Child well-being in the European Union Better monitoring instruments for better policies

Online Annex 1 Expert opinions on education, health and risk behaviour indicators

May 2011 Budapest

THIS PAPER WAS COMMISSIONED FROM TRKI SOCIAL RESEARCH INSTITUTE (BUDAPEST) BY
THE

STATE SECRETARIAT OF SOCIAL INCLUSION OF THE MINISTRY OF PUBLIC ADMINISTRATION AND JUSTICE. THE REPORT IS A BACKGROUND PAPER TO SUPPORT THE HUNGARIAN EU PRESIDENCY.

CONTRACT NR: VI-SZ/KIM/553/2/2010

EDITOR AND PROJECT COORDINATOR: ANDRS GBOS (TRKI)

THIS REPORT AND ALL SUPPORTING DOCUMENTS (INCLUDING ANNEXES) ARE AVAILABLE ONLINE AT: WWW.TARKI.HU/EN/

CORRESPONDENCE: GABOS@TARKI.HU, TOTH@TARKI.HU

TRKI Social Research Institute Inc. H-1112 Budapest, Budarsi t 45, Hungary Tel.: +36-1-309 7676, Fax: +36-1-309 7666 Internet: www.tarki.hu

Introduction: Identifying indicators - concepts and decision points

The child well-being indicator portfolio suggested in the main report, must serve the ongoing purpose of feeding into a regular monitoring process, the aim of which is to identify indicators that can together provide a tool for individual Member States to benchmark their policy achievements and better identify areas in need of increased policy attention.1 For this, policyresponsive indicators are needed that cover dimensions open to policy influence. When a limited set of child well-being indicators is suggested, it is understood that, as well as providing the means of monitoring policies, they must be informative for the development of strategies aimed at reducing child poverty and promoting social inclusion among children in Member States. So far as the technical aspects are concerned, according to the streamlined 2006 Social OMC indicator selection criteria, an indicator should:
capture the essence of the problem and have a clear and accepted normative in-

terpretation;
be robust and statistically validated; provide a sufficient level of cross-country comparability, as far as practicable with

the use of internationally applied definitions and data-collection standards;

be built on available underlying data, and be timely and susceptible to revision;

and
be responsive to policy interventions, but not subject to manipulation.
2

These broad requirements have been used to inform the selection of indicators from the wide range suggested in the literature.3,4 The criterion of general relevance is sometimes difficult to judge. There are a large number of relevant indicators, and for many there is academic support in the economic, sociological and psychological literature. To take this criterion into account, therefore, it may be useful to differentiate between various types of indicator. The literature on human capital formation and on child development points forcefully to the use of forward-looking indicators that encompass the chances children have to accumulate knowledge and societal skills and to enhance the physical development necessary for successful adulthood. In this regard, those indicators of well-being are considered, in the first place, that are good proxies for, or predictors of, childrens future prospects, and consequently of their performance as adult members of society. Since policies to reduce poverty have long-lasting effects if and only if they can break the intergenerational transmisThe introductory part of the Annex is an edited version of Section 3.2 of the TRKI-Applica (2010) report. The setting of these criteria goes back to the Social Protection Committee 2001 decisions endorsed at Laeken. For the streamlined OMC process, see: EC DG EMPL 2006, Proposal for a portfolio of overarching indicators and for the streamlined Social Inclusion, Pensions, and Health portfolios (adopted at 22 May 2006 SPC). 3 While we went through a large number of potentially useable indicators, we do not see the point of presenting a full or comprehensive list here. The UNICEF paper prepared by Bradshaw, Hoelscher and Richardson (2006) reports that, in building up the UNICEF report cards, a full account of 614 separate indicators was taken; the (then) OECD list of child well-being indicators contained 40 of these elements, grouped into 18 components and aggregated into six dimensions. What is more important, however, is to present those that are relevant from the point of view of the Social OMC. Nevertheless, the list we suggest as a pool, from which the ISG can select, will still be very large.
2 1

Other criteria to set-up an indicator portfolio can be also considered. The UNICEF suggests the following five aspects: (i) choosing, (ii) ordering, (iii) diversifying, (iv) summarising and (v) link to policies.

sion chain of poverty and social exclusion, the indicators selected need to give more attention to life-cycle elements, developmental aspects and life trajectories. The focus of concern is also on the distribution of well-being. More specifically, in addition to the general level of well-being of children, it is suggested that the social gap between the poorer and excluded on the one hand, and the better off on the other, should be monitored. Concern with the disadvantage of children, as opposed to their well-being, is consistent with the focus of the study on identifying the combination of policies that is most likely to reduce poverty and exclusion among children in EU countries, while the conceptualisation of some positive indicators is also of importance. The need for an indicator to capture the essence of the problem raises the issue of the aggregation level of indicators. While it is clear that, in some cases, aggregation of elementary variables from micro-surveys might help to achieve a more robust indicator (such as, for example, counting the number of items missing in a household to define material deprivation or, at a country level, averaging immunisation rates for various diseases), the calculation of socalled composite indices, which encompass information from across a range of dimensions, is not considered a suitable option here. Not only does the issue of relative weighting of the various elements need to be resolved, but also the more composite an indicator, the less guide does it provide to policy.5 Statistical validation in this context means an assessment of various statistical features of the selected indicators. Especially in the case of survey-based indicators, statistical reliability (in terms of sample sizes and confidence intervals) needs to be assessed. Related to this, indicators should preferably show (statistically significant) variance across countries and be reasonably stable over time. In the case of those indicators where we have access to microdata, we try to assess the breakdowns for which we think robustness can be maintained.6 For cross-country comparability, it is important not only that there should be methodological harmonisation, but also that the risk of distortions resulting from differences in culture and custom (wording, understanding, etc.) should be minimised. As regards availability, it is important to ensure that Member States can produce the data for those indicators selected within a reasonable interval of time. Consistent and comparable data should be available for a sufficient number of countries. However, current availability is not an absolute criterion it might be possible to institute new surveys and data-collection activities for some indicators. Another important criterion is policy relevance, which is interpreted as meaning indicators that can support the design, implementation and evaluation of policies. In consequence, the indicators suggested are those that can be directly used to measure the impact of specific policies or policy packages, and that are measurable, transparent and robust to policy changes. Most importantly, those with policy relevance should be responsive to policy
This is not to say that composite indicators cannot serve as important tools for raising awareness. On the contrary: league tables based on overall child well-being indices help identify overall policy failures in the national context and are also very important in giving momentum to child mainstreaming in many countries. Also, when it is decided that composite indicators will be developed, this, in itself, creates need for collecting each element which is positive function of for the development of monitoring tools. This is well illustrated by the impact of the child well-being indices developed under the auspices of UNICEF (see Bradshaw, Hoelscher and Richardson 2006, Bradshaw and Richardson 2009). Nevertheless, it is better to keep composites as instruments for the above. To quote Richardson (2009) on this: Dimensions are useful for passing on the quick message of relative success or failures; they say where countries are in relation to comparators and competitors; but do not address why they are where they are, or indeed what or how to change. In order to answer the why, what and how questions, one must refer to the raw data. And this is the basic rationale behind the suggestions for individual indicators to use in a child-related portfolio for the OMC. 6 We concentrate on cell sizes that remain in various breakdowns and also on width of confidence intervals for the various point estimates. As may be expected, the robustness understood this way varies from country to country for each of the variables and each of the breakdowns. The validation marks express the extent and severity of the emerging cell size problems.
5

change: that is, they should indicate phenomena for which the causal chain between policy shifts and societal outcomes is relatively straightforward. The establishment of selected indicators of child outcome should encourage governments to consider either the effectiveness or the equity aspects (or both) when promoting and implementing policies. The latter point means that not only should favourable outcomes be pursued on average, but they should also be spread across the population of children or social groups. We take these aspects into consideration, though this distinction cannot serve as a criterion for choosing between the various potential indicators. In addition to the above criteria, it is also important that the indicators chosen should be useful in creating links between policy analysis and the analysis of EU, national and sub-national data. The use of indicators in the policy experience of the Member States and of the OMC is instrumental in facilitating the identification of explanations for inter-country variance in policy performance, and also in measuring progress made in respect of the agreed common objectives. The indicators should, therefore, be designed in such a way that they allow a reconciliation of comparative EU-level monitoring figures with national headline figures. In addition, the use of indicators in national settings can help in developing joined-up government, as well as a more concrete target-setting for national and sub-national agencies.7

See more on the use of indicators in Marlier et al. (2007: 4654).

B1. Child well-being indicators in the European Union: Education-related indicators

Background material provided by Annamria Gti (TRKI-TUDOK) Educational institutions are primary importance in relation to childrens socialization and have effects on their life chances later on. As declared in the United Nations Convention on the Rights of the Child (1989)8 every child has the right to education and this right should be developed on the basis of equal opportunity (Art. 28). As this right is guaranteed by the state educational institutions are subject to direct policy interventions. There are two basic types of indicators to monitor child well-being in terms of educational outcomes: on the one hand, participation in education or training from pre-school to uppersecondary education and beyond; on the other, the performance of children in assimilating what they are taught. With regard to participation, this is (though only at a late stage) partially covered by the early school-leaver indicator, though it could be supplemented by indications of attendance at preschool at the other end of the scale (receipt/non-receipt of childcare by those under compulsory schooling age). The recognition of the importance of participation in pre-school education is growing and evidence from PISA 2009 indicate that pupils in most countries benefit from pre-primary education and those who received child care before compulsory education score higher on the performance tests than those who did not receive any pre-primary education.9 With regard to performance, various surveys differentiate between reading literacy, mathematical literacy or numeracy, and basic understanding of science literacy. The starting point in this respect is a measure of low reading literacy of pupils aged 15 is already part of the agreed portfolio. There are, however, good arguments for monitoring literacy performance at an earlier age, especially since there are widely available data sources for children at 10 years of age.10 A particular issue here is which of the three literacy indicators should be used in monitoring. While there are good reasons to combine them (as occurs in the OECD report),11 there is also a case for keeping them separate and for focusing on reading literacy. Though the difference may not be large, in terms of equity, reading literacy may be more relevant than the other two (especially when ethnicity and migrant status are considered), since it measures competencies that are more basic than the other two (from the perspective of social inclusion).12 The main suggestion here is to supplement the present PISA- based indicator with an indicator of childrens reading literacy at age 10, based on PIRLS, broken down in various ways. Considering educational indicators another dimension may be added to the portfolio. Educational deprivation is relevant because of its association with performance and well-being as well. Possession of educational resources such as textbooks, computer and appropriate circumstances to study (e.g. quiet place to study) are necessary for good school performance. Finally we would like to elaborate on the issue of measuring performance in early childhood. Economic literature has been putting an emphasis on showing evidence of how early investhttp://www2.ohchr.org/english/law/crc.htm PISA in focus 1, Online: http://www.pisa.oecd.org/dataoecd/37/0/47034256.pdf 10 Like PIRLS (Progress in International Reading Literacy Study). 11 OECD 2009: 40. 12 Another argument for keeping these separate is that science and maths literacy scores for 10-year-olds are collected in surveys (TIMSS), separate from the reading literacy scores for the same ages in PIRLS.
9 8

ments in education have higher returns and therefore more relevance in improving life chances compared to investments in education in later phases of peoples life. This suggests that monitoring child well being in early childhood has relevance. It is an ongoing dilemma however if it is really any kind of performance that one should measure. In the very early ages the use of the term performance may not be appropriate. State/status would be more relevant and from this angle child well being in early childhood may be best approached through the monitoring of health indicators (eg. data from nurses about 0-2 years olds, health status at the age of 5). Other measures that may be treated as performance measures in the early ages may not be indicator type measures: game ability, kindergarten conformity, social maturity, etc. Indicators may be constructed when taking into account attendance rates and use of several services such as early development services. Availability of childcare institutions, kindergarten/school starting age, quality indicators of childcare institutions (professionals qualifications, children/professional ratio, group sizes etc.) may also be considered. There is a growing trend however in measuring abilities and performance in the early stages of life which indicates that from an educational point of view monitoring well being at an early age would mean that we need to find some kind of achievement indicators. The idea of measuring performance has been posing important dilemmas for scientists which must be considered.13 Firstly, the definition of early childhood must be agreed about. Does it cover the entire preschool phase or is it just the phase between 0-3 years? This decision has central importance in order to choose suitable measurements. It is possible to measure some dimensions of performance/status between 0-3, but the measurements used at this age are almost exclusively based on observations and therefore dependent on numerous subjective factors. After age 3 tests may be used but these early intelligence tests also have limitations. From the practical point of view it must also be considered that carrying out observations and tests in the early ages is more time and money consuming than later examinations and in most cases requires well-trained professionals. Further limitations14 of early screening highlight the fact that young children's behaviour is dynamic and unstable. A test given at one point in time cannot be assumed to reflect the child's status a relatively short time later. Also, there is not widespread agreement on how to decide which children are at risk for learning problems and school failure and early screening programs alone do not accurately predict which children are likely to have significant future problems; they work best for children who happen to be at either end of the range of performance on the tests. As a performance indicator school readiness of 6 years olds may be utilized and there is a growing knowledge about tests that are already in use to assess the development of children. It must be noted however, that background information from parents is not collected upon the administration of any of these tests.

Measuring cognitive child outcome in pre-school ages

The Bayley Scales of Infant Development (BSID)15

This section was written with the help of experts in the field of early childhood education: Judit Kereki (Etvs Lrnd University - Brczi Gusztv Faculty of Special Education; AITA), gnes Darvas (Etvs Lrnd University Faculty of Social Sciences; Hungarian Academy of Sciences' Program to Combat Child Poverty). 14 Gredler, G. R. (1992). 15 http://media.wiley.com/product_data/excerpt/18/04713265/0471326518.pdf

13

Invented: first edition 1969; a second edition - 1993 Use: worldwide What is measured: mental development, motor development, behavior of infants When: 1-42 months of age Time: 45-60 minutes Execution: administered by examiners who are experienced clinicians specifically trained in BSID test procedures; the examiner presents a series of test materials to the child and observes the child's responses and behaviors Content: Mental scale: sensory/perceptual acuities, discriminations, and response; acquisition of object constancy; memory learning and problem solving; vocalization and beginning of verbal communication; basis of abstract thinking; habituation; mental mapping; complex language; and mathematical concept formation Motor scale: the degree of body control, large muscle coordination, finer manipulatory skills of the hands and fingers, dynamic movement, postural imitation, and the ability to recognize objects by sense of touch Behavior rating scale: 30-item scale rates the child's relevant behaviors and measures attention/arousal, orientation/engagement, emotional regulation, and motor quality

The DENVER II. test 16

Invented: first edition 1967; a second edition - 1992 Use: worldwide What is measured: covers four general functions: personal social (such as smiling), fine motor adaptive (such as grasping and drawing), language (such as combining words), and gross motor (such as walking) When: 0-6 years of age Time: 20 minutes Execution: can be administered by professional, para-professional, and lay screeners Content: -

Child Development Charts17

Invented: Use: What is measured: Five developmental areas are covered: social, self help, gross motor skills, fine motor skills and language. It also identifies typical developmental milestones and the range of "normal," or when to be concerned about a child whose development is below age expectations. When: The tool includes two sides: The Infant Development Chart, for use up to 18 months, and a First Five Years Development Chart for toddlers and preschoolers.
16 17

http://www.denverii.com/benefits.html http://www.childdevrev.com/page4/page23/cdchealthcare.html

Time: Execution: Content: Sample: http://www.childdevrev.com/CDC_3_Sample.pdf

Data infrastructure
The Programme for International Student Assessment (PISA) is undertaken by the OECD every three years and focuses mainly on educational attainment. It is based on large school-based samples of 15-year-olds. The most recently published results are from the 2006 survey. PISAs main potential contribution is to the access-to-education aspect of wellbeing. The data might be exploited further, especially as regards the breakdowns by parental education and the migrant status of parents. Progress in International Reading Literacy Study (PIRLS) is a worldwide comparative reading assessment that is carried out every five years. It is based on school-based samples of 9- and 10-year-olds (the fourth grade of elementary school). The most recently published results are from 2006. The number of participating countries is growing: the most recent (2006) wave covers 40 countries. PIRLS provides important information on childrens reading literacy achievement, as well as on various influences (home, school, national) on how efficiently students learn to read. It is suggested that the coverage of the child-related indicator pools should be extended to the reading literacy of 10-year-olds, broken down by parental education level, using the PIRLS survey.

In addition to PIRLS, the Trends in International Mathematics and Science Study (TIMSS) is undertaken every four years, at the fourth and the eighth grades, to provide data on maths and science. The most recent available results are from the 2007 wave, which covers 62 countries. At this stage, there is no suggestion that science and maths indicators should be included, but TIMSS is a potential source of such data.

10

B2. Child well-being indicators in the European Union: Health-related indicators of child poverty
Background material provided by Anna Aszmann, Andrs Klt, gnes Nmeth, and Ildik Zakaris (National Institute of Child Health18)
Many research data, conclusions and everyday life experiences give strong support to the notion that children living in poverty and at disadvantageous environment will be adults who suffer material and social deprivation compared to those who had a childhood in relatively affluent family. Therefore the problem of child poverty, respectively child well-being is a political priority of the European Union. It was recommended that reporting on child poverty and child well-being should include (i) a comparative EU analysis of the risk of child poverty on the basis of the framework proposed by the Task-Force and (ii) an analysis of other dimensions of child well-being identified by it. It was suggested that all the relevant indicators already agreed at EU level should be used in this process, as well as (then) yet-tobe developed indicators of material deprivation, housing and child well-being, including those available at the national level. This analysis and the collection and the development of the related indicators have been carried out by TRKI Social Research Institute, Inc. (Budapest, Hungary) and Applica sprl. research company (Brussels, Belgium). Those institutions published a study titled Child well-being indicators in the European Union. National Institute of Child Health (OGYEI) was requested to collaborate and contribute to the further development of those indicators which may reflect on child poverty from the aspects of somatic and psychosocial well-being. The current material contains our suggestions for the indicator development and the most up-to-date and exact data are provided regarding to the indicators. The demand to develop health indicators has increased in the past years. Several international programs have aimed to define and use indicators reflecting on the differences of health status between countries, different areas within a country, and social groups. Indicator development has become a special field of public health nowadays. Between 2000 and 2002, Child Health Indicators of Life and Development (CHILD) program supported by the European Council, took place. The indicators of the program have also been used by the WHO, they were built into the Information Tools part of the document called European strategy for child and adolescent health and development, 2005 International organizations like the WHO and the UNICEF have also published several documents about the influence of social inequality on child health and the quality of life/ or well-being. These documents list several possible indicators concerning the holistic health status (somatic, mental, social) of children but only a few can be claimed to be well-defined, regularly and uniformly collected and suitable for international comparison. The influence of SES on child-health indicators is proved by several studies world-wide but the definition of social background is not uniform and not every country has comparable hierarchic classification for it.19 First a short summary is provided about the current indicators and the suggested changes in the indicator set, along with some theoretical and methodological considerations. In the next session a more detailed description is provided about the suggested indicators, along with the scientific rationale supporting their use. Finally, an overview is given about the well-being of European children, based on data update for all indicators considered within the Health dimension. Revised and newly-developed indicator sheets are annexed.

18

Orszgos Gyermekegszsggyi Intzet OGYEI. Halldorsson et al. (2000); Larsonet al. (2008); Stuart and Spencer (2000).

19

11

Well-being and health

Well-being is a multidimensional concept and health which is defined as the resource of both the individual and the society, the accomplishment of the human potential is an important part of it. The accomplishment of the human potential, through the development of the individual, serves the advance of the society, and this is also true to children and childhood. Childhood well-being refers to healthy birth and optimal somatic, psychomotor, social and cognitive development. In the next part of the study we collect scientific evidence underpinning the well-known fact that a healthy and happy child will be able to acquire better cognitive and psychosocial skills, therefore he or she may perform better in school, which means that he or she will have better chance to reach a good position in the labour market.20

Current health-related indicators and suggestions for change

The monitoring of the risk of child poverty and of the well-being of children is a complicated matter, made more complicated by the nature of the subject children themselves. While there is a need to monitor different dimensions of child well-being, it is equally important that the indicators should reflect the various stages of childhood development. The combination of the dimensions and of child age groups results in a matrix, where all the elements need to be properly assessed, as the study puts it. The relationship between child health and adulthood affluence is an even more complex pathway, with a large amount of mediating variables which may also modulate each other. Compiling an indicator set reflecting on this complexity, TRKI has selected indicators which fulfil the following criteria: a) relevant to child poverty and have a clear and accepted normative interpretation; b) robust and statistically validated; c) able to be the subject of a cross-country comparison, as far as internationally applied definitions and data collection standards make it possible; d) underlying data is available and up-to-date; e) responsible to policy interventions but not to political manipulations. However, they were prevented from detailed consideration of some important potential indicators (those produced by Health Behaviour in School-aged Children [HBSC], for example) because of the microdata werent available. Time (or life-cycle) aspect was also taken into account: while a child might live in poverty or be socially excluded at any age throughout childhood, when it happens might well have a different effect on the outcomes. Therefore they have selected indicators which arguably distinguish between different age groups and not just relate to the 017 age group. Indicator selection was made by 05, 611 and 1217 age group decomposition. That grouping is supported by developmental psychological literature.21 Taken these considerations in account, the following indicators were used: infant mortality, perinatal mortality, vaccination, low birth weight and breastfeeding for the 05 age group; overweight, daily fruit consumption and eating breakfast every school day for the 611 age group; self-perceived general health and physical activity for the 1217 age group. Life expectancy at birth was used as an overall indicator. Table 1 contains the original indicator set.

20 21

Briggs-Gowan (2008). Cole (2004).

12

Table 1: Original health-related indicator set of child poverty and well-being by age group, suggested by TRKI
Dimension B2: Health Child age group 05 (02, 35) 611 1217 Infant mortality (by Overweight Self-perceived genSES) eral health Fruit daily Perinatal mortality Breakfast every Physical activity Vaccination school day Low birth weight Breastfeeding Life expectancy at birth (by SES)

We agree on using most of the variables, however we suggest some changes. First of all, perinatal mortality (PNM) and infant mortality (IM) are very strongly correlated to each other; therefore it doesnt seem parsimonious to use both of them. Most of their variance is shared and can be explained in 7080% by the combination of deprivation, ethnicity and maternal age.22 For the sake of economy, we suggest using only IM. Although we agree on the theoretical decomposition age groups 611 and 1217, it doesnt seem reasonable to split the indicators of these two groups. Research data and common sense dictates that all children of these age ranges should consume fruit, eat breakfast and take part in physical activity. Statistically valid evidence is given for that there are some tools to measure life satisfaction (self-perceived quality of life) from the age of 5 to 20.23 Agreeing with low birth weight and exclusive breastfeeding as indicators for the wellbeing of 05 group, we suggest adding oral health for the 611 and 1217 group (scientific evidence above). Current findings suggest that obesity (and other nutritional status data) does not have a consistent negative correlation with material welfare. From HBSC survey conducted in 2005/2006 it can be concluded that family affluence is significantly associated with overweight or obesity just in around half of countries. In most of these cases for boys, and all of them for girls, those from lower affluence families are more likely to be overweight or obese. This pattern is strongest in Western Europe. On the other hand, in some Northern countries (in Greenland and Latvia, namely), in Russia and in Turkey the boys of more affluent families proved to be significantly more obese. In other Southern and Eastern countries no significant relationship was found.24 Overweight inequality, measured by regression analysis, supports the inconsistency across countries.25 HBSC findings stem from self-reported BMI data. There are no internationally comparable published results based on measured data assessing nutritional status of children and young people. We strongly suggest starting such a standardized data collection throughout EU countries. Data breakdown by social status is also far recommended. Based on these findings and considerations we suggest that obesity should be omitted. The summary of the suggested changes and the new indicator set can be seen on Table 2. Table 2: Health-related indicator set of child poverty and well-being by age group, suggested by OGYEI
22 23 24 25

Freemantle et al. (2009). Drotar (1998). Currie (2008). Due (2009).

13

7 Dimension B2: Health

Child age group 05 (02, 35) 611 and 1217 B2.2 Infant mortality B2.6 General life satisfaction B2.3 Vaccination coverage B2.7 Oral health B2.4 Low birth weight B2.8 Daily fruit consumption B2.5 Exclusive breastfeeding B2.9 Breakfast every school day B2.1 Life expectancy at birth

Socio-economic differences in child health

To analyze socio-economic inequalities in child health, various aspects of socio-economic status of children can be considered. Several of these factors are measured in the HBSC study, including occupational status of parents, family affluence and family poverty. The social status background variable called Family Affluence Scale (FAS) is recommended to use for making breakdowns according to social status within HBSC subjective well-being and health behavior indicators. The FAS measure is based on a set of questions on the material conditions of the households in which young people live. The questions are easy for children and young people to answer and cover car ownership, bedroom occupancy, holidays and home computers. The measure has several benefits, such as the low percentage of missing responses from young people and its cross-national comparability. By contrast, parental occupation measures tend to suffer from missing data and differences in countries classification schemes. Family poverty affects a minority of young people (although this varies from country to country), but all young people can be categorized according to their family affluence. To this end, young people in each country are classified according to the summed score of the items, and this overall score is recoded to give values of low (FAS1), middle (FAS2) and high (FAS3) family affluence.26 Where it was possible (for the HBSC-indicators), we carried out statistical analyses of the indicators using the breakdown of the FAS classification.

B2.1 Life expectancy

Many research data support the notion that poverty leads to shorter life. That relationship may not be direct causality, rather a complex system of many factors. However, when 149 countries were sorted into quintiles according to GDP per capita in the late 1990s, those in the middle quintile had 20 years higher life expectancy (LE) than countries in the lowest quintile (and the highest quintile 10 years more than the middle quintile).27 A study carried out in England and Wales, analyzing demographic data from 19721991 clearly showed that the less is the social class of a person, the less long is his/her life expectancy. Although the increase of LE was constant throughout the three decades, the increase is respectively more rapid in the higher social classes.28 Long life means that the person has a relatively healthy, disease-free, meaningful, enabling life style, in other words length of LE reflects on wellbeing. Taken into account that it seem to be consistently and strongly associated with socioeconomic status it seems reasonable to use it as an overall health-related indicator of child well-being.

26 27 28

Currie et al. (2008). Fuchs (2004). Hattersley (1999).

14

B2.2 Infant mortality

Mortality indicators have a traditional role among the health indicators. Higher mortality rate shows several avoidable death causes and a significant difference between developed (or rich) and underdeveloped (poor) countries, as well as between the advanced and depressed regions of a country. Total infant mortality is a world-wide acknowledged, well-defined, comparably collected indicator. It is in close connection with living conditions including the distribution of material sources, the quality of health care, the accessibility of that, and the differences of the above mentioned factors in a certain country. Comparative studies and international as well as national statistics revealed that there is a significant difference in infant mortality data between developed and developing countries in the world, between different regions of Europe (Northern, Southern, Eastern and Western regions), and between developed and underdeveloped regions of the countries.29 At an individual level, maternal age (being under 19 or over 35), poor health conditions, nutritional habits, smoking, unsatisfactory genital hygiene and stress have negative impacts on the outcome of the pregnancy, just like limited access to healthcare services. Within the one year period of the infant mortality we can differentiate shorter periods: neonatal mortality (027 days) and late infant mortality (28 days1 year). Although there are slight differences in these specific indices, just the health care providers need such a detailed analysis for evaluation and source allocation. In countries with high quality health care the major part of first-year mortality is constituted by neonatal mortality. (Most newborns die in the first 27 days.) Analyses carried out with decomposing maternal occupation, education level30 or SES revealed that the higher is the mothers deprivation, the higher is the perinatal and infant mortality rate.31 Significant differences were also found between countries and micro-regions. Increased investment in improving the national32 (or the regional)33 health care system results reduced level of infant mortality.

B2.3 Vaccination coverage

Immunization is one of the most powerful and cost-effective forms of primary prevention. Among child health indicators immunization coverage reflects on the quality of the health care service.34 According to the WHO Health For All database, 90% of children should be immunized by 2000 to avoid preventable common contagions. Deaths attributable to infectious diseases which can be prevented by vaccination are low in the high income countries in the EU region compared with global rates; still, some evidence show that incomplete or cancelled vaccina29 30 31 32 33

ONS (2004). Mackenbach (2005). Mackenbach (2005). Conley and Springer (2001).

Regional differences in infant mortality rate have been reported in Germany, with a twofold difference between the federal states of Baden-Wrttemberg and Bremen in 2002 (Bertram, 2006, cited by N. Spencer in Health Consequences of Poverty for Children /www.endchildpoverty.org.uk/)

34

Child Health Indicators of Life and Development (CHILD) Project Report to the European Commission, September 2002.

15

tion occur in the most developed countries as well, resulting in outbreaks of preventable diseases.35 There are considerable differences in vaccine policy and legislation between EU countries but most of these differences have historical, religious and cultural reasons rather than a solid basis of science. Attitudes towards vaccination have a great variance across different countries and population groups. Despite high official immunization rates in general immunization among the marginalized groups are low as a consequence of neglect of the needs of Roma population.36 Nations in EU all collect and analyze vaccination coverage data regularly, but the methods the different countries use to assess vaccination coverage and the frequency are highly variable, making comparison difficult.37 VENICE consensus document (Stockholm, 8th December 2010) stated that Collection of existing VC data in EU countries could be more efficient and representative with a standardized data collection fitting in European needs.38 Children in different countries are vaccinated by a different schedule and dosage phases. For instance, diphtheria immunization can be dosed in 1, 2 or 3 injections in different ages. It can be seen on the regarding indicator sheet, there are differences in the national immunization schedules by the first and third dose of DPT vaccination (DPT1 and DPT3, respectively). Some national data are missing, or just regarding to overall vaccination. Despite of that, vaccines are given against DPT, poliomyelitis and MMR are registered in all countries and may be compared to each other. Relationship between immunization and socio-economic status is not consistent across countries and studies. Two surveys carried out in Flanders in 1999 and 2005 have drown different conclusions: the first one did not find association between vaccination coverage and socio-demographic factors39, but in the latter one low education of parents and the low income of the families resulted in incomplete vaccination. In another research conducted in the UK, an interesting phenomenon was observed: there was significant association between the incomplete immunization and large family size, lone parent status, residence in disadvantaged or ethnic wards, maternal smoking in pregnancy, and in addition unimmunized infants were more likely to have older ( 40 years) and more highly qualified mothers.40 Therefore we suggest using vaccination coverage as a child poverty indicator with precaution.

B2.4 Low Birth Weight (LBW)

According to the widely used WHO definition, LBW means less than 2500 g birth weight irrespective of the time of pregnancy. Babies born underweighing 2500 g may be further classified according to birth weight and the time of pregnancy.
Infants with very low weight: birth weight under 1500gr Real premature infants: pre-term birth (<36 weeks gestation) and very pre-term (<32

weeks) gestation Infants with intrauterine growth retardation: birth weight in the lowest ten per cent for gestational age (SGA, small for gestation age). The life prospects of very preterm babies and those with intrauterine retardation are less favorable: they constitute the vast majority of infant deaths. Many of them needs intensive
35 36 37 38 39 40

Dominiguez et al. (2008). Loewenberg (2006). Report on vaccination coverage assessment in Europe (Venice report). Giambi et al. (2010). Vellinga, Depoorter and Van Damme (2002). Samad et al. (2006).

16

neonatal care and even those who survive the first week have a great risk of handicapped development. That causes worse chance of proper education and career possibilities for these children compared to those who were born with normal weight and in time. 41 With early interventions these chances may be improved but of course it means more work and higher expenses for the health care and the education.42 Being born with low weight has an impact beyond childhood as well. It has been proven that LBW is related to adulthood cardiovascular and cerebrovascular diseases43 and disorders of glucose metabolism,44 which seriously harm the health and work capacity. The relationship between low weight, premature birth and social status has been proved by several studies and by the statistics of several countries.45

B2.5 Exclusive Breastfeeding (EBF)

Lots of studies prove that breastfeeding (BF) is not just providing the most optimal nutrition for the infants, but it is associated with several types of health benefits for the children and the mothers, too. Compared with formula-fed infants, the breastfed babies have less frequent acute and chronic respiratory and gastro-intestinal diseases, in their later life less diabetes mellitus and obesity. Breastfeeding contributes to the health of mothers, as it helps them to space their children, and it reduces the risk of ovarian and breast cancer.46 Several evidence is given for the positive association between BF and cognitive development in early childhood and academic achievement in the school age. Those who had breast milk for six months or longer achieved higher scores in mathematics, spelling, reading and writing.47 Relationship between BF and multiple dimensions of SES has been proven. After adjustment for many potential confounders (family income, maternal occupation, national poverty level, racial and ethnic groups) maternal and paternal education remained positively associated with BF. In US the foreign born Latina women were the most likely to breastfeed.48 The similar result of a study carried out in Italy underscores the association between BF and the mother higher social class.49 Besides the health benefits of BF its effect on the health care expenditure which can be reduced is highly considerable. This saving would result from reducing both direct costs (formula cost, costs connecting diseases) and indirect (time and wages lost parents).50 Unfortunately, data collection of BF is very scattered and not standardized. Some database contain information on partial BF (when any other solid or liquid nutrition is given to the baby), while others on exclusive BF (the baby just receives breastfeeding, not any other liquid or solid food, except vitamin solutions or medication). There is also a difference in the
41 42 43 44 45 46 47 48 49 50

Briggs-Gowan and Carter (2008). Maggi et al. (2005). Osmond, Barker and Winter (1993). www.endchildpoverty.org.uk/files/Childhood_Poverty_and_Adult_Health.pdf Spencer (2010); Spencer et al. (1999). Kramer and Kakuma (2004). Anderson, Johnstone and Remley (1999). Hecket al. (2006). Riva et al. (1999). Ball and Wright (1999).

17

age of the baby when the data is collected. Some database contains information of breastfeeding rate of 3, 4 or 6 months old babies, while others are collected at the first birthday of the children, retroactively. Since the indicator is very valuable in the respects of child wellbeing and economic reasons an investment into better quality data will be necessary. Since the most reliable and extensive data were collected using the WHOs definition of exclusive breastfeeding, we suggest to use that indicator in the current research, projected to 6 months old children. The WHO definition of EBF is the following: The infant has received only breast milk from his/her mother or a wet nurse, or expressed breast milk, and no other liquids or solids with the exception of drops or syrups consisting of vitamins, mineral supplements or medicines.51

B2.6 General Life satisfaction (GLS)

Optimal human functioning includes both the absence of illness and the presence of wellbeing.52 Well-being has many aspects. Living without distress has a major importance, but positive emotions like happiness and excitement are not less relevant. Life satisfaction is defined as the persons affective perception of his or her life. It has been studied from both global (that is, satisfaction with life as a whole) and domain-specific perspectives (such as satisfaction with school or home experiences). Life satisfaction is associated with many health-related outcomes, such as substance use and participation in physical activity. Having positive feelings about school is associated with higher levels of life satisfaction among adolescents, while a negative experience of school is related to lower life satisfaction. It seems obvious at least in European cultures that life satisfaction has a strong correlation with material background. HBSC data indicates that high life satisfaction is significantly associated with higher family affluence in all countries (except of Greenland) for both boys and girls.53 Life satisfaction is very strongly correlated to optimism, goal adjustment and ability for coping with adversities.54 Beside the direct relationship, the latter three may mediate the relationship between life satisfaction and adulthood material situation. Therefore we argue that GLS is a good indicator in mapping the relationship between child well-being and poverty.

B2.7 Oral health

The two leading dental diseases, namely caries and periodontal disease, could have been easily prevented by good oral hygiene and limited sugar consumption. Toothbrushing can maintain gum health and control plaque formation. Optimally, toothbrushing happens twice a day, with fluoride toothpaste.55 Relationship between poverty and bad oral hygiene might be circular. It has been shown that insufficient oral health cause limited personal possibilities, social desirability and lowers the perceived quality of life (therefore it might contribute to worse career outlooks).56 Adults of better socio-economic position have higher rates of tooth retention and less destructive periodontal disease.57 On the other hand, children living in a relative material deprivation brush their teeth less regularly, therefore they suffer from more oral health problems than those who are living in a more affluent family and/or with parents
51 52 53 54 55 56 57

WHO (1996), cited by Yngve and Sjstrm (2001). Seligman and Cskszentmihlyi (2000). Currie et al. (2008). Wrosch and Scheier (2003). Le (2000). Macgregor, Regis and Balding (1997). Burt, Ismail and Eklund (1985).

18

with higher-level occupations. An American study revealed that children of low-income families experienced more oral disease (being also more extensive), and they needed more frequent dental service for pain relief.58 HBSC data collected in 2005/2006 suggests that lower levels of toothbrushing more than once a day are significantly associated with lower family affluence; this is true for both boys and girls in almost all countries.59

B2.8 Daily fruit consumption

Healthy food habits during adolescence are important for several reasons. Young peoples eating practices affect their risk of developing a number of immediate health and social problems, such as obesity and type 2 diabetes, disordered eating habits and poor academic performance. Additionally, evidence suggests that adolescents consumption patterns track into young adulthood. A diet with low fruit, vegetable and fiber intake and high sodium and fat intake exposes adolescents to a higher risk for long-term health problems such as cancer and cardiovascular diseases. Fruit intake seems to have a special importance in the period of transition from childhood to adolescence, as fruits contribute significantly to bone mineralization.60 In line with the next indicator, regular breakfast eating, fruit consumption shows a decreasing tendency. All resources and authorities agree that fruit and vegetable consumption should be strongly encouraged, as it is contributing to optimal nutrition, which reduces the risk of many diseases and fosters good health. HBSC data analysis revealed that low fruit intake has a significant association with lower frequency of fruit consumption among boys and girls in the majority of the countries.

B2.9 Breakfast every school day

According to the findings of the literature, regular breakfast plays an important role in healthy lifestyle. Besides the influence on daily well-being, eating breakfast contributes to the quality of the daily dietary intake, balanced metabolism and improved cognitive performance during the daytime.61 It has short-term and long-term effects. Eating breakfast has an immediate beneficial effect on neurohormonal functioning during the following forenoon. An experiment proved that those children who were given breakfast for 4 successive mornings performed better in the tests measuring attention, working memory and secondary episodic memory.62 A direct long-term association was found between regular breakfast eating and achievement in reading and mathematics skills of children who took part in a school breakfast program during a semester; the program significantly reduced tardiness and absence.63 These data suggest that regular breakfast eating in the long run contributes to better academic performance, which is substantiating their position on the labor market. Nevertheless breakfast skipping has become increasingly widespread among children and adolescents. Omitting breakfast seems to be associated with several other health compromising behaviors such as smoking, alcohol and drug use, sedentary lifestyles and obesity.64 HBSC data suggests that eating breakfast daily is significantly associated with family affluence in the majority of countries for

58 59 60 61 62 63 64

Edelstein (2002). Currie et al. (2008). Vatanparast et al. (2005) Pollitt (1995). Wesnes et al. (2003). Meyers et al. (2003). Vereecken (2005).

19

boys and over half for girls. It is associated in most cases with higher family affluence, particularly in western and northern Europe.65

Data infrastructure
The Health Behaviour in School-aged Children Survey (HBSC), coordinated by the World Health Organization (WHO), is carried out every four years. It is based on school-based samples of 11-, 13- and 15-year-olds. Country coverage is being extended wave by wave: the most recent wave (2005/06) covers 41 countries. The HBSC is an important source of data on behaviour and risks, subjective well-being and health, relationships, and school wellbeing. The survey is coordinated by the HBSC research network. which is an international alliance of researchers and research teams that collaborate on the cross-national survey of school students. The variables and items are chosen on the basis of the overall objectives of the study and on the scientific rationale underlying their use. Questions are subject to piloting and pre-testing at international and national levels prior to the main survey. The international questionnaire consists of mandatory items employed in all participating countries and optional items, which are included by subsets of countries based on national interest, need and expertise. Many countries also include specific national questions, often of historic or local importance. The international standard questionnaire is developed in English and is subsequently translated into national and sub-national languages. The research protocol also includes recommendations for layout and question order. Specific guidance is provided for translators on the underlying concepts being addressed. Questionnaires are then translated back into English for checking by the International Coordinating Centre, but it is important to acknowledge that some cross-national variation in the way students understand certain terms may remain. Cross-national differences in the interpretation of the questionnaire items have been subject to validation exercises, and every attempt has been made to achieve equivalence in meaning for questionnaire items.

Sampling
The international data file from the 2005/2006 survey contains data from more than 200,000 young people. Sampling is conducted in accordance with the structure of national education systems within countries and is sometimes stratified by region or school type. The primary sampling unit is the school class or the whole school where a sample frame of classes is not available, classes then being randomly selected. The non-independence of students within classrooms is considered in the procedures for sample-size calculation, based on the deft values identified in previous survey rounds).

65

Currie et al. (2008).

20

B3. Child well-being indicators in the European Union: Social risk behaviour indicators
Background material provided by Zsuzsanna Elekes (Institute for Sociology and Social Policy, Corvinus University of Budapest)

B3.1 Smoking
For measuring smoking habit the most prevalent indicators are smoking frequencies for different time frame (whole life, 12 months, 30 days, last week, daily) and the quantity of cigarettes smoked in a given day. Other routine indicator is the rate of actual smoking. Lifetime prevalence and last 12 months prevalence give some basic information about child smoking in different countries. The proportion of ever smoked is high in Europe: every second 16 years old person tried smoking at least once in the life by ESPAD (Hibell et al. 2009). The indicator better reflect the childs attitude to try everything, than the risky behaviour. Smoking frequency in the last 30 days was asked by ESPAD and GYTS (Global Youth Tobacco Survey). Data for smoking at least once a week is available from HBSC survey (Currie, C. et al). Last 30 days and last week prevalence rates are suitable both for having a general impression about childs smoking in Europe and also appropriate for measuring a more frequent but still occasional smoking. Daily smoking reflects an actual, risky smoking behaviour. The proportion of daily smokers is 18% by the ESPAD average and 14% by HBSC average (HBSC average includes some non EU countries with low smoking rates). Suggested indicator for measuring risky smoking habit is daily smoking.

B3.2 Alcohol use

When measuring alcohol use as a risky behaviour we can select from three main types of indicators. One describes the general drinking habit of a population or age group, other measures risk drinking and the third describes alcohol related troubles. Alcohol related troubles (dependence, addiction, alcohol related accidents) are not relevant in childhood. Measuring general drinking habit is justified by the total consumption model stated by Bruun et al. in 1975. This model states a strong correlation between general alcohol consumption level of a given population and alcohol related problems of the same population. Quantity-frequency (QF) method is the most widely used indictor in Europe for measuring general drinking habit. The time frame of frequency might be lifetime, last 12 months, last 30 days or last week. The quantity might refer to a typical or to the last occasion. QF is used also for calculating yearly per capita consumption. High proportion of European students drinks alcoholic beverages with some regularity. By the ESPASD results 89% of 16 years olds has already tried some alcoholic drink in their life. The last 12 months prevalence rate is not much lower (82%). Lifetime and last 12 months figures dont indicate heavy drinking. Last week prevalence is a preferred indicator in several surveys (HBSC, European Health Survey). Due to the short period it is assumed that people can better recall their alcohol use. The main disadvantage of this indicator is also the short measurement interval. This excludes infrequent or occasional heavy drinking occasions, what is typical in younger age groups.

21

Alcohol use in the last 30 days reflects for both occasional and more regular drinking. Frequency of alcohol use in the last 30 days allows measuring a normal drinking habit even within the young population characterized by a relatively rare drinking frequency. Meanwhile a more frequent use of the last 30 days allows measuring frequent alcohol consumption. 6+ drinking occasion in a month (more than weekly regularity) might be a good indicator of frequent alcohol use in this age group. Drunkenness is a frequently used indicator of risk drinking. The main problem with this indicator is its subjectivity. Drunkenness might mean completely different state for child living in different drinking cultures. For eliminating the subjectivity of drunkenness SMART (Standardized Measurement of Alcohol Related Troubles) Project suggests to combine the indicator of frequency of drunkenness with the number of drinks to get drunk (SMART 2011). For the same purpose, ESPAD asks the self estimated level of intoxication of the last drinking occasion. Both ESPAD and HBSC provide information on the frequency of lifetime drunkenness, ESPAD also provide information on last 12 months and last 30 days drunkenness. Widely discussed indicator of risk drinking is heavy episodic drinking or binge drinking or risky single occasion drinking or extreme drinking. All these terms include more intensive, concentrated alcohol consumption, taking place within a short period. It is measured by 5/6 drinks in a row or in one occasion, a quantity of ethanol what increase blood alcohol concentration within an occasion (Plant and Plant 2006). Despite of criticisms, heavy episodic drinking is widely accepted in international comparisons (ld. GENACIS (2005), SMART (2011), ESPAD) as an indicator of risk drinking. It is less subjective and easier to standardized indicator as drunkenness. Heavy episodic drinking is typical for young people and well describes their risk drinking habit.

B3.3 Other Drugs

For measuring illicit drug use, both lifetime prevalence rate of total illicit drug use and lifetime prevalence rate of marijuana use is an acceptable indicator. Marijuana is the dominant illicit drug used by adolescent in Europe, and well describes changes in their drug using habit. (Lifetime prevalence rate for any illicit drugs was 20%, and for marijuana 19% in 2007, by ESPAD). Last 12 months prevalence rate of cannabis is slightly lower than lifetime rate (14% by ESPAD). On the basis of HBSC 12% of 15-year-olds have used marijuana in the last 12 months and 6% of students used marihuana in the last 30 days (but HBSC includes USA and Canada with their high prevalence rates). Frequent or actual use of marijuana is rare among young general population. As a European average, 7% of students used marijuana at least once in the last 30 days (range from 1% in Romania to 20% in Spain). Considering that the structure of illicit drug use is in change, and the supply of new illicit drugs is rapidly increases lifetime use of any illicit drug is suggested for measuring childs risk behaviour. Use of tranquilizers/sedatives is widespread among adolescents. After marijuana, this is the most widespread substance in Europe, both with or without medical prescription. Use of tranquillizers/sedatives might be an indicator of substance use, but also might refer to some mental problem/disorder of adolescents. It might be an additional indicator for risk behaviour.

Breakdowns by socio-economic status

Both ESPAD and HBSC ask questions about socio-demographic status of childs family. ESPAD asks about parental education and (not as a core question) about economic situation (how well off students think they families are compared to other families). ESPAD analysed the relation between the socio-economic status and substance use in 2003 (Hibell et al. 2004).

22

HBSC asks about the occupational status of parents, family affluence and family poverty. In 2005/2006 the relation between family affluence and substance use were analysed. The Family Affluence Scale was constructed on the basis of questions on the material conditions of the household in which young people live (Currie. C. et al. 2008). By the ESPAD results higher level of parental education is associated with less smoking. Smoking is also more common in poorer family. HBSC also found a negative correlation between smoking and family affluence (higher the family affluence, lower the smoking rate) especially for girls in northern and western countries of Europe, while in eastern and southern countries family affluence was not associated with weekly smoking. In case of alcohol consumption the association is not so clear by the ESPAD. In some countries parental education level and alcohol consumption has negative correlation (mostly in northern countries); in other countries the correlation is positive. The positive correlation was mostly found in eastern part of Europe. Alcohol use has no consistent association with economic situation either. Association between family affluence and weekly drinking is not obvious by the HBSC either: they have found positive association in over a third of countries for boys and in fewer for girls. In the rest of the countries the association was not significant. Only a small minority of countries show significant association between drunkenness and family affluence. The association is mostly positive. The positive correlation between parental education and cannabis use is more characteristic by the ESPAD. Cannabis use is either unrelated to the economic situation of the family, or more prevalent in more affluent families. HBSC study found some positive correlation mostly in eastern and southern countries, while the association was mostly negative in northern countries. As a whole, socio-economic status of the family (measured by parental education (ESPAD) and economic situation (ESPAD and HBSC)) has mostly associated with smoking habit of child (lower the SES, more frequent is the smoking), while drinking habit and illicit drug use is not clearly associated with family status.

Data infrastructure
ESPAD is a school survey project on substance use among students is European countries, repeated by 4 years. First data collection was in 1995, last data collection was in 2007. The next survey is conducted in 2011. Number of participating countries varies by data collection, but as an average 35 European countries participated in the last surveys. 25 EU member states participated in the project in 2007, and comparative figures are available for Spain. Luxemburg was not among the participating countries. The project collects data for 15/16 years old (turning 16 years old in the year of the data collection) studying in school. ESPAD includes questions on
smoking frequency in the life, and quantity-frequency in the last 30 days drinking alcoholic beverages in the life, during the last 12 months, and during the last

30 days monthly figures are also available by types of alcoholic beverages quantity of consumed alcohol of the last occasion frequency of drunkenness in the life, during the last 12 months and during the last 30 days heavy episodic drinking during the last 30 days frequency of different illicit drug use in the life, and frequency during the last 30 days for marijuana, ecstasy and inhalants frequency of use of tranquilizers/sedatives (without medical advice) and alcohol with pills in the life

23

 use of tranquilizers/sedatives for medical order in the life

Detailed figures are available from the ESPAD reports published after each data collection (Hibell et al. 1997, 2000, 2004, 2009) and also available from ESPAD website (www.espad.org). Since 2003 data collection of all national datasets are merged into common databases. These databases are stored and maintained by the Databank Manager and may be used for research purposes.

Sampling
Tobacco and alcohol related information are collected for the age of 11, 13 and 15 within the HBSC project, information on cannabis use are collected for the 15 year olds. HBSC includes questions on: smoking frequency at present o data are available for lifetime smoking, at least weekly smoking (only by gender) and daily smoking frequency of alcohol drinking by types of beverages o data are available for drinking any alcohol at least once a week (only by gender), and weekly consumption of individual drinks frequency of drunkenness in the life o data are available for having been drunk at least twice in the life (only by gender frequency of cannabis use in the life o data are available for lifetime prevalence rate (only by gender) and last 12 months prevalence rate Selected data are published after every data collection (Currie 2008), and available on HBSC website (www.hbsc.org). An international data file is created from all national data for each HBSC survey and stored at the Norwegian Social Science Data Services. The international data file is restricted for the use of member country teams for a period of three years from its completion. After this time the data is available for external use by agreement with the International Coordinator and the Principal Investigators. The latest accessible data is from the 2001/02 survey. GYTS (Global Youth Tobacco Survey) is a school based survey of students aged 13-15 years. GYTS monitors the knowledge, and attitudes toward smoking, prevalence of smoking and other tobacco related issues. GYTS is not a regularly repeated data collection and includes only a few member states. EHIS (European Health Interview Survey) is a data collection planned to repeat every 5 year on the health status and the health-related behaviours of adult population based on personal household interviews. The survey covers the population 15 years old and older and so provides information on 15-18 years old young people. While EHIS actually a voluntary data collection for EU member states, it is planned to be compulsory. In the actual version of the questionnaire EHIS asks about: smoking o actual smoking (daily or occasional) o number of cigarettes per day

24

o earlier smoking o passive smoking Alcohol consumption o frequency during the last 12 months o short term recall for the last week by type of beverages o frequency of heavy episodic drinking during the last 12 months Both GYTS and EHIS might be considered as a potential data source for passive smoking and other information on risk behaviour.

25

Sample sizes of different international comparative surveys relevant from a child well-being perspective
Number of respondents in different educational surveys, by country
PISA 2006 Belgium Flemish French Bulgaria Czech Rep. Denmark Germany Estonia Ireland Greece Spain France Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden United Kingdom England Scotland Wales
4,498 5,927 4510 4,884 4,865 4,585 4,871 19,604 4,684 21,753 4,719 4,744 4,567 4,490 4,848 4,925 5,547 5,092 5,118 6,576 4,729 4,714 4,443 13,050 4,507 6,064 5,924 4,979 4,727 3,937 4,969 25,887 4,298 30,905 4,502 4,528 4,622 4,605 4,760 6,590 4,917 6,298 4,776 6,155 4,555 5,810 4,567 12,179 8,857

PISA 2009
8,501

PIRLS 2006
4,479 4,552 3,863 4,001 7,899

4,094 4,404 3,581 4,162 4,701 5,101 4,068 4,156 5,067 4,854 4,273 5,337 5,380 4,394 4,036 3,775

26

Number of respondents in the HBSC and ESPAD surveys by country, gender and age groups (HBSC only)
Boys Belgium Flemish French Bulgaria Czech Rep. Denmark Germany Estonia Ireland Greece Spain France Italy Cyprus Latvia Lithuania Luxembourg Hungary Malta Netherlands Austria Poland Portugal Romania Slovenia Slovakia Finland Sweden United Kingdom England Scotland Wales
2,198 2,313 2,405 2,411 2,727 3,632 2,217 2,451 1,746 4,368 3,551 1,974 2,034 2,904 2,162 1,677 686 2,114 2,340 2,649 1,884 2,139 2,549 1,794 2,474 2,179 2,308 3,032 2,169 2,113 2,163 2,449 2,364 2,955 3,592 1,944 2,389 1,944 4,523 3,590 1,946 2,187 2,728 2,138 1,821 703 2,114 2,435 2,840 2,035 2,545 2,570 2,083 2,719 2,213 2,460 3,113 2,227 1,291 1,459 1,586 1,509 2,093 2,231 1,087 1,370 1,087 2,985 2,493 1,242 1,425 1,864 1,262 1,096 509 1,350 1,694 1,550 1,201 1,639 1,716 1,298 1,783 1,513 1,655 1,691 1,505 1,404 1,603 1,580 1,601 2,037 2,441 1,187 1,785 1,187 2,841 2,426 1,343 1,466 1,907 1,531 1,215 526 1,515 1,587 1,652 1,335 1,440 1,842 1,327 1,725 1,353 1,662 2,256 1,541 1,616 1,414 1,688 1,665 1,552 2,552 1,416 1,685 1,416 3,065 2,222 1,335 1,330 1,861 1,507 1,187 354 1,363 1,494 2,287 1,383 1,605 1,561 1,252 1,685 1,526 1,451 2,198 1,350 4,311 4,476 4,854 4,775 5,682 7,224 3,690 4,840 3,690 8,891 7,141 3,920 4,221 5,632 4,300 3,498 1,389 4,228 4,775 5,489 3,919 4,684 5,119 3,877 5,193 4,392 4,768 6,145 4,396 969 1,203 1,852 409 2,402 1,186 1,003 1,433 1,490 5,335 3,080 1,119 1,172 1,356 1,722 994 1,384 988 1,471 1,009 1,582 1,218 2,297 1,550 1,004 920 1,150 2,049 468 2,609 1,186 1,218 1,627 1,426 4,646 3,260 1,156 1,239 1,461 1,946 1,097 1,187 1,132 1,670 1,280 1,503 1,250 2,691 1,629 1,175 1889 2,353 3,901 877 5,011 2,372 2,221 3,060 2,916 9,981 6,340 2,275 2,411 2,817 3,668 2,091 2,571 2,120 3,141 2,289 3,085 2,468 4,988 3,179 2,179

Girls

HBSC 2005/06 11 13

15

Total

ESPAD 2007 Boys Girls Total

27

References
Anderson, J. W., B. M. Johnstone, and D. T. Remley (1999): Breast-feeding and cognitive development: a meta-analysis. American Journal of Clinical Nutrition, 70(4), 525535. Ball, T. M. and A. I. Wright (1999): Health care costs of formula-feeding in the first year of life. Pediatrics,103(4):87076. Bradshaw, J. and D. Richardson (2009): An index of child well-being in Europe, J. Child Indicators Research, 2, 3, 319. Bradshaw, J., P. Hoelscher and D. Richardson (2006): Comparing Child Well-Being in OECD Countries: Concepts and Methods. Innocenti Working Paper No. 2006-03. Florence, UNICEF Innocenti Research Centre. Briggs-Gowan, M. J., and A. S. Carter (2008): Social-emotional screening status in early childhood predicts elementary school outcomes. Pediatrics 121 (5): 957-62. Bruun, K., G. Edwards, M. Lumio, K. Mkela, L. Pan, R. Popham, R. Room, W. Schmidt, O-J. Skog, P. Sulkunen, and E. sterberg (1975): Alcohol Control Policies in Public Health Perspective .The Finnish Foundation for Alcohol Studies Vol. 25. Burt, B. A., A. I. Ismail and S. A. Eklund (1985): Periodontal disease, tooth loss, and oral hygiene among older Americans. Community Dent Oral Epidemiol, 13: 9396. Cole M, Cole SR (2004): The development of children. New York: Worth Publishers. Conley, D. and K. W. Springer (2001): Welfare state and infant mortality. Am J of Sociology, 107(3):768807. Currie, C. et al. (2008): Inequalities in young peoples health. Health Behaviour in Schoolaged Children (HBSC): International report from the 2005/2006 survey. World Health Organization. Currie, C., S. Gabhainn, E. Godeau, C. Roberts, R. Smith, D. Currie, W. Picket, M. Richter, A. Morgan, and W. Barnekow (eds.) (2008): Inequalities in Young Peoples Health. HBSC International Report from the 2005/2006 Survey. WHO. Dominiguez, A. et al. (2008) Large Outbreak of Measles in a Community with High Vaccination Coverage: Implications for the Vaccination Schedule. Clinical Infectious Diseases, 47(9):11431149. Drotar, D. (ed.) (1998): Measuring health-related quality of life in children and adolescents: implications for research and practice. Mahwah, New Jersey: Lawrence Erlbaum Associates, Inc. Due, P. et al. (2009): Socioeconomic position, macroeconomic environment and overweight among adolescents in 35 countries. International Journal of Obesity, 33:108493. Edelstein, B. L. (2002): Disparities in oral health and access to care: Findings of national surveys. Ambulatory Pediatrics, 2(2):14147. Freemantle, N., J. Wood, C. Griffin, P. Gill, M. J. Calvert, A. Shankar, K. Chambers, and C. MacArthur (2009): What factors predict differences in infant and perinatal mortality in primary care trusts in England? A prognostic model. British Medical Journal, 339:b2892. Fuchs, V. R. (2004): Reflections on the socio-economic correlates of health. Journal of Health Economics, 23:65361.

28

GENACIS (2005): Gender, Culture and Alcohol Problems: A Multi-national Study. Project Final Report. Charit Campus Benjamin Franklin. An EU-Concerted Action. Giambi, C. et al. (2010). A model to collect vaccination coverage data from EU/EEA countries:a proposal of the VENICE network. ECDC Conference, Stockholm, 10 Dec 2010. Gredler, G. R. (1992): School readiness: Assessment and educational issues. Brandon, VT: Clinical Psychology Publishing. Halldorsson, M., A. E. Kunst, L. Khler, and J. P. Mackenbach (2000): Socioeconomic inequalities in health of children and adolescents: a comparative study of five Nordic countries. European J of Public Health 10: 281289. Hattersley, L. (1999): Trends in life expectancy by social class an update. Health Statistics Quarterly, 2:1624. Heck, K. E., P. Braveman, C. Cubbin, G. F. Chvez, J. L. Kiely (2006): Socioeconomic status and breast feeding initiation among Californian mothers. Public Health Rep, 121(1):51 59. Hibell, B., B. Andersson, S. Ahlstrm, O. Balakireva, T. Bjarnasson, A. Kokkevi, M. Morgan (2000): The 1999 ESPAD Report. The European School Survey Project on Alcohol and Other Drugs. Alcohol and Other Drug Use Among Students in 30 European Countries Stockholm. CAN, Council of Europe pp. 362. Hibell, B., B. Andersson, T. Bjarnasson, A. Kokkevi, M. Morgan, A. Narusk (1997): The 1995. ESPAD Report - Alcohol and Other Drug Use Among Students in 26 European Countries. The European School Survey Project on Alcohol and Other Drugs Stockholm. CAN, Council of Europe pp. 294 Hibell, B., B. Andersson, T. Bjarnasson, S. Ahlstrm, O. Balakireva, A. Kokkevi, and M. Morgan (2004): The ESPAD Report 2003. Alcohol and Other Drug Use Among Students in 35 European Countries Stockholm. CAN, Council of Europe pp. 436. Hibell, B., U. Guttormsson, S. Ahlstrm, O. Balakireva, T. Bjarnason, A. Kokkevi and L. Kraus (2009): The 2007 ESPAD Report. Substance Use Among Students in 35 European Countries. Stockholm. CAN, EMCDDA, Council of Europe. Kramer, M. S. and R. Kakuma (2004). The optimal duration of exclusive breastfeeding: a systematic review. Adv Exp Med Biol, 554:6377. Larson, K., S. A. Russ, J. Crall and N. Halfon (2008): Influence of multiple social risk on childrens health. Pediatrics, 121(2): 33744. Loewenberg, S. (2006): The Health of Europe's most marginalised populations. Lancet, 368:2115. Macgregor. I. D. M., D. Regis, J. W. Balding (1997): Self-concept and dental health behaviors in adolescents. Journal of Clinical Periodontology, 24:335339. Mackenbach, J. P. (2005): Inequalities in infant mortality by parental occupational class or educational level in England and Wales, Belgium, Austria, Croatia and Hungary, 1980 1995. In: Mackenbach, J. P. (ed.): Health inequalities: Europe in profile. Rotterdam: Erasmus University Medical Center (http://ec.europa.eu/health/ph_determinants/socio_economics/documents/ev_060302_r d06_en.pdf, retrieved: 21 February 2008).

Maggi, S. L. G. Irwin, A. Siddiqi, I. Poureslami, E. Hertzman and C. Hertzman (2005): Analytic and Strategic review Paper International perspective on Early Child Development prepared by the Knowledge Network for Early Child Development for the WHO. www.who.int/social_determinants/resources/ecd.pdf
Marlier, E., T. Atkinson, B. Cantillon, and B. Nolan (2007): The EU and social inclusion. Facing the challenges. The Policy Press 2007.

29

Oddy, W. H., J. Li, A. J. O. Whitehouse, S. R. Zubrick, and E. Malacova (2010): Breastfeeding Duration and Academic Achievement at 10 Years. Pediatrics, 127:e137-e145. OECD (2009): Doing Better for Children OECD: Paris, 2009. ONS (2004). Focus on Social Inequalities. London: The Stationery Office. Cit. N. Spencer, in Health Consequences of Poverty for Children /www.endchildpoverty.org.uk/ Osmond, C., D. J. P. Barker DJP, Winter PD (1993). Early Growth and Death from Cardiovascular Disease in Women, British Medical Journal, 307:151924. Plant, Martin, Plant, Moira (2006): Binge Britain. Alcohol and the national response. Oxford University Press Pollitt, E. (1995). Does breakfast make a difference in school? Journal of American Diet Association 95(10): 113439. Samad, L., A. R. Tate, C. Dezateux, C. Peckham, N. Butler and H. Bedford (2006): Differences in risk factors for partial and no immunisation in the first year of life: prospective cohort study. BMJ, 332:13124. Seligman, M. E. P., M. Cskszentmihlyi (eds.) (2000): Special issue on happiness, excellence, and optimal human functioning. American Psychologist, 55:1. SMART (2011): Pilot drinking survey report. Standardized Measurement on Alcohol Related Troubles. EAHC Project Final Report Spencer N. (2010): Poverty and child health in the European Region. In: Poverty and social exclusion in the European Region: Health systems respond. Copenhagen, WHO Regional Office for Europe. Spencer, N. J., S. Bambang, S. Logan, L. Gill (1999): Socioeconomic status and birth weight: comparison and area based measure with the Registar Generals social class. J Epidemiol Commun Health, 53: 49598. Stuart, L. and N. Spencer (eds.) (2000): Inequality and childrens health Child: Care Health and Development, 26: 13. TRKI-Applica (2010): Child poverty and child well-being in the European Union. Report prepared for the DG Employment, Social Affairs and Equal Opportunities (Unit E.2) of the European Commission, Budapest. http://www.tarki.hu/en/research/childpoverty/index.html Vatanparast, H., A. Baxter-Jones, R. A. Faulkner, D. A. Bailey, and S. J. Whiting (2005): Positive effects of vegetable and fruit consumption and calcium intake on bone mineral accrual in boys during growth from childhood to adolescence: the University of Saskatchewan Pediatric Bone Mineral Accrual Study. American Journal of Clinical Nutrition, 82(3):700706. Vellinga, A., A. M. Depoorter, and P. Van Damme (2002): Vaccination coverage estimates by EPI cluster sampling survey of children (18-24 months) in Flanders, Belgium. Acta Pediatrica, 91(5):599_603. Vereecken, C. (2005): HBSC Research Protocol for 2005/06 Survey. Section 2, Scientific rationales for focus areas: Eating habits. Manuscript. Weimer, J. P. (2001): The economic benefits of breastfeeding: a review and analysis. Food Assistance and Nutrition Research Report, No.13. Wesnes, K.A., C. Pincock, D. Richardson, G. Helm, and S. Hails (2003): Breakfast reduces declines in attention and memory over the morning in schoolchildren. Appetite 41:329 331. WHO Headquarters Nutrition Unit (1996): Global Data Bank on Breast-feeding. Geneva: WHO, 1996.
30

Wrosch, C. and M. F. Scheier (2003): Personality and quality of life: The importance of optimism and goal adjustment. Quality of Life Research 12 (Suppl. 1): 5972. Yngve, A. and M. Sjstrm (2001): Breastfeeding in countries of the European Union and EFTA: current and proposed recommendations, rationale, prevalence, duration and trends. Public Health Nutrition, 4(2B):63145.

31