Exploring a Preliminary Set of Indicators to Measure Adolescent Health: Results From a 12-Country Feasibility Study.

PURPOSE: To explore data availability, perceived relevance, acceptability and feasibility of implementing 52 draft indicators for adolescent health measurement in different countries globally. METHODS: A mixed-methods, sequential explanatory study was conducted in 12 countries. An online spreadsheet was used to assess data availability and a stakeholder survey to assess perceived relevance, acceptability, and feasibility of implementing each draft indicator proposed by the Global Action for Measurement of Adolescent health (GAMA). The assessments were discussed in virtual meetings with all countries and in deep dives with three countries. Findings were synthesized using descriptive statistics and qualitative thematic analysis. RESULTS: Data availability varied across the 52 draft GAMA indicators and across countries. Nine countries reported measuring over half of the indicators. Most indicators were rated relevant by stakeholders, while some were considered less acceptable and feasible. The ten lowest-ranking indicators were related to mental health, sexual health and substance use; the highest-ranking indicators centered on broader adolescent health issues, like use of health services. Indicators with higher data availability and alignment with national priorities were generally considered most relevant, acceptable and feasible. Barriers to measurement included legal, ethical and sensitivity issues, challenges with multi-sectoral coordination and data systems flexibility. DISCUSSION: Most of the draft GAMA indicators were deemed relevant and feasible, but contextual priorities and perceived acceptability influenced their implementation in countries. To increase their use for a more comprehensive understanding of adolescent health, better multi-sectoral coordination and tailored capacity building to accommodate the diverse data systems in countries will be required.

Challenges and Opportunities to Advance Adolescent Health Measurement in Armenia: Alignment Between Global Priority Indicators and National Policies, and Feasibility of Collecting Sexual, Reproductive, and Mental Health Indicators.

PURPOSE: To assess alignment of the Global Action for Measurement of Adolescent health (GAMA) draft adolescent health indicators with national policies and explore challenges and opportunities for collecting data on adolescent sexual, reproductive, and mental health in Armenia. METHODS: We reviewed Armenia's national laws, decrees, policies, strategies, and programs for content related to the draft indicators. We conducted three focus group discussions with government and nongovernmental stakeholders and youth representatives on the feasibility of collecting the draft indicators, and analyzed the discussion segments related to sexual, reproductive, and mental health indicators. RESULTS: The policy review included 22 documents. Armenia's national laws, policies, strategies, orders, and decrees mention a range of tracking and monitoring activities in adolescent health, and many draft GAMA indicators are already incorporated into national statistics and are collected in ongoing surveys. However, policies and strategies often lack specificity around how to measure and report indicators. Sexual, reproductive, and mental health indicators were particularly sensitive to collect due to Armenian cultural norms and expectations, especially for younger adolescents under the age of 15 years. DISCUSSION: Guidance should be developed to facilitate the formulation of relevant policies with well-defined indicators and complete tracking and reporting information. Data collection should be further harmonized within the overall health information flow to avoid data overlap. While sensitization work and interviewer training can help address some issues around collecting data on sexual, reproductive, and mental health, it may be necessary to adapt certain indicators to be culturally acceptable in Armenia, such as by limiting the age range to above 15 years for highly sensitive indicators.

Cross-national variation in the association between family structure and overweight and obesity: Findings from the Health Behaviour in School-aged children (HBSC) study.

Background: Trends of increased complexity in family structure have developed alongside increasing prevalence of overweight and obesity. This study examines cross-national variations in the likelihood of living with overweight and obesity among adolescents living with one parent versus two parents, as well as the influence of living with stepparents, grandparents and siblings. Furthermore, the study explores how these associations relate to age, gender and individual-level socioeconomic status (SES) and country-level SES. We hypothesised that adolescents living in one-parent versus two-parents families, were more likely to live with overweight and obesity. Methods: The study is based on nationally representative data from 41 countries participating in the 2013/14 Health Behaviors in School-Aged Children study (n = 211.798). Multilevel logistic regression analysis was used to examine the associations between family structure and overweight and obesity by age, gender, SES, and geographic region, among adolescents aged 11, 13 and 15 years. Results: Living with one versus two parent(s) was associated with a higher likelihood of overweight and obesity (ORadj.1.13, 95%CI 1.08,1.17). Age, gender, individual-level SES, and living with grandparents were also associated with a higher likelihood of overweight and obesity, whereas living with siblings was associated with a lower likelihood of overweight and obesity. The effect of family structure varied also by age and gender with no significant associations found between living with one parent and overweight and obesity in the 15-year-old age group. Some cross-national variation was observed, and this was partly explained by country-level SES. The effect of family structure increased by a factor 1.08 per one-unit change in country-level SES (OR 1.08, 95%CI1.03, 1.12). Conclusion: The study indicates that living in a one-parent family, as well as living together with grandparents, are associated with overweight and obesity among adolescents, particularly in the Nordic European region. Existing welfare policies may be insufficient to eliminate inequalities related to family structure differences.

Weight Status and Mental Well-Being Among Adolescents: The Mediating Role of Self-Perceived Body Weight. A Cross-National Survey.

PURPOSE: Overweight and obesity are associated with poor mental health in adolescents. However, little is known about whether the influence of overweight and obesity on mental well-being is mediated by self-perceived body weight. Exploring the mechanisms underlying the relationships between obesity and mental well-being is of interest to policy makers and others working in the field of adolescent health. METHODS: This study was based on nationally representative data from adolescents (age 15 years) who participated in the 2017/2018 Health Behaviour in School-aged Children study (47 countries, N = 76,998). Mixed regression models that included gender and socioeconomic status as covariates were used to identify associations between weight status and mental well-being (life satisfaction and subjective health complaints) and to explore whether self-perceived body weight (feeling too thin or too fat) has a mediating effect. Associations between weight status, self-perceived weight, and mental well-being were further assessed country by country. RESULTS: Self-perceived body weight mediated the observed associations between overweight or obesity and mental well-being. Perceiving one's body weight as "too thin" or "too fat" was associated with poorer mental well-being, regardless of weight status. Self-perceived body weight varied by gender, socioeconomic status, and country. DISCUSSION: Self-perceived body weight may explain, to a greater extent than body mass index, variation in mental well-being among adolescents. These results are important to policy makers, clinicians, and others targeting adolescent health.

Typologies of Joint Family Activities and Associations With Mental Health and Wellbeing Among Adolescents From Four Countries.

PURPOSE: This study aims to identify distinct typologies of joint family activities and the associations with mental health and wellbeing among adolescents across four countries from the World Health Organization European region. METHODS: The 2017/2018 data from adolescents from Armenia (n = 3,977, Mage = 13.5 ± 1.6 years, 53.4% female), Czechia (n = 10,656, Mage = 13.4 ± 1.7, 50.1% female), Russia (n = 4,096, Mage = 13.8 ± 1.7, 52.4% female), and Slovakia (n = 3,282, Mage = 13.4 ± 1.5, 51.0% female) were collected in schools. The respondents self-reported their participation in joint family leisure-time activities, life satisfaction, psychological and somatic complaints, as well as a range of demographic and family situational factors. Stratified by countries, latent class analysis identified typologies of joint family activities, and logistic regression models explored cross-sectional associations with life satisfaction, and psychological and somatic complaints. RESULTS: Three typologies were identified across each of the four countries, distinguished by low, moderate, and high levels of family engagement. Adolescents with higher family engagement generally reported greater life satisfaction and fewer psychological complaints compared to those with lower family engagement. Russian adolescents in the high family engagement typology reported fewer somatic complaints compared to those with low family engagement. In addition, adolescents from Czechia and Russia showing moderate family engagement also reported fewer psychological complaints compared to those in the low family engagement typology. DISCUSSION: Our findings from four countries suggest that adolescents with high family engagement have greater life satisfaction and fewer psychological complaints, pointing toward a need for interventions to support family engagement among adolescents. Further research is needed to fully explore underlying mechanisms.

Family Support as Smoking Prevention during Transition from Early to Late Adolescence: A Study in 42 Countries.

Family support has a beneficial impact on protecting health-risk behaviour in adolescents. This study aimed to explore whether family support is associated with risk of smoking during transition from early (11 years) to late (15 years) adolescence across 42 countries. The data from the cross-national Health Behaviour in School-aged Children (HBSC) study in 2017/2018 were employed (N = 195,966). Family support was measured using the four-item Family dimension of the Multidimensional Scale of Perceived Social Support (sum score 20 or more was categorised as high family support). Smoking was defined as a reported cigarette smoking at least 1-2 days in the last 30 days. The association between smoking and family support was assessed using a prevalence ratio (PR) obtained from the multivariate Poisson regression. Over two thirds of adolescents reported high levels of support from their family. Family support was found to significantly decrease with age in most of the countries, with the boys reported high level of family support more often than girls. The adolescents who reported having low family support also were more likely to smoke compared to their peers who reported having high family support (PR = 1.81; 95% CI: 1.71-1.91 in boys, and PR = 2.19; 95% CI: 2.08-2.31 in girls). The countries with a stronger effect of family support in reducing smoking risk indicated lower rates of adolescent smoking as well as lower increases in the cigarette smoking prevalence during the age period from 11 to 15 years. This study reinforces the need for family support, which is an important asset helping adolescents to overcome the risk of smoking during their transition from early to late adolescence.

Methodology and implementation of the WHO European Childhood Obesity Surveillance Initiative (COSI).

Establishment of the WHO European Childhood Obesity Surveillance Initiative (COSI) has resulted in a surveillance system which provides regular, reliable, timely, and accurate data on children's weight status-through standardized measurement of bodyweight and height-in the WHO European Region. Additional data on dietary intake, physical activity, sedentary behavior, family background, and school environments are collected in several countries. In total, 45 countries in the European Region have participated in COSI. The first five data collection rounds, between 2007 and 2021, yielded measured anthropometric data on over 1.3 million children. In COSI, data are collected according to a common protocol, using standardized instruments and procedures. The systematic collection and analysis of these data enables intercountry comparisons and reveals differences in the prevalence of childhood thinness, overweight, normal weight, and obesity between and within populations. Furthermore, it facilitates investigation of the relationship between overweight, obesity, and potential risk or protective factors and improves the understanding of the development of overweight and obesity in European primary-school children in order to support appropriate and effective policy responses.

The information capacity of adolescent alcohol consumption indicators along a continuum of severity: A cross-national comparison of sixteen Central and Eastern European countries.

BACKGROUND: Because there is high variability among European countries in prevalence levels of various alcohol consumption measures, the informational value of adolescent's alcohol consumption indicators is uncertain. The present study aimed to examine information capacity and measurement invariance of different alcohol consumption indicators in adolescents from countries of the former Soviet (Eastern) Bloc in Central and Eastern Europe (CEE). METHODS: Data were collected in 16 CEE countries, as part of the 2013/2014 wave of the Health Behavior in School-aged Children study. Data from adolescents (age 15) who reported having consumed alcohol at least once in their lifetime were analyzed. Four binary items selected for analysis measured the presence or absence of alcohol consumption in the last 30 days, lifetime drunkenness, weekly drinking frequency, and binge drinking on a typical occasion. Multiple group confirmatory factor analysis and item response theory analysis were used to examine the data. RESULTS: In most of the included countries, alcohol consumption in the last 30 days and lifetime drunkenness were indicative at lower severity levels, while binge drinking and weekly drinking frequency were informative at higher levels of alcohol use severity. A low proportion of the estimated intercepts and factor loadings were noninvariant, which indicated approximate cross-national invariance of these indicators. CONCLUSIONS: Adolescent alcohol consumption indicators are informative for different severity levels and enable cross-nationally invariant measurement. However, different indicators suggested the presence of diverging drinking cultures in the CEE regions, with the highest discrimination capacity at the lower and higher ends of the continuum of alcohol use severity.

Socioeconomic disparities in physical activity, sedentary behavior and sleep patterns among 6- to 9-year-old children from 24 countries in the WHO European region.

Physical activity, sedentary behavior, and sleep are important predictors of children's health. This paper aimed to investigate socioeconomic disparities in physical activity, sedentary behavior, and sleep across the WHO European region. This cross-sectional study used data on 124,700 children aged 6 to 9 years from 24 countries participating in the WHO European Childhood Obesity Surveillance Initiative between 2015 and 2017. Socioeconomic status (SES) was measured through parental education, parental employment status, and family perceived wealth. Overall, results showed different patterns in socioeconomic disparities in children's movement behaviors across countries. In general, high SES children were more likely to use motorized transportation. Low SES children were less likely to participate in sports clubs and more likely to have more than 2 h/day of screen time. Children with low parental education had a 2.24 [95% CI 1.94-2.58] times higher risk of practising sports for less than 2 h/week. In the pooled analysis, SES was not significantly related to active play. The relationship between SES and sleep varied by the SES indicator used. Importantly, results showed that low SES is not always associated with a higher prevalence of "less healthy" behaviors. There is a great diversity in SES patterns across countries which supports the need for country-specific, targeted public health interventions.

A Snapshot of European Children's Eating Habits: Results from the Fourth Round of the WHO European Childhood Obesity Surveillance Initiative (COSI).

Consuming a healthy diet in childhood helps to protect against malnutrition and noncommunicable diseases (NCDs). This cross-sectional study described the diets of 132,489 children aged six to nine years from 23 countries participating in round four (2015-2017) of the WHO European Childhood Obesity Surveillance Initiative (COSI). Children's parents or caregivers were asked to complete a questionnaire that contained indicators of energy-balance-related behaviors (including diet). For each country, we calculated the percentage of children who consumed breakfast, fruit, vegetables, sweet snacks or soft drinks "every day", "most days (four to six days per week)", "some days (one to three days per week)", or "never or less than once a week". We reported these results stratified by country, sex, and region. On a daily basis, most children (78.5%) consumed breakfast, fewer than half (42.5%) consumed fruit, fewer than a quarter (22.6%) consumed fresh vegetables, and around one in ten consumed sweet snacks or soft drinks (10.3% and 9.4%, respectively); however, there were large between-country differences. This paper highlights an urgent need to create healthier food and drink environments, reinforce health systems to promote healthy diets, and continue to support child nutrition and obesity surveillance.

Weight Reduction Behaviors Among European Adolescents-Changes From 2001/2002 to 2017/2018.

PURPOSE: The purpose of this study was to analyze changes in the prevalence of weight reduction behaviors (WRBs) among European adolescents from 26 countries between 2001/2002 and 2017/2018. The impact of the perception of body weight on WLB was also analyzed, with particular attention being paid to overestimation. METHODS: The data of 639,194 European adolescents aged 11, 13, and 15 years who participated in the Health Behaviour in School-aged Children survey were analyzed. Age-standardized prevalence rates of WRB were estimated separately by survey round and gender for each country, using the overall 2017/2018 Health Behaviour in School-aged Children study population as the standard. Multivariate logistic regression analyses were used to assess WRB trends over time, adjusted for survey year, body mass index, body weight misperception, and family affluence and stratified by gender and age. RESULTS: In the 26 countries examined, the overall age-adjusted prevalence rates of WRB were 10.2% among boys and 18.0% among girls. The prevalence of WRB was higher for girls, but in the more recent surveys, gender differences in WRB decreased. There was a significant increase in the percentage of WRB among boys in most countries. Among girls, most countries did not experience significant changes. Increases in body mass index and overestimation of body weight were significant factors increasing the risk of WRB in both genders. CONCLUSIONS: The change in the prevalence of WRB by gender warrants greater attention from researchers and practitioners alike.

Sufficient Social Support as a Possible Preventive Factor against Fighting and Bullying in School Children.

Background: This study aims to explore how sufficient social support can act as a possible preventive factor against fighting and bullying in school-aged children in 9 European countries. Methods: Data for this study were collected during the 2013/2014 Health Behaviour in School-aged Children (HBSC) survey. The sample consisted of 9 European countries, involving 43,667 school children in total, aged 11, 13 and 15 years. The analysed data focus on social context (relations with family, peers, and school) as well as risk behaviours such as smoking, drunkenness, fighting and bullying in adolescents. The relationships between social support and violent behaviour variables were estimated using multiple regression models and multivariate analyses. Results: Bullying, across 9 countries, was more prevalent than fighting, except for Armenia, Israel, and Poland. The prevalence among countries differed considerably, with fighting being most expressed in Armenia and bullying—in Latvia and Lithuania. The strongest risk factors for bullying and fighting were male gender (less expressed for bullying), smoking and alcohol consumption. In addition, for bullying the social support was similarly strong factor like above-mentioned factors, while for fighting—less significant, but still independent. All forms of social support were significantly relate with lower violent behaviour of school children, and family support was associated most strongly. Regardless the socioeconomic, historical, and cultural differences among selected countries, the enhancement and reinforcement of the social support from possible many different resources should be taken into consideration in prevention programs against school violence behaviours.

Child and Adolescent Health in Armenia: Experiences and Learned Lessons.

The health of children and adolescents of Armenia has been affected by various socioeconomic, environmental, educational, and behavioral factors, demonstrating trends typical for both developed and developing countries. Key issues to be addressed by Armenian pediatricians are child mortality, malnutrition, and growth failure in the early years and overweight in later years. The case of Armenia illustrates how countries in transition are currently tackling both "old" problems (mortality and malnutrition) and "new" emerging morbidities (chronic diseases and adolescent health problems) based on social and health determinants, but the financing of the health system is far from satisfactory. Lessons of Armenia indicate the need for more cooperation between general practitioners and pediatricians at a primary care level. In addition, a better balance between inpatient and outpatient care could be achieved, which is not yet the case. Nevertheless, the overall performance of the Armenian child health care system can be considered satisfactory when bearing in mind the limitation of resources. Among the successful factors are those inherited from the Soviet period health system, including key institutions such as rural health posts and health centers, city polyclinics, and hospitals. These institutions mostly meet the needs of Armenian children and families today.