Socio–economic differences in health risk behavior in adolescence: Do they exist?
Introduction
Socio–economic health differences are age-specific. In contrast to adults and children, most studies have found little variation by social class in morbidity and mortality among adolescents (West et al., 1990; Macintyre and West, 1991; Rahkonen, 1993; Rahkonen et al., 1995). These studies conclude that adolescence is characterised, unlike other stages in the course of life, more by the absence than the presence of socio–economic health differences. Recently, however, some suggestions have been made that there may be socio–economic health differences in adolescence (Tuinstra et al.). However, these differences are relatively small and are also found only for a limited number of health measures.
Even if there are no consistent social class differences in health among adolescents, there might be socio–economic differences in health risk behaviors during this period of life. These health risk behaviors have an adverse effect on health in the long term, which has often been established (Pietilä et al., 1995). Therefore, socio–economic differences in health risk behaviors in adolescence are one of the predictors of socio–economic health differences in adulthood. We consider this hypothesis as the hypothesis of latent differences: while there are few differences in health in adolescence, health behaviors are class differentiated. We refer specifically to health risk behavior, in contrast to West, who used the same concept for, for example, height (West, 1988).
In addition, in the inequality debate, lifestyle or behavioral factors are seen as providing an important area of explanation for socio–economic health differences (Van der Lucht, 1992; Ranchor, 1994; Stronks et al., 1996). Studies on adults have established that these behavioral factors often show a pattern which is disadvantageous to the lowest socio–economic status (SES) groups (Ranchor et al., 1990; Graham, 1994; Ranchor, 1994; Kooiker and Christiansen, 1995; Van der Lucht and Groothoff, 1995; Stronks et al., 1996; Sanderman et al., submitted). People with a low SES exhibit more risk behaviors, such as smoking, poor diet and physical inactivity, than high-SES people. Alcohol consumption, however, is a common exception. The relation between SES and alcohol consumption is usually weak or reversed (Mackenbach, 1992; Mulder et al., in press).
Evidence about the relationship between SES and health risk behaviors in adolescence, however, is often inconsistent or even contradictory. Some studies support the hypothesis that behavior like smoking, drinking, drug use and physical inactivity is more frequent among adolescents with a low family SES (Green et al., 1991; Greenland et al., 1995; Pietilä et al., 1995; Lowry et al., 1996). Other studies reject this hypothesis and show that SES has little or no relationship to health risk behaviors (O'Malley et al., 1993; Donato et al., 1994; Glendinning et al., 1994; Donato et al., 1995). The picture gets even more complex with the introduction of differences between male and female adolescents.
Recently, the importance of the combination of health risk behaviors has been acknowledged (Osler, 1993), mainly supported by the very strong associations between the behaviors (Lytle et al., 1995). Also, the cumulative effect of health risk behaviors is to make people vulnerable to health complaints, so that in combination they have a greater power to predict the occurrence of ill health. Recent studies support the idea that an accumulation of health risk behaviors is associated with SES, both for adults (Sanderman et al.; Mulder et al., in press) and for adolescents (Raitakari et al., 1995; Lowry et al., 1996). These socio–economic differences in adolescence might be one of the preludes to the re-emergence of socio–economic health differences in adulthood.
Three questions are asked: firstly, whether a relationship could be found between SES and health risk behaviors, for the separate health risk behaviors on the one hand, and for the combination of these behaviors, on the other. Secondly and thirdly, we examined the main and the interacting influences of gender in the relationship between SES and health risk behavior.
Section snippets
Procedure and sample
Data were collected in 1994 and 1995 with the cooperation of four Public Health Services in four provinces in the north of the Netherlands, one from each province. In these areas, a random sample of 18 secondary schools, vocational and high schools, was drawn. Only two of the 18 schools approached refused to cooperate. To acquire the desired sample number of adolescents, an additional sample was drawn from two areas, one school per area. Eventually, 1984 of the total sample (N=2090) of fourth
Separate health risk behaviors
The first set of analyses examined the effect of the SES of the parents, of gender and of the interaction between these two variables on the separate health risk behaviors (Table 1).
As can be seen from Table 1, the relations of SES and gender vary for the different behaviors. With respect to SES, we found no overall relationship with smoking and alcohol consumption. For drug use and physical exercise, the relationship with SES was statistically significant.
Taking a closer look at the overall
Conclusion and discussion
The most important conclusion of our study is that the idea of latent differences in health in adolescence is in general not supported by the data. Latent differences are defined as a combination of a lack of socio–economic health differences with the presence of differences in health risk behaviors, which can be seen as one of the forerunners of the re-emergence of socio–economic health differences in adulthood.
The overall conclusion is that no relationships exist between SES and smoking,
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