Factors associated with unhealthy

behaviours and health outcomes: a cross-

sectional study among tuscan
adolescents (Italy)
 Giacomo Lazzeri,
 Elena Azzolini,
 Andrea Pammolli,
 Rita Simi,
 Veronica Meoni &
 Mariano Vincenzo Giacchi

International Journal for Equity in Healthvolume 13,

Article number: 83 (2014) | Download Citation

Abstract

Background
We aimed to determine the extent to which three core variables (school environment,
peer group and family affluence) were associated with unhealthy behaviours and health
outcomes among Tuscan adolescents. The unhealthy behaviours considered were
smoking, alcohol consumption, sedentary lifestyle and irregular breakfast consumption;
health outcomes were classified as self-reported health, multiple health complaints and
life satisfaction. School environment was measured in terms of liking school, school
pressure, academic achievement and classmate support; peer groups were evaluated in
terms of the number of peers and frequency of peer contact. Family affluence was
measured on a socioeconomic scale.

Methods
Data were taken from the Tuscan 2009/10 survey of "Health Behaviour in School-aged
Children", a WHO cross-national survey. A binary logistic multiple regression (95%
confidence intervals) was implemented.

Results
The total sample comprised 3291 school students: 1135 11-year-olds, 1255 13-year-olds
and 901 15-year-olds. Peer group and school environment were associated with
unhealthy behaviours such as smoking, alcohol consumption and sedentary lifestyle.
Family affluence proved to have less impact on unhealthy behaviours, except in the case
of adolescents living in low-income families. Poor health outcomes were directly related
to a negative school environment. Regarding the influence of family affluence, the
results showed higher odds of life dissatisfaction and poor self-reported health status in
medium-income families, while low-income families had higher odds only with regard
to life dissatisfaction. A consistent pattern of gender differences was found in terms of
both unhealthy behaviours and health outcomes.

Conclusions
Unhealthy behaviours are strongly related to the school environment and peer group. A
negative school environment proved to have the strongest relation with poor health
outcomes.

Introduction

One of the main priorities of European public health decision-makers is to reduce health
inequalities, which persist in spite of the "Health for All" policy of the World Health
Organization (WHO) [1]. According to Health 2020 the European policy for health and
well-being, it is of primary importance to address the social determinants of health and
to reduce health inequalities. Health is influenced by the way in which people live, their
access to health care, schools and leisure opportunities, their homes, communities and
towns. Although socioeconomic inequalities are known to influence health-related
behaviour, little is known about the differential effects of health promotion across
socioeconomic groups. Several studies have correlated unhealthy behaviours, such as
physical inactivity, unhealthy eating habits, smoking and alcohol consumption, with
lower socioeconomic status [2]-[6]. However, other studies have found weak or non-
existent relationships between socioeconomic status (SES) and health behaviours [7]-
[13].

Among adolescents, unhealthy behaviour in the school environment has been associated
with low academic achievement, obesity, poor self-reported health status, more
numerous health complaints, regular smoking, longer time spent watching TV,
unhealthy eating habits and drunkenness, and poor emotional well-being, life-skills,
health behaviours and life satisfaction [10,11,14,15]. Some studies have found that
smoking and physical inactivity are associated with the size of the peer group, and that
smoking, alcohol use and physical inactivity are connected with the frequency of peer
contact [16,17]. Various authors have reported that health inequalities related to school
and peer environments are found both in risky health behaviours, such as smoking and
alcohol consumption, and in various positive health behaviours [18]. Moreover, studies
on socioeconomic status have found that differences among youths are better explained
by the school environment and peer group rather than by SES [10,15,16].

The main aim of the present study was to ascertain which of the following factors -
school environment, peer group, family affluence (an indicator of SES as measured by
Family Affluence Scale (FAS)), gender, municipality size and nutritional status - were
associated with unhealthy behaviours and negative health outcomes in Tuscan
adolescents. A further aim was to determine the relative magnitude of these factors, in
order to identify the primary influences on health behaviours and health outcomes
within the study group.

Materials and methods

Study
Data were taken from the Tuscan 2009/10 survey of "Health Behaviour in School-aged
Children" (HBSC), a WHO cross-national survey which collects data every fourth year
from a random sample of schools [19,20]. The Ethics Committee of the National
Institute of Health approved the protocol and agreed to the use of an opt-out consent
form.

Design, sampling and data collection

The methods used to gather these data are described in detail elsewhere [19]. An
anonymous structured questionnaire was administered in classrooms by trained
personnel [20]. Dependent and independent variables were considered in the analysis.

Dependent variables
Five specific measures of unhealthy behaviour (smoking, alcohol consumption, physical
inactivity, sedentary lifestyle and irregular breakfast consumption) and three measures
of health outcomes (multiple health complaints, self-reported health and life
satisfaction) were used as dependent variables.

Adolescent smoking habits were assessed by asking the participants how often they
smoked tobacco. Response options were "every day", "at least once a week", "less than
once a week" and "I don´t smoke". Subsequently, smokers (the first three response
categories) were compared with non-smokers.

The level of sedentary lifestyle was measured by asking participants how many hours a
day they spent watching television or using a computer, play-station or similar media
devices [21,22]. The use of screen-based media (SBM) was scored by summing the mean
number of hours per day engaged in screen-based activities. Respondents´ behaviour
was regarded as positive when they spent no more than two hours a day in front of the
TV or PC screen.

Physical activity (PA) was defined as "any activity that raises your heart rate and which
possibly leaves you out of breath". Respondents´ behaviour was regarded as negative if
they did not meet the physical activity guideline (PAGL) (at least 60minutes of PA seven
days a week). Participants were categorized as "not meeting PAGL" or "meeting PAGL"
[23].
In order to assess the frequency of breakfast consumption during the week (Monday to
Friday), respondents were asked to indicate how many days a week they had breakfast.
Having breakfast five days a week was considered to be a positive health behaviour,
while less frequent breakfasting was classed as "irregular breakfast habits".

Alcohol use was assessed by the question: "How often do you drink alcohol, such as beer
or wine?". Responses were registered on a five-point scale. Infrequent drinking (rarely
or never) was regarded as healthy behaviour, while other patterns were classed as
unhealthy behaviour.

Respondents were regarded as suffering from multiple health complaints if they

reported experiencing two or more symptoms "more than once a week" or "about every
day" [24]. Respondents were assessed for eight symptoms on a five-point scale:
difficulty in falling asleep, headache, feeling dizzy, stomach-ache, backache, depression,
irritability or bad temper, and nervousness [25].

Self-reported health was assessed by means of a four-point scale; "fair" or "poor"

perceptions were classed as "poor self-reported health" [19].

General life satisfaction was assessed by means of the Cantril ladder (1-10 points) [19].
Participants were shown a picture of a ladder and asked: "The top of the ladder (10) is
the best possible life for you and the bottom (1) is the worst possible life. In general,
where on the ladder do you feel you stand at the moment?". A score of 5 or less was
taken to indicate dissatisfaction [19].

Independent variables
The independent variables used in the analysis were: family affluence, school
environment, peer group, nutritional status and demographic size of the adolescent´s
municipality of residence. These analyses were controlled for gender, as gender
differences have been reported in the literature [26,27].

Socioeconomic status was evaluated by means of the FAS, Currie et al. have reported the
scale´s characteristics and modality of use [19].

Principal-component analysis was used to calculate a one-dimensional representation of

the school environment. The analysis considered six variables, three concerning
scholastic activity - "feeling pressured by schoolwork (retrospectively recorded)",
"academic achievement", "liking school" - and three concerning peer support - "students
in my class like being together", "students in my class are kind and helpful" and
"students in my class accept me for who I am". On summing the number of indicators,
the resulting first major component corresponded to 33% of the overall variance.
Saturations of individual variables ranged from 0.36, for "academic achievement", to
0.68, for "students in my class are kind and helpful". The new composite variable
"school environment" was mainly representative of the three items on peer support, and
considerably less so for the other three items ("liking school", "feeling pressured by
schoolwork" and "academic achievement"). Lastly, the scores derived from the first
component factor were recorded in a new categorical variable, "school environment",
consisting of three categories: "favourable", "medium" and "poor".

The peer group indicator was used as a one-dimensional indicator which took into
account both the frequency of peer contact and the size of the peer group. While the
number of factors was limited to one, there were originally four variables: "time spent
after school with friends", "number of close friends of the opposite gender", "electronic
communications with friends" and "number of close friends of the same gender". From
the total variance, 38% was assigned to the first main component extracted. The new
composite variable "peer group" was mainly influenced by the size of the peer group
(number of close friends), while "contact with peers" (electronically and after school)
had less impact. Individual variables displayed saturations within a range of 0.30-0.80,
where the lower end reflected "electronic communications" and the higher end reflected
"number of close friends of the opposite gender". Moreover, the scores derived from the
first component factor were recorded in a new categorical variable, "peer group",
consisting of three categories: "favourable", "medium" and "poor".

Nutritional status
Self-reported weight and height were used to calculate Body Mass Index (BMI in
kg/m2). We applied age- and gender- specific cut-offs, as recommended by the
International Obesity Task Force [28,29]. Both underweight (U) and normal-weight (N)
subjects were grouped into the "Under/Normal-weight" (UN) category, while both
overweight (Ow) and obese (O) individuals constituted the "Overweight group" (Ow/O).

Demographic size of the adolescent´s municipality of residence

In order to determine the demographic size of the adolescents´ municipalities of
residence, the samples were divided into four categories:<10,000 inhabitants; 10,000-
50,000 inhabitants; >50,000 inhabitants, and >50,000 within a metropolitan area,
according to the National Statistics Institute classification [30].

Statistical analysis
Analysis was carried out by means of the SPSS 20.0 statistical software package (SPSS
Inc., Chicago, IL, USA). Binary logistic regression analysis was used to produce adjusted
odds ratios (ORs) with 95% CIs and asymptotic, two-sided, statistical significance.
Throughout this paper, statistical significance is defined by the conventional levels
of P < 0.05 and P < 0.01.