I vs. 75% in group VI. Among boys, however, we found no difference across OSC. Boys in all the OSC groups had about half the odds (i.e., medium OSC boys: OR = 0.48 (95% CI: 0.32-0.72) of having a smoke-free contract compared to girls from a high OSC. CONCLUSION: future interventions should include initiatives to involve families from all OSC groups and allow for different preferences among boys and girls.

Recurrent abdominal pain among adolescents: trends and social inequality 1991-2018.

OBJECTIVES: The association between socioeconomic status and recurrent abdominal pain (RAP) among adolescents is an understudied issue. No study has examined whether such an association changes over time. The aim was to examine trends in RAP among adolescents in Denmark from 1991 to 2018, to examine whether there was social inequality in RAP and whether this inequality varied over time. METHODS: The study used data from the Danish part of the international Health Behaviour in School-aged Children (HBSC) study of nationally representative samples of 11-, 13- and 15-year-olds. This study pooled data from eight comparable surveys from 1991 to 2018, overall participation rate 88.0%, n=30,048. The definition of RAP was self-reported stomach-ache daily or several days per week during the past six months. We reported absolute inequality as prevalence difference in RAP between low and high socioeconomic status and relative inequality as odds ratio for RAP by socioeconomic status. RESULTS: In the entire study population, 5.6% reported RAP, 3.1% among boys and 7.8% among girls. There was a significant increase in RAP from 1991 to 2018 among boys and girls, test for trend, p<0.0001. The prevalence of RAP was significantly higher in low than high socioeconomic status, OR=1.63 (95% CI: 1.42-1.87). The absolute social inequality in RAP fluctuated with no consistent increasing or decreasing pattern. CONCLUSIONS: The prevalence of RAP increased from 1991 to 2018. The prevalence was significantly higher among girls than among boys, and significantly higher in low socioeconomic status families. Professionals should be aware of RAP as common and potentially serious health problems among children and adolescents. In addition to clinical examination it is important to focus on improving the child's quality of life, reduce parents' and children's concerns about the seriousness of the condition, and consider supplements to medicine use.

Trends in social inequality in overweight and obesity among adolescents in Denmark 1998-2018.

OBJECTIVES: The aim was to analyze trends in overweight and obesity in relation to socioeconomic position among Danish adolescents in the 20-year period 1998-2018. METHODS: The study used data on self-reported height and weight and parents' occupational social class (OSC) from 11-, 13- and 15-year-old schoolchildren in 1998, 2002, 2006, 2010, 2014 and 2018, n = 22,177. The analyses included absolute social inequality in overweight/obesity (prevalence difference between low and high OSC) and relative social inequality (OR for overweight/obesity). RESULTS: In the total sample, the prevalence of overweight and obesity was 9.7% and 1.4%, respectively, with significantly higher prevalence in low than high OSC. There were significantly increasing trends in both overweight and obesity 1998-2018 in low OSC and no significant increase in high OSC. The OR for overweight was 1.59 (1.42-1.74) in middle and 2.16 (1.89-2.46) in low OSC, OR for obesity 1.74 (1.29-2.34) in middle and 2.97 (2.15-4.11) in low OSC. Associations were not modified by survey year. CONCLUSIONS: There was a persistent absolute and relative social inequality in overweight and obesity 1998-2018 among Danish adolescents.

Intake of sugar sweetened soft drinks among adolescents: Trends and social inequality in Denmark 2002-2018.

BACKGROUND: Intake of sugar sweetened soft drinks (SSSD) has decreased among adolescents, but trends in social inequality in SSSD intake are unknown. AIM: Examine trends in social inequality in SSSD intake among adolescents in Denmark during 2002-2018. METHODS: Five Health Behaviour in School-aged Children surveys with data on SSSD intake and parents' occupational social class (OSC) from nationally representative samples of 11, 13 and 15 year olds, n =20,112. RESULTS: The overall prevalence of daily SSSD intake decreased from 10.1% in 2002 to 6.4% in 2018. The prevalence decreased in both high OSC (from 8% to 5%) and middle OSC (from 10% to 6%) but remained around 12% in low OSC. The odds ratio (OR) estimates of low compared with high OSC increased over the years around an overall OR of 2.01 (1.74-2.34). CONCLUSIONS: Danish adolescents' SSSD intake decreased during 2002-2018 and was higher the lower the parents' OSC. Thus, social inequality increased during 2002-2018.

Trends in socioeconomic differences in daily smoking among 15-year-old Danes 1991-2014.

Aim: To examine trends in socioeconomic differences in daily smoking among 15-year-old Danes between 1991-2014, using occupational social class as indicator of socioeconomic status. Methods: The study included 15-year-olds participating in seven Danish Health Behaviour in School-aged Children studies between 1991-2014, n = 8,641. The analyses focused on absolute socioeconomic differences (prevalence difference between low and high occupational social class) and relative socioeconomic differences communicated by odds ratio for daily smoking. Results: The prevalence of daily smoking declined from 18.6% in 1991 to 4.5% in 2014. Across all surveys, the prevalence was 8.9% in high, 12.8% in middle and 16.5% in low occupational social classes (p < 0.0001). The absolute socioeconomic differences increased from 1991 to 2006 and declined thereafter. Across all survey years, the odds ratio (95% confidence interval) for daily smoking was 1.40 (1.19-1.65) in middle and 1.90 (1.56-2.32) in low versus high occupational social classes. The statistical interaction between occupational social class and survey year was significant (p = 0.0404), suggesting increasing relative socioeconomic differences from 1991 to 2014. Conclusions: There was a substantial decline in daily smoking among 15-year-olds between 1991-2014 in all occupational social class groups. The prevalence of daily smoking was highest in the low occupational social class during the entire period. The absolute socioeconomic differences in daily smoking increased between 1991-2006 and declined thereafter. The relative socioeconomic differences increased over 1991-2014. Studies of change in socioeconomic differences over time should address both absolute and relative socioeconomic differences as they may result in different conclusions and because important improvement in prevalence patterns may be disguised by exclusive focus on changes in relative socioeconomic differences.

Difficulties falling asleep among adolescents: Social inequality and time trends 1991-2018.

Sleep problems in adolescence are increasingly common, and associated with adverse health and psychological outcomes. Adolescents' sleep problems may be related to the family's socioeconomic status, but studies are few and no study has examined whether social inequality in sleep problems changes as sleep problems become increasingly common. This study examined trends in difficulties falling asleep among adolescents in Denmark, whether this sleep problem was associated with socioeconomic status, and whether this association changed from 1991 to 2018. The study applied data from eight comparable surveys among 11-15 year olds in Denmark 1991-2018, the Danish arm of the international Health Behaviour in School-aged Children study, N = 30,002. The prevalence of daily difficulties falling asleep increased from 7.0% to 13.4% in 1991-2018 with higher frequencies among girls and younger adolescents. The odds ratio (95% confidence interval) for daily difficulties was 1.14 (1.05-1.24) in middle and 1.52 (1.37-1.69) in low compared with high socioeconomic status. The absolute social inequality in difficulties falling asleep was persistent in 1991-2018 whereas the relative social inequality may have decreased. The increasing prevalence and the social inequality in difficulties falling asleep among adolescents is a serious public health concern that calls for more attention and efforts.

Short report: persistent social inequality in poor self-rated health among adolescents in Denmark 1991-2014.

The aim was to examine trends in social inequality in poor self-rated health (SRH) among adolescents in Denmark 1991-2014. The analysis included 18 996 11-15-year-old school children from the cross-sectional Health Behaviour in School-aged Children studies in 1991, 2002, 2006, 2010 and 2014. Across the five surveys, the prevalence of poor SRH was 14.2%, remaining almost unchanged from 1991 to 2014. The proportion with poor SRH was 12.2% in high, 14.3% in middle and 17.6% in low occupational social class. This social inequality in poor SRH was persistent during the entire study period, both in terms of absolute and relative social inequality.

Brief Report: Trends in Social Inequality in Drunkenness Among Danish Adolescents, 1991-2014.

OBJECTIVE: This study examined whether social inequality in frequent drunkenness among Danish adolescents changed from 1991 to 2014. METHOD: We used data from the international Health Behaviour in School-aged Children (HBSC) study, which provided nationally representative samples of 15-year-olds from seven comparable cross-sectional studies in Denmark (N = 8,655). The students provided data about frequency of drunkenness and parents' occupation. RESULTS: In total, 38.6% reported to have been drunk at least four times, decreasing from 44.2% in 1991 to 21.2% in 2014. Most of the decrease took place in the latter part of the period. This decrease was found in all occupational social classes, but there was no change in absolute social inequality in drunkenness four or more times reported from 1991 to 2014. The sex- and yearadjusted odds ratio for frequent drunkenness was 0.80, 95% CI [0.70, 0.93] in low compared with high occupational social class. The statistical interaction between survey year and occupational social class was insignificant (p = .3601); that is, there was no change in relative social inequality in frequent drunkenness over time. CONCLUSIONS: Drunkenness was more prevalent among adolescents from the high occupational social class, and this social inequality did not change from 1991 to 2014.

Measurement of alienation among adolescents: construct validity of three scales on powerlessness, meaninglessness and social isolation.

BACKGROUND: Psychological alienation is an important concept in the study of adolescents' health and behavior but no gold standard for measuring alienation among adolescents exists. There is a need for new scales with high validity for use in adolescent health and social research. The purpose of the present study was to develop and validate alienation scales in accordance with Seeman's conceptualization of alienation focusing on three independent variants specifically relevant in adolescent health research: powerlessness, meaninglessness and social isolation. METHODS: Cross-sectional data from 3083 adolescents aged 13 to 15 years from the Danish contribution to the cross-national study Health Behaviour in School-aged Children (HBSC) were used. We identified and developed items, addressed content and face validity through interviews, and examined the criterion-related construct validity of the scales using graphical loglinear Rasch models (GLLRM). RESULTS: The three scales each comprised three to five face valid items. The powerlessness scale reflected the adolescent's expectancy as to whether his/her behavior can determine the outcome or reinforcement he/she seeks. The meaninglessness scale reflected the expectancy as to whether satisfactory predictions regarding the effects of one's behavior are possible. Finally, the social isolation scale reflected whether the adolescent had a low expectancy for inclusion and social acceptance. All scales contained some uniform local dependency and differential item functioning. However, only to a limited degree, which could be accounted for using GLLRM. Thus the scales fitted GLLRMs and can therefore be considered to be essentially construct valid and essentially objective. CONCLUSION: The three alienation scales appear to be content and face valid and fulfill the psychometric properties of a good construct valid reflective scale. This suggests that the scales may be appropriate in future large-scale surveys to examine the relation between alienation and a range of adolescent health outcomes such as health, behavior and wellbeing.

High impact of implementation on school-based smoking prevention: the X:IT study-a cluster-randomized smoking prevention trial.

BACKGROUND: Implementation fidelity describes how well an intervention is implemented in the real-world setting. Assessing implementation fidelity is essential in the understanding of intervention results. In most studies, implementation fidelity is measured insufficiently, though, not taking into account the complexity of the concept nor the intervention. The objective of the present study was to develop an overall quantitative measure of implementation fidelity, to examine the degree of implementation fidelity and the association of implementation and effect of a randomized school-based smoking prevention trial-the X:IT study. METHODS: A cluster-randomized trial testing is a multi-component intervention to prevent smoking among adolescents in 94 Danish elementary schools (51 intervention, 43 control schools). Participants were grade 7 pupils (mean age 12.5 years). Data was collected by electronic questionnaires among pupils at baseline (n = 4161), the first follow-up (n = 3764), and the second follow-up (n = 3269) and among school coordinators at intervention schools at the first and second follow-up (50 and 39 coordinators). INTERVENTION: The intervention included three components: (1) smoke-free school grounds, (2) smoke-free curriculum, and (3) parental involvement, contracts, and dialogues. Implementation fidelity was assessed by four domains: adherence, dose, quality of delivery, and participant responsiveness. These were combined into an overall school-wise implementation index. The association of implementation and smoking was examined by logistic regression analyses. RESULTS: One fourth of the schools was characterized as high implementers of the program (all three components) at both first (12 schools, 24.0 %) and second follow-up (11 schools, 28.2 %). Implementation fidelity was strongly associated with smoking at the first and second follow-up, e.g., the odds for smoking at schools with high implementation both years were OR = 0.44 (95 % CI 0.32 to 0.68). CONCLUSIONS: Using an overall measure based on several aspects of implementation fidelity, we showed a negative graded association between implementation and smoking. This study suggests that higher degrees of implementation will improve the effect of the X:IT intervention. Studying the association between implementation and effect is extremely important; only by doing so, we can distinguish the quality of the intervention from the success of the implementation. TRIAL REGISTRATION: Current Controlled Trials ISRCTN77415416.

Loneliness and Ethnic Composition of the School Class: A Nationally Random Sample of Adolescents.

Loneliness is a public health concern that increases the risk for several health, behavioral and academic problems among adolescents. Some studies have suggested that adolescents with an ethnic minority background have a higher risk for loneliness than adolescents from the majority population. The increasing numbers of migrant youth around the world mean growing numbers of heterogeneous school environments in many countries. Even though adolescents spend a substantial amount of time at school, there is currently very little non-U.S. research that has examined the importance of the ethnic composition of school classes for loneliness in adolescence. The present research aimed to address this gap by exploring the association between loneliness and three dimensions of the ethnic composition in the school class: (1) membership of ethnic majority in the school class, (2) the size of own ethnic group in the school class, and (3) the ethnic diversity of the school class. We used data from the Danish 2014 Health Behaviour in School-aged Children survey: a nationally representative sample of 4383 (51.2 % girls) 11-15-year-olds. Multilevel logistic regression analyses revealed that adolescents who did not belong to the ethnic majority in the school class had increased odds for loneliness compared to adolescents that belonged to the ethnic majority. Furthermore, having more same-ethnic classmates lowered the odds for loneliness. We did not find any statistically significant association between the ethnic diversity of the school classes and loneliness. The study adds novel and important findings to how ethnicity in a school class context, as opposed to ethnicity per se, influences adolescents' loneliness.

Breakfast frequency among adolescents: associations with measures of family functioning.

OBJECTIVE: To investigate (i) associations between adolescents' frequency of breakfast and family functioning (close relations to parents, quality of family communication and family support) and (ii) if any observed associations between breakfast frequency and family functioning vary by sociodemographic factors. DESIGN: School-based cross-sectional study. Students completed a web-based questionnaire. Associations were estimated by multilevel multivariate logistic regression. SETTING: Danish arm of the Health Behaviour in School-aged Children study, 2014. SUBJECTS: Adolescents aged 13 and 15 years (n 3054) from a random sample of forty-one schools. RESULTS: Nearly one-quarter of the adolescents had low breakfast frequency. Low breakfast frequency was associated with low family functioning measured by three dimensions. The OR (95 % CI) of low breakfast frequency was 1·81 (1·40, 2·33) for adolescents who reported no close relations to parents, 2·28 (1·61, 3·22) for adolescents who reported low level of quality of family communication and 2·09 (1·39, 3·15) for adolescents who reported low level of family support. Joint effect analyses suggested that the odds of low breakfast frequency among adolescents with low family functioning compared with high family functioning were highest among adolescents being girls, immigrants and living in other than a traditional family structure. CONCLUSIONS: Low breakfast frequency was associated with low family functioning measured by close relations to parents, quality of family communication and family support. Further, analyses suggested that the associations were more pronounced among girls, immigrants and adolescents from other family structure than traditional. The study highlights the importance of the family setting in promoting regular breakfast frequency among adolescents.

Trends in Social Inequality in Tooth Brushing among Adolescents: 1991-2014.

This study examines whether social inequality in tooth brushing frequency among adolescents changed from 1991 to 2014. The data material was seven comparable cross-sectional studies of nationally representative samples of 11- to 15-year-olds in Denmark with data about frequency of tooth brushing and occupation of parents. The total number of participants was 31,464, of whom 21.7% brushed their teeth less than the recommended 2 times a day. The absolute social inequality measured as prevalence difference between low and high social class increased from 7.7% in 1991 to 14.6% in 2014. The relative social inequality assessed by odds ratios for infrequent tooth brushing also increased from 1991 to 2014.

Trends in overweight prevalence among 11-, 13- and 15-year-olds in 25 countries in Europe, Canada and USA from 2002 to 2010.

BACKGROUND: The purpose of this study was to assess recent changes in the prevalence of overweight (including obesity) among 11-, 13- and 15-year-olds in 33 countries from 2002 to 2010. METHODS: Data from 25 countries from three consecutive survey cycles (2002, 2006 and 2010) that had at least 80% response rate for self-reported height, weight and age were analysed using logistic regression analysis. RESULTS: Overweight prevalence increased among boys in 13 countries and among girls in 12 countries; in 10 countries, predominantly in Eastern Europe, an increase was observed for both boys and girls. Stabilization in overweight rates was noted in the remaining countries; none of the countries exhibited a decrease over the 8-year period examined. In the majority of countries (20/25) there were no age differences in trends in overweight prevalence. CONCLUSION: In over half of the countries examined overweight prevalence did not change during 2002-2010. However, increasing overweight prevalence was noted in many Eastern European countries over this time period. Overweight prevalence remained high in several countries in Europe and North America. These patterns call for continued research in youth overweight and highlight the need to understand cross-national differences by examining macro-level indicators. Such research should feed into developing sound translations and practices to prevent and reduce overweight in youth.

Socioeconomic differences in emotional symptoms among adolescents in the Nordic countries: recommendations on how to present inequality.

AIMS: This comparative study examines absolute and relative socioeconomic differences in emotional symptoms among adolescents using standardised data from five Nordic countries and gives recommendations on how to present socioeconomic inequality. METHODS: The Health Behaviour in School-aged Children (HBSC) international cross-sectional study from 2005/2006 provided data on 29,642 11-15-year-old adolescents from nationally random samples in Denmark, Finland, Iceland, Norway and Sweden. The outcome was daily emotional symptoms. Family Affluence Scale (FAS) was used as indicator of socioeconomic position. We applied four summary measures of inequality: Prevalence Difference, Odds Ratio, Slope Index of Inequality and Relative Index of Inequality, and presented the socioeconomic inequality by a graphical illustration of the prevalence of emotional symptoms, the size of the FAS groups and the summary indices of inequality in each country. RESULTS: The prevalence of emotional symptoms ranged from 8.1% in Denmark to 13.2% in Iceland. There were large country variations in the size of the low FAS-group ranging from 2% in Iceland to 12% in Finland. The largest absolute and relative socioeconomic inequalities were found in Iceland and the smallest in Finland for girls and in Denmark for boys. CONCLUSIONS: Emotional symptoms were more common among nordic adolescents from low affluence families this association appeared in the study of both absolute and relative inequality. A comprehensive presentation of socioeconomic inequality should include the prevalence of the health outcome, the size of the socioeconomic groups, and the regression line representing the summary indices of inequality.

Close relations to parents and emotional symptoms among adolescents: beyond socio-economic impact?

OBJECTIVES: This study examined the relationship between trustful communication with parents and frequency of emotional symptoms in schoolchildren and whether this relationship was modified by the family's socio-economic position. METHODS: Pooled data (n = 15,646) from the Danish Health Behaviour in School-aged Children surveys 2002, 2006 and 2010 were analysed by multilevel multivariable logistic regression. RESULTS: 8 % of all schoolchildren reported emotional symptoms almost daily. Odds ratio for daily symptoms was 2.1 (1.8-2.4) for children without trustful communication with parents compared to children with trustful communication. This association appears unaffected by family occupational class. A substantial socio-economic gradient in emotional symptoms persisted, independent of parent-child communication. CONCLUSIONS: Trustful communication with parents might have a fundamental importance, regardless of socio-economic position.

Adolescent alcohol use: a reflection of national drinking patterns and policy?

AIMS: To analyse how adolescent drunkenness and frequency of drinking were associated with adult drinking patterns and alcohol control policies. DESIGN, SETTING AND PARTICIPANTS: Cross-sectional survey data on 13- and 15-year-olds in 37 countries who participated in the Health Behaviour in School-Aged Children (HBSC) Study in 2010 (n = 144 788) were linked to national-level indicators on alcohol control policies and adult drinking patterns. MEASUREMENTS: Outcome measures were self-reported weekly drinking and life-time drunkenness (drunk once or more). Data were analysed using multi-level logistic regression models. FINDINGS: In the mutually adjusted models, adolescent drunkenness was associated significantly with high adult alcohol consumption [odds ratio (OR) = 3.15 among boys, 95% confidence interval (CI) = 2.13-4.64, OR girls = 2.44, CI = 1.57-3.80] and risky drinking patterns in the adult population (OR boys = 2.02, CI = 1.33-3.05, OR girls = 1.61, CI = 1.18-2.18). The level of abstainers in the adult population was also associated significantly with girls' drunkenness; a 10% increase in the number of abstainers in a country reduced the odds of drunkenness with 21% (OR = 0.79, CI = 0.68-0.90). Weekly drinking was associated significantly with weak restrictions on availability (OR boys = 2.82, CI = 1.74-4.54, OR girls = 2.00, CI = 1.15-3.46) and advertising (OR boys = 1.56, CI = 1.02-2.40, OR girls = 1.79, CI = 1.10-2.94). CONCLUSIONS: Comparing data cross-nationally, high levels of adult alcohol consumption and limited alcohol control policies are associated with high levels of alcohol use among adolescents.