Elsevier

Social Science & Medicine

Volume 66, Issue 6, March 2008, Pages 1429-1436
Social Science & Medicine

Short report
Researching health inequalities in adolescents: The development of the Health Behaviour in School-Aged Children (HBSC) Family Affluence Scale

https://doi.org/10.1016/j.socscimed.2007.11.024Get rights and content

Abstract

Socioeconomic inequalities in adolescent health have been little studied until recently, partly due to the lack of appropriate and agreed upon measures for this age group. The difficulties of measuring adolescent socioeconomic status (SES) are both conceptual and methodological. Conceptually, it is unclear whether parental SES should be used as a proxy, and if so, which aspect of SES is most relevant. Methodologically, parental SES information is difficult to obtain from adolescents resulting in high levels of missing data. These issues led to the development of a new measure, the Family Affluence Scale (FAS), in the context of an international study on adolescent health, the Health Behaviour in School-Aged Children (HBSC) Study. The paper reviews the evolution of the measure over the past 10 years and its utility in examining and explaining health related inequalities at national and cross-national levels in over 30 countries in Europe and North America. We present an overview of HBSC papers published to date that examine FAS-related socioeconomic inequalities in health and health behaviour, using data from the HBSC study. Findings suggest consistent inequalities in self-reported health, psychosomatic symptoms, physical activity and aspects of eating habits at both the individual and country level. FAS has recently been adopted, and in some cases adapted, by other research and policy related studies and this work is also reviewed. Finally, ongoing FAS validation work is described together with ideas for future development of the measure.

Introduction

Health inequalities stemming from the unequal distribution of social and economic resources pervade many societies. Until the last decade or so, inequalities in adolescent health received little attention compared to health inequalities in adults and young children (DiLiberti, 2000, Macintyre and West, 1991, Marmot, 2005, West, 1997). Existing adolescent studies, including those at a cross-national level, have used a variety of different measures of both socioeconomic status (SES) and health outcomes, as well as different age groups, making it difficult to draw general conclusions about health inequalities among adolescents (Case et al., 2007, Chen et al., 2006, Chen et al., 2007, Starfield et al., 2002).

In adults, SES is usually measured by income, education or occupation. Adolescents themselves have little economic power; are still in schooling and lack occupational social status, as normally they do not participate in the labour market. Most often, the SES of the father, mother or head of the household is the proxy applied to adolescents. However, data on family SES can be difficult to collect from young people because they do not know or are not willing to reveal such information resulting in non-response on parental occupation varying from 20% to 45% reported by various studies (Currie et al., 1997, Molcho et al., 2007, Wardle et al., 2002). Additionally, bias has been reported with greater non-response in low socioeconomic groups (Lien et al., 2001, Wardle et al., 2004).

One study that has addressed the issue of the adolescent SES measurement problem is the HBSC study (Currie et al., 1997). HBSC is the Health Behaviour in School-Aged Children: WHO Collaborative Cross-National Study, which conducts a self-report questionnaire based survey of schoolchildren every four years with nationally representative samples of children in member countries. This study has been monitoring the health and well-being of young people aged 11, 13 and 15 years since 1982 in a growing number of countries in Europe and North America (Currie et al., 2004). The issue of a low response on parental occupations was first addressed in the HBSC study in Scotland through the development of a supplementary measure of SES, the Family Affluence Scale (FAS) (Currie et al., 1997).

Currie et al. (1997) used the concept of material conditions in the family to base the selection of items for the Family Affluence Scale. In particular the work of Carstairs and Morris (1991) and Townsend (1987) was drawn upon. Townsend's concept of material deprivation was based on the notion of lacking material standards ordinarily available in the society but in FAS both ends of the scale are considered – the more affluent as well as the deprived. Items selected for FAS met the following criteria:

  • items should be simple to answer, non-intrusive and non-sensitive;

  • multiple rather than single component items should be used;

  • items should be relevant to contemporary economic circumstances;

  • there should be the potential to create a common set of indicators for future cross-national HBSC surveys.

The criteria used were in agreement with the ideas presented by other authors, including Abrahamson, Gofin, Habib, Pridan, and Gofin (1982) and Liberatos, Link, and Kelsey (1988), who were concerned with practical considerations as well as conceptual issues when developing socioeconomic indicators.

This paper aims to review the use of FAS as a measure of adolescent socioeconomic circumstances in the context of HBSC and other studies. It presents the key findings and methodological approaches to analysis as well as validation work and ideas for future development of FAS.

Section snippets

The development of the Family Affluence Scale

When formulating the Family Affluence Scale, Currie et al. (1997) chose a set of items which reflected family expenditure and consumption that were relevant to family circumstances in the early 1990s in Scotland. Possessing these items was considered to reflect affluence and their lack, on the other hand, material deprivation. In its initial format as used in the 1990 Scottish HBSC survey (Currie et al., 1997), FAS was comprised of three easily answered, non-sensitive component items: number of

Use of FAS in HBSC

FAS has been used to examine and explain socioeconomic inequalities in a wide range of health indicators in the HBSC study over the last 10 years. In the main these analyses are cross-national although a few are based on national data. Low affluence is associated with a decreased risk for medically attended injuries and specifically for sport related injuries (Pickett et al., 2005), but with an increased risk for fighting injuries (Simpson, Janssen, Craig, & Pickett, 2005); children with lower

Use of FAS and similar measures in non-HBSC studies

FAS has informed research outside the context of the HBSC study (e.g. Koivusilta et al., 2006, Sleskova et al., 2006, Von Rueden et al., 2006, Wardle et al., 2002, Wardle et al., 2004, West and Sweeting, 2004, Williams et al., 1997). Williams et al. (1997) devised a measure based on FAS but using only the car and bedroom items and producing a four point scale. This modified FAS was associated with injury risk behaviour among a Scottish sample of adolescents. In a study in the North of England,

Validation of FAS in the HBSC study

From its early development, there have been efforts to validate FAS at both national and international levels. When the first FAS paper was published (Currie et al., 1997), it included the validation of the measure against self-reported parental occupation, finding moderate correlation between the two measures and broadly similar patterns of association with health indicators and health behaviours. In a Welsh study children's reports on the FAS items validated against their parents' report

The development of FAS

The evidence presented above on FAS shows its usefulness as an indicator of child material affluence both in research and policy contexts and as a predictor of health outcomes in young people. Yet there is a need to continue to critically review the component items and consider future developments.

The FAS was developed in the early 1990s reflecting family material affluence/deprivation at the time. Since then, as described above, some additional items have been included in FAS to reflect

Discussion

Health inequalities in young children and adults are well-established but there has been debate about health inequalities in adolescents (West & Sweeting, 2004). The difficulty of assigning SES to adolescents has been a problem in the study of health inequalities in this age group and has been especially challenging in the cross-national context. This paper has reviewed the development of the Family Affluence Scale, originally designed to be a supplementary measure to the traditional

Acknowledgement

The authors would like to thank members of the Health Behaviour in School-Aged Children (HBSC): WHO Collaborative Cross-National Study research network and especially the Social Inequalities Focus Group. We are particularly grateful to HBSC colleagues: Christina Schnohr, Dorothy Currie and Kate Levin who gave comments on earlier drafts of the paper. The HBSC International Coordinator is Professor Candace Currie, Child and Adolescent Health Research Unit (CAHRU), University of Edinburgh; the

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