School Manchester Sven Bremberg

Children and adolescents: health protective factors in education

Sven Bremberg

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Education and health

Health education

Health behaviour

Health

Problems with the educational approach to adolescent public health

• Few school education programmes demonstrate behaviour effects: alcohol, tobacco, drugs, nutrition, exercise

• Individual behaviour is determined by social context

• Low long term stability of health behaviours during adolescence

Educational approach to adolescent sexual health

• Systematic reviews of RCT:s • Behaviour effects (contraceptive use)• DiCenso 2002

– 7 studies, pooled estimate: males ns, females ns.– 1 study in favour of controls in males

• Bennett 2005– 10 studies, 5 in favour of intervention– 2 studies in favour of controls in females

Public health policy

EconomyLife

chancesLifestyle -

environmentHealth QoL

General politics

Social policy

Public health policy

Health promotion Health care

Upstream Downstream

Swedish national public health targets

• Mainly structural targets focusing institutions• 11 targets approved by the parliament in 2003• Structural targets

– Democracy - participation– Economic and social security

– Positive conditions during childhood and adolescence

– Healthier working life– …

• Some downstream targets– Reduced use of tobacco and alcohol– …

Determinants of U-5 female child mortality rate in 118 nations - t-values. Total model R2=0.79 (Safaei 2006)

-6,3-5,52

-2,65 -2,65

3,04

1,69

-7

-6

-5

-4

-3

-2

-1

0

1

2

3

4

Education GNP Democracy

Health (public) Health (private)Gini

Effects of education on adult health - a natural experiment (Spasojevic 2003)

• Compulsory schooling was extended in Sweden from 7 to 9 years; decided at municipal level, 1950 -

• Men born 1945-1955. Health 1981-91 - control for SES

• One extra year of schooling: 19% less risk of ill health, 12% less obesity

Effects of education on adult health -other natural experiments (Feinstein et al 2006) - effects demonstrated on

• Mortality• Hospital care• Management of chronic

diseases• Depression• Smoking• Physical activity

Determinants of adolescent health

Alcohol, tobacco Mental health

Obesity Unsafe sex

Literacy Levels by Physical, Mental or Other Health Conditions – USA (Quantitative)

0

10

20

30

40

50

60

1 2 3 4 5

Per

cen

t

Level NALS, p. 44, 2002

Health Problems

Mental or Emotional Problems

Long-term Illness

Competences include abilities …(after Martha Nussbaum)

to solve problems

to attach to other people

to take part in social life

to reflect critically

to form a concept of what is good

…

Association between mortality and cognitive ability at age 10 in men born in Malmö 1928, hazard ratio, crude and adjusted for parental income and class (Lager 2008)

CrudeAdjusted for parents’ income 1933 Adj. for parents’ income 1933 and parents’

class 1938

Hazard Ratio Confidence Interval Hazard Ratio Confidence Interval Hazard Ratio Confidence Interval

Highest quartile 1.00 Reference 1.00 Reference 1.00 Reference

Second highest quartile 1.40 1.00-1.95 1.29 0.92-1.81 1.31 0.93-1.84

Second lowest quartile 1.56 1.13-2.17 1.44 1.04-2.01 1.48 1.07-2.07

Lowest quartile 1.95 1.42-2.69 1.67 1.21-2.32 1.72 1.23-2.40

Table 1. Cognitive ability and mortality. Men (n=834, 349 deceased)

Remains

Education and health

Health Ability to adaptCompetencies

Time sequence for problematic health behaviours (after Roe)

Year 1 Year 4 Year 7 Year 10

Antisocial behaviour/depression

Problematic health behaviour

School failure

Emphasis on health promotion or effective schools - municipalities in Stockholm county (Guldbrandsson 2005)

Effective schools

Healt

h p

rom

oti

on

Potential contribution to schools from the health sector

• Programmes that facilitates learning

• Programmes with direct effects on health or determinants of health

• Programmes with demonstrable effects

Measures for schools proposed by the Swedish National Institute of Public Health

• Social and emotional training (SET) • Prevention of bullying• Aggression preventive programmes • Programmes based on cognitive psychology• Local quality assurance programmes using

both educational and health data• Parental support programmes

Effects of SET in Botkyrka grades 4-9 controlled trial (Kimber 2008)

Variable Effect size

Body image 0,48

Psychological well-being 0,33

Aggressiveness 0,33

Bullying 0,39

Alcohol (grade 7-9) 0,26

Narcotics (grade 7-9) 0,23

Prevention of bullying– Olweus’ model– Three controlled

trials • 40% reduction

– Four levels• Students• Teachers• Headmasters• Parents

Programmes preventing behaviour problems including aggression in the classroom: effect at follow up (Wilson 2007)

ACT - a preventive programme based on cognitive psychology

• Third generation CBT programme

• Year 10-12 students - 3*3 hours (Livheim, 2006)

• Reduced anxiety after 2 years

Self asContext

Contact with the Present Moment

Defusion

Acceptance

Committed Action

Values

ACT modellen

Structured methods for parents of children age 3-9 years, based on methods like PMT, COPE etc. adapted for universal use in

Sweden…

• Parental groups • Starting with

videotaped problem situations

• Modelling • Role play

Education and sexual health

Sexual health Ability to adaptCompetencies

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