The WHO Regional Office for Europe A snapshot of the health of young people in Europe

The World Health Organization (WHO) This report has been prepared by the WHO Regional Office for Europe for the European
is a specialized agency of the United Commission conference, Youth health initiative: be healthy, be yourself, held in Brussels,
Nations created in 1948 with the primary Belgium on 9 and 10 July 2009.
responsibility for international health
matters and public health. The WHO The conference reflects the high priority given to youth health by the European

A snapshot of the health of young people in Europe

Regional Office for Europe is one of six Commission. This is a vital commitment, because securing the health and well-being of
regional offices throughout the world,
each with its own programme geared young people today is an essential investment in securing the health, well-being and
to the particular health conditions of prosperity of the Europe of tomorrow.
the countries it serves.
The report provides a “snapshot” of the health of young people in Europe rather than
Member States a more comprehensive account.
Albania An editorial board was formed to oversee production of the report, and expert writers
Andorra were commissioned to make specific contributions. Their expertise and knowledge of
Armenia the underpinning issues makes for an authoritative yet succinct overview of the health
Austria
Azerbaijan issues that are important to Europe’s young people now and for the future, including:
Belarus
Belgium
• mental health
Bosnia and Herzegovina • overweight and obesity
Bulgaria • physical activity and sedentary behaviour
Croatia • substance misuse
Cyprus
Czech Republic • sexual health.
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
A snapshot of the health
Tajikistan
The former Yugoslav
Republic of Macedonia
of young people in Europe
Turkey
Turkmenistan
Ukraine a report prepared for the european commission conference on
United Kingdom youth health, brussels, belgium, 9–10 July 2009
Uzbekistan

World Health Organization

Regional Office for Europe
Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark
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Fax: +45 39 17 18 18.
E-mail: [email protected]

Web site: www.euro.who.int

 A snapshot of
the health of
young people
in Europe

A report prepared for the

European Commission Conference on Youth Health
Brussels, Belgium
9−10 July 2009
Abstract
This report has been prepared by the WHO Regional Office for Europe to support the European Commission conference, Youth health
initiative: be healthy, be yourself, held in Brussels, Belgium on 9 and 10 July 2009. The report offers a “snapshot” of the health of young
people in Europe with data drawn from an extensive range of sources, but in particular the 2006 Health Behaviour in School-aged
Children (HBSC) survey report. The HBSC Survey covers health behaviours of 11-, 13- and 15-year-olds; data on 16−25-year-olds,
who are the main focus of the European Commission Conference on Youth and Health, are more difficult to find. This snapshot report
nevertheless presents valid and informative data on a wide range of health issues that are important to young people, including injuries
and accidents, mental health, overweight and obesity, physical activity and sedentary behaviour, substance misuse and sexual health.

Keywords
ADOLESCENT BEHAVIOUR
CHILD WELFARE
HEALTH BEHAVIOUR
EDUCATION
HEALTH SURVEYS
HEALTH STATUS INDICATORS
SOCIOECONOMIC FACTORS
EUROPE

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© World Health Organization 2009

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 Contents

Contributors VI
Editorial board VI
Writer group VII

1 Background and context 1

1.1 Introduction 3

1.2 Young people’s health: the equality lens 7

Transition from school to work 12
Poverty 12
Employment 13
Access to health services 14

2 Young people in the 21st century 17

2.1 Demographic trends 19

Why is this issue important to young people? 20
What do we know? 20
What are the challenges? 22

2.2 Education 25
Why is this issue important to young people? 26
What do we know? 26
Perceived school performance 28
Liking school 28
Pressured by schoolwork 28
What are the challenges? 30

3 Health outcomes 33

3.1 Injuries and accidents 35

Why is this issue important to young people? 36
What do we know? 36
Overview: morbidity and mortality 36
Road traffic injuries 37
Injuries in the community 39
What are the challenges? 40

3.2 Mental health and well-being 41

Why is this issue important to young people? 42
What do we know? 42
Overall prevalence estimates of mental disorders 44
Well-being and happiness 44
Multiple health complaints 44
Subclinical symptoms 44
Suicide 46
Inequalities 46
What are the challenges? 48
Trends in mental ill health: an increase over time? 48
Mental health of migrant adolescents 48
Self-harm procedures 48
Online games addiction 49
Gaps and problems with data 49

3.3 Overweight and obesity 51

Why is this issue important to young people? 52
What do we know? 53
Distribution of overweight and obesity 53
Body image 56
What are the challenges? 57
Increasing trend of overweight and obesity 57
Key gaps and priority areas for further research 58

 4 Health and risk behaviours 61
4.1 Eating patterns 63
Why is this issue important to young people? 64
Diet-related diseases 64
Good nutrition during childhood 64
What do we know? 65
HBSC survey 66
The HELENA study 68
What are the challenges? 68
4.2 Physical activity and sedentary behaviour 71
Why is this issue important to young people? 72
What do we know? 73
Physical activity 73
Sedentary behaviour 75
Computer use 76
What are the challenges? 77
4.3 Alcohol, drugs and tobacco 79
Why is this issue important for young people? 80
What do we know? 80
Tobacco 80
Alcohol 82
Cannabis 84
Other drugs 86
Substance use and criminality 88
What are the challenges? 88
Areas for further research 88
Policy and tailored preventive interventions 90
4.4 Sexual health 91
Why is this issue important to young people? 92
What do we know? 93
Sexual experience 93
Condom use 93
Contraceptive pill use 94
Unintended pregnancy 94
Abortion 96
Sexually transmitted infections (STIs) (including HIV) 96
Human papilloma virus (HPV) vaccination 98
What are the challenges? 98
References 102
 Contributors

Editorial board

Vivian Barnekow Child and Adolescent Health and Development, Country Policies and Systems,
WHO Regional Office for Europe
Candace Currie HBSC International Coordinator, Director Child & Adolescent Health Research
Unit, University of Edinburgh, Scotland, United Kingdom
Cara Letsch HBSC Research Communications Officer, Child & Adolescent Health Research
Unit, University of Edinburgh, Scotland, United Kingdom
Margaretha de Looze Faculty of Social and Behavioural Sciences, Utrecht University, the Netherlands
Antony Morgan CAHRU Honorary Research Fellow, Child & Adolescent Health Research Unit,
University of Edinburgh, Scotland, United Kingdom

Editorial and production team

Alex Mathieson Freelance Writer and Editor, Edinburgh, Scotland, United Kingdom
Damian Mullan Designer, So... it begins, Edinburgh, Scotland, United Kingdom
www.soitbegins.co.uk

VI
Writer group

José Alves Diniz Professor, Faculdade de Motricidade Humana,

Universidade Técnica de Lisboa, Portugal
Namanjeet Ahluwalia Senior Scientist, INSERM U558: Epidemiology and Public Health Analysis,
Faculty of Medicine, University Paul Sabatier III, Toulouse, France
Luis Calmeiro Lecturer in Sport and Exercise Psychology, University of Abertay,
School of Social and Health Sciences, Dundee, Scotland, United Kingdom
Candace Currie HBSC International Coordinator, Director Child & Adolescent Health Research
Unit, University of Edinburgh, Scotland, United Kingdom
Wolfgang Dür Director, Ludwig Boltzmann Institute Health Promotion Research (LBIHPR),
Vienna, Austria
Mafalda Ferreira Faculdade de Motricidade Humana, Universidade Técnica de Lisboa, Portugal
Margarida Gaspar de Matos Health and Clinical Psychologist, Professor of International Health,
FMH/UTL and CMDT-LA/UNL, Lisbon, Portugal
Emmanuelle Godeau Public Health Service Médical du Rectorat de Toulouse,
and UMR INSERM U558 − Université Paul Sabatier, Toulouse, France
Robert Griebler Senior Researcher, Ludwig Boltzmann Institute Health Promotion Research
(LBIHPR), Vienna, Austria
Anne Hublet Universiteit Gent Vakgroep Maatschappelijke Gezondheidkunde, Belgium
Markus Hojni Junior Researcher, Ludwig Boltzmann Institute Health Promotion Research
(LBIHPR), Vienna, Austria
Ronald Iannotti Staff Scientist, National Institute of Child Health and Human Development,
Maryland, United States
Colette Kelly Senior Researcher, Health Promotion Research Centre, School of Health Sciences,
National University of Ireland, Galway, Ireland
Margaretha de Looze Faculty of Social and Behavioural Sciences, Utrecht University, the Netherlands
Nuno Loureiro FMH/UTL and CMDT-LA/UNL, Lisbon, Portugal
Antony Morgan CAHRU Honorary Research Fellow, Child & Adolescent Health Research Unit,
University of Edinburgh, Scotland, United Kingdom
Michal Molcho Lecturer in Health Promotion, Health Promotion Research Centre,
School of Health Sciences, National University of Ireland, Galway, Ireland
Celeste Simões Professor, Faculdade de Motricidade Humana, Universidade Técnica de Lisboa,
Portugal
Dora Varnai Psychologist, Researcher, National Institute of Child Health (OGYEI),
Budapest, Hungary

VII
 A Snapshot of the Health of Young People in Europe 2009

VIII
Background 1
and context


 A Snapshot of the Health of Young People in Europe 2009


Introduction 1
.1


 A Snapshot of the Health of Young People in Europe 2009

Introduction
This report has been prepared for the European Commission conference, Youth health initiative: be healthy, be
yourself, held in Brussels, Belgium on 9 and 10 July 2009. More than 400 delegates, including young people from
across Europe, representatives from youth organizations, health professionals working with and for young people,
national and international organizations and European Union (EU) institutions will be represented.

The conference reflects the high priority given to youth health by the European Commission. This is a vital commitment,
because securing the health and well-being of young people today is an essential investment in securing the health,
well-being and prosperity of the Europe of tomorrow.

The primary aim of the conference is to listen to young people and to involve them in decision-making processes
about their health. It also aims to generate commitment from stakeholders to improve the health of young people.

The European Commission asked the WHO Regional Office for Europe to prepare this report to support the conference.
An editorial board was formed to oversee production of the report, and expert writers were commissioned to make
specific contributions.

The decision was taken early in the process to produce a “snapshot” report, rather than one which would provide
comprehensive detail. This partly reflected the time scale available in which the report could be produced, and
partly because of gaps in the data on young people’s health. While individual countries compile national reports on
youth health trends and issues, these are seldom consolidated in international reports. This highlights the worrying
problem of both lack of data and lack of availability of existing data on youth health in Europe.

The report focuses on EU27 countries (those belonging to the EU after January 2007) but also includes data from
other European countries. It relies heavily on the valid and reliable information on the health status of 13- and 15-
year-olds produced by the Health Behaviour in School-aged Children (HBSC) study, whose most recent report reflects
the survey carried out in 2005/2006. It has been more challenging, however, to access valid, relevant data on health
issues among 16–25-year-olds, who are the main focus of the European Commission Conference on Youth and
Health. Much of the information that does exist on health, such as the EUROSTAT and WHO Health for all databases,
is often not age and gender disaggregated.

There are consequently limitations on the scope and completeness of the data presented in this report. The report
does, however, present a wide range of valid and useful data on important health issues for young people, particularly
for those aged 13 and 15 years.

The primary underpinning of the report, and the “lens” through which its content is presented, is awareness of the
growing inequalities in societies that are having significant impacts on the health and life opportunities of young
people. Socioeconomic factors are key considerations that must come into the equation when considering how the
health of young people in Europe can be protected and improved.

The report shows that in general, young people do not suffer from serious and life-threatening communicable and
noncommunicable diseases. Although deaths and disability caused by suicide and accidents in young people are
considerable, the overall morbidity and mortality patterns of young people compare very favourably to, say, those
of men aged 50–60 years.

But many of the health problems young people will encounter as adults – problems such as cardiovascular disease,
diabetes, stroke, cancers and mental disorders – will have their genesis in the child and adolescent years, even if
they do not manifest at that time. There are therefore enormous opportunities for – and a clear responsibility to take
– positive action on young people’s health to reduce these causes of adult morbidity and mortality. This points to the
need for multisectoral action across Europe to address these important issues.

It is hoped that the information and data presented in this report and the four main recommendations below
will be useful in different contexts in Europe and, in particular, will be helpful to policy-makers, decision-makers,
researchers, teachers, people working in youth programmes and young people themselves.


 introduction

Recommendations
• There is a need to analyse where gaps in data exist and identify all sources of currently
available data on young people’s health in Europe.
• More data is required to identify the key determinants of ill health in children and young
1
.1
people, supported by resources to enable effective interventions to be developed.
• There is a need for work to enable a better understanding of the links between
socioeconomic factors and health among young people.
• There is a need for comprehensive national health and development policies and action
plans based on a life-course perspective and with a focus on youth.


 A Snapshot of the Health of Young People in Europe 2009


Young people’s health: 1
.2

the equality lens


 A Snapshot of the Health of Young People in Europe 2009

Young people’s health: the equality lens

Any presentation or synthesis of data aiming to promote the health of young people should examine the differences
in health status and its related determinants. Each chapter in this report therefore attempts to present data which
describe the differences in health experience using recognized dimensions of inequalities including age, gender and
socioeconomic status.

The issue of health inequalities is firmly embedded in contemporary international policy development due to the
growing body of evidence gathered over the last two decades which indicates the increased health risks associated
with disadvantaged social circumstances (1–3). The WHO Commission on the Social Determinants of Health claims
that the vast majority of inequalities in health between and within countries are avoidable (4), yet across Europe,
young people of all ages experience inequalities in health, in social and economic determinants of health (5) and,
indeed, in poverty (6).

Social and economic disadvantage can have a range of impacts on the health of young people. Processes and effects
include: social exclusion and lack of opportunity in activities that promote or support health; impacts of perceived
low social and economic status on well-being; direct effects of material deprivation and poverty on social and living
conditions; and lack of social support to withstand and cope with hardship.

As well as economic disadvantage, other dimensions of inequality are manifested as: gender and age differences;
differences stemming from family structure and from neighbourhood and living areas; and differences due to ethnic
and cultural issues. Labour market influences are also important, especially in the transition from school to work
and from home to independent living. Local and global economic conditions may affect the material resources that
young people have access to and may have a direct impact on their aspirations and sense of achievement, which
may manifest in mental health outcomes.

Access to health care may not be evenly distributed according to age, gender, socioeconomic background, ethnicity,
area of living and country. In addition to access to general medical services, this population group has a particular
need for easily accessible specialist services, including those that provide sexual health advice and treatment and
mental health services.

The impact of inequalities may be immediate, with poor outcomes being apparent in a range of health indicators and
health behaviours during childhood and adolescence. These may reduce young people’s ability to participate fully in
many aspects of life and affect, for example, school attendance and academic achievement, social functioning, sports
participation and uptake of employment opportunities. Quality of life and mental well-being may consequently be
affected. Poor material circumstances may affect purchasing power of families, reducing access to healthy foods and
affecting nutritional health.

Previous understandings of child health placed future health as adults as a priority within a perspective that saw
early stages in the life-course as transition phases to adulthood. Within this paradigm, experience of poor health in
childhood is of primary concern as a predictor of poorer health status in adulthood. While this approach remains
vitally important, a more child-centred approach developed over recent years has placed children’s health at a
premium, giving emphasis to positive well-being and quality of life in this age group as a goal for public health.
An analysis of the perspectives of children and young people (in the age range 5–17 years) on their experiences
of economic adversity suggests that their concerns focus not so much on lack of resources per se, but on being
excluded from activities that other children appear to take for granted. They experience embarrassment and shame
at not being able to participate on equal terms with other children (7).

The Policy paper on the health and well-being of young people (8) places high importance on the issue of inequalities
and states that “all young people, regardless of their economic situation or residence status , of their sexual orientation
or ethnic and religious background, marital status, gender, age or disability, should be entitled to health care and
social protection”. Access to health care should be free to all young people under the age of 18 and affordable to
those above to ensure universal access.


 young people’s health: the equality lens

Fig. 1.2.1
FAMILY AFFLUENCE ACCORDING TO 2005/2006
FAMILY AFFLUENCE SCALE (FAS) COMPOSITE SCORES (ALL AGES) HBSC survey

1
Iceland 2 26 72 FAS 1 (low)
FAS 2 (medium)
Norway 4 27 69
England 8 31 60
FAS 3 (high)
.2
Luxembourg 8 33 59
Sweden 7 38 56

Netherlands 8 41 52
Denmark 8 41 51
France 12 38 50
Switzerland 9 43 48
Belgium (Flemish) 10 42 47
Germany 13 40 47
Slovenia 11 44 45
Wales 14 41 45
Belgium (French) 15 41 43
Scotland 16 41 43
Austria 13 45 42
Finland 13 46 42
Spain 14 46 40
Ireland 16 47 37
Italy 21 46 33
Portugal 24 43 33
Greece 25 47 28
Hungary 29 47 25
Estonia 32 44 24
Poland 32 43 24
Czech Republic 30 47 24
Croatia 30 48 22
Latvia 33 46 22
TFYR Macedonia† 39 44 17
Bulgaria 32 51 17
The former Yugoslav Republic of Macedonia

Lithuania 38 46 16
Malta 35 50 15
Slovakia 46 40 14
Romania 45 42 13

Turkey 70 25 5
†


 A Snapshot of the Health of Young People in Europe 2009

Evidence from the Health Behaviour in School-aged Children (HBSC) study shows wide variations in social circumstances
according to age, gender, socioeconomic status and geography across Europe (5). One way of measuring socioeconomic
status in the HBSC study is to assess family affluence using the HBSC Family Affluence Scale (FAS) (9). Data collected
in 2006 show wide variations between European countries in levels of affluence (Fig. 1.2.1).

These data collected from young people allow ranking of countries on the basis of families’ material resources,
including car ownership, child having own bedroom, family holidays and family computers. Rankings match closely
with country levels of gross domestic product (GDP) (10). This is therefore a useful device for gaining a view of the
material circumstances of young people who are not themselves in the labour market.

Family affluence is associated with a wide range of social as well as health outcomes for adolescents. Young people
from more materially well-off families tend to report closer relations with parents and peers; they are more likely
to use electronic media to communicate with friends and to be doing well at school. Almost all perceived health
measures, including self-rated health and life satisfaction, show positive associations with higher levels of family
affluence (Table 1.2.1).

Many aspects of health promoting behaviour, such as fruit eating, regular breakfast consumption and toothbrushing,
are more frequent among adolescents from more affluent families, and injuries are less common.
Table 1.2.1 2005/2006 HBSC survey
With respect to gender, it is found that there are
consistent and widespread differences in health
determinants and health outcomes between boys
(5) and girls across Europe. School experience is known
to be an important determinant of adolescent health
and, generally, girls report higher levels of academic
achievement, classmate support and school satisfaction.
However, school pressure increases with age for girls:
at 15 years, they experience higher levels of school-
related stress, which can have a negative impact on
well-being. Girls’ perceptions of their health and well-
being are poorer than those of boys on most outcome
measures, including life satisfaction, health complaints
and self-reported health, but boys are more likely to
have poorer outcomes for overweight and injuries
(Fig.1.2.2, 1.2.3).

Inequalities are also seen in relation to age, with

consistent patterns that have important implications
for the timing of health interventions. Between the
ages of 11 and 15 years, the prevalence of a range of
risk behaviours, including smoking, alcohol use, drug
use and sexual risk, increases. Preventive strategies
therefore need to take into consideration the fact that
interventions need to precede onset. Other health
habits, such as those related to oral health, eating
habits and physical activity, have already become
established by age 11; these generally worsen across
the teenage years. Interventions addressing the early
years of childhood are therefore implied.

10
 young people’s health: the equality lens

Fig.1.2.3
Fig.1.2.2 15-YEAR-OLDS WHO REPORT AT
15-YEAR-OLDS WHO RATE 2005/2006 LEAST ONE MEDICALLY ATTENDED 2005/2006
THEIR HEALTH AS FAIR OR POOR HBSC survey INJURY IN THE LAST 12 MONTHS HBSC survey

*Malta 36 Girl % 49 Girl %

21 *Spain 65
33 Boy % 49 Boy %
*Hungary 21 *Iceland 59

1
34 50
*Belgium (French) 19 Norway 53
33 45
*Wales *Switzerland
.2
20 55
34 45
*Scotland 18 *Czech Republic 54
32 43
*England 18 *Lithuania 56
28 48
*Lithuania 17 Denmark 49
27 39
*Latvia 16 *England 55

*Iceland 23 44
19 *Germany 50
26 39
*Romania 13 *Italy 55
26 39
*Turkey 16 *Scotland 55

*Belgium (Flemish) 24 38
17 *Malta 55
26 39
*Luxembourg 14 *Latvia 51
26 41
*Netherlands 12 *Austria 49

*Estonia 21 37
15 *Belgium (Flemish) 50

*Denmark 23 39
14 *Luxembourg 46

*Croatia 24 36
11 *Belgium (French) 49
21 32
*Norway 15 *Wales 53

*Portugal 24 37
9 *Slovakia 48

*Ireland 20 34
15 *Ireland 50
21 37
*Austria 12 *France 46

*Poland 21 37
12 *Hungary 47
19 34
*Sweden 13 *Croatia 49
20 34
*Germany 12 *Portugal 49
21 36
*France 9 *Finland 45
18 31
*Slovenia 11 *Greece 43
15 31
Finland 12 *Netherlands 42
16 30
*Czech Republic 10 *Estonia 42
17 34
*Bulgaria 8 Sweden 37
16 27
*Italy 7 *Slovenia 41
14 26
*Switzerland 7 *Turkey 40
13 25
*Spain 6 *Romania 37
The former Yugoslav Republic of Macedonia

The former Yugoslav Republic of Macedonia

*Greece 11 *Poland 26
4 34

*Slovakia 9 *TFYR Macedonia 24

5 35
8 *Bulgaria 21
*TFYR Macedonia† 4 28
22 36
Average (gender) 13 Average (gender) 48
Average (total) 18 Average (total) 43
†

* indicates a significant gender difference (at p<0.05)

11
 A Snapshot of the Health of Young People in Europe 2009

Transition from school to work

The life-course approach is a useful tool in enabling understanding of the health inequalities that may be experienced
and accumulated by young people as they grow up (11). The transition from school to work is particularly important
and may provide a means of understanding how social advantages and inequalities are handed down from one
generation to the next (8). Changing patterns of education, family life and new forms of flexible working in the
labour market all have an influence on young people’s ability to sustain health as they move into young adulthood.
The risk of becoming homeless also has its health consequences for young people as they make that transition into
adult life, particularly through poor access to services and higher risk of engaging in risk-taking behaviour. Increased
migration also adds to the complexity of understanding health inequalities and how they might change over time.

Unfortunately, there are gaps in our knowledge on some of these determinants. While some data may exist within
countries, systematic collection of these important influences on health has not yet been achieved at the European
level. Recent recommendations from the Measurement and Evidence Knowledge Network of the Commission on
the Social Determinants of Health (12) may provide a useful framework for moving towards a more systematic
approach to introducing an “equality lens” on monitoring the health of young people as they move into adulthood.
The examples given below relating to poverty, employment and access to services provide illustrations of the types
of data that are useful to include in an equality-focused monitoring framework.

Poverty
Three aspects of disadvantage are used to examine the experience of poverty among 16–29-year-olds in the 15
countries belonging to the European Union (EU) before May 2004 (EU15) – income poverty (the net income of the
household is less than 60% of the average income of the country), monetary deprivation (a relative measure based
on income in relation to total population) and non-monetary deprivation (based on assessment of economic well-
being of the household to which the individual belongs, such as having basic household facilities and appliances,
condition of housing, environmental problems etc.) (6).

As well as individual poverty experience, the welfare support that young people may receive to alleviate their condition
depends on the country in which they live. Countries have been grouped into welfare state typologies (13,14). Young
people living in “social democratic” regime types may have high levels of state support – these countries include
Scandinavian countries and the Netherlands. While the emphasis in these countries is on the individual rather than
the family, in the “conservative” regime types such as France, Germany, Belgium and Luxembourg, there is an
emphasis on insurance-based benefits for families rather than individuals.

In “liberal” welfare states, there is modest welfare provision which tends to be means-tested. This is found in, for
example, the United Kingdom and Ireland. In the southern group of “residual” welfare states, including Italy, Spain,
Portugal and Greece, there are low levels of welfare provision and a reliance on family as a locus of support. Poverty
therefore impacts at both individual and country level, which might help to explain some of the differences in health
outcomes seen across Europe.

Youth poverty rates vary greatly across Europe. Iacovou & Aassve (6) have developed a summary of various data
sources to create a table of contemporary poverty in three age groups (Table 1.2.2).

12
 young people’s health: the equality lens

Table 1.2.2 poverty rates by country, age group and whole population Iacovou et al, 2007

16–19 years 20–24 years 25–29 years Whole population

Finland 12.5 29.9 13.0 10.8
Denmark
Netherlands
United Kingdom
Ireland
8.4
18.1
22.7
24.2
21.7
27.1
20.3
11.5
9.7
12.1
14.3
14.3
10.3
10.5
18.8
22.1
1
.2

France 21.1 21.0 11.4 15.0

Germany 13.1 13.6 11.2 11.1
Austria 9.8 8.2 8.4 11.4
Belgium 17.9 13.9 9.5 15.4
Portugal 15.4 9.6 9.3 16.4
Spain 24.6 17.4 13.3 18.2
Italy 27.0 24.7 19.4 18.6
Greece 20.5 18.6 13.2 19.4

Four factors that are associated with youth poverty are: living away from the parental home; living alone; having
children; and not having a job. A critical point for young people is leaving the family home: living away from home
has the greatest influence on poverty risk of all the above factors.

The age that young people leave home varies across Europe. In the youngest age group, the highest proportion of
young people who have left home (12%) is in the United Kingdom, with 7% in Scandinavian countries and 3% or
less in southern Europe. For the 20–24 age group, the highest proportion of young people who have left home is
found in the social democratic countries and the lowest in the southern European countries. This correlates with
levels of welfare available to young people themselves.

There is also a strong relationship between poverty rates and age at leaving home, which is somewhat counter
intuitive. Where there are large differences in poverty rates within a country between young people living with their
parents and those living away from home, leaving home tends to be earlier. The possible reasons for this are complex
and are beyond the scope of this report (6).

Employment
The Youth poverty in Europe report (6) states that a young person’s risk of poverty is affected by his or her employment
status. Having work is associated with lower poverty among those over 20 years, but for the 16–19 age group,
poverty levels for those in work are higher than for older age groups, and in some countries students are better
off than their peers who are in work. Countries vary in the distribution of poverty among employed, unemployed
and student populations of youth. This complex picture relates to a number of factors, including welfare systems,
living arrangements and wage levels among others. In all countries, the risk of poverty declines with age across the
twenties.

In terms of employment, stable long-term employment is critical to financial stability and avoiding poverty.

The recent report Pathways to work: current practices and future needs for the labour market integration of young
people (15) categorized countries according to how youth friendly their labour markets are (Table 1.2.3).

13
 A Snapshot of the Health of Young People in Europe 2009

Table 1.2.3 youth friendliness of countries labour markets Institute for the Development of Vocational Training, 2008

Friendly Labour Markets The main challenges

Highest human development indicators and best i) Reductions of the high level of youth unemployment
performer in youth employment ii) Social inclusion of the weaker young groups
iii) Reduction of the share of young people not in education, employment or training
Austria, Denmark, Netherlands, Sweden, Finland, iv) Completion of the education system reforms
United Kingdom and Ireland

rigid Labour Markets The main challenges

Low youth employment and good capability i) Flexibility of the education and training system
indicators ii) Labour market flexibilization
iii) Integration and personalization of life-cycle oriented policies and services
iv) Development of workforce approaches
v) Cooperation among public and private employment services
France, Belgium, Germany, Luxembourg
and Slovenia vi) Participation of young females in the labour market

strongly segmented The main challenges

youth Labour Markets i) Creation of a competitive, pluralistic, integrated, personalized,market-oriented
and high-quality system of lifelong learning
ii) Promotion of economic independence for young adults
iii) Integration of labour-market flexibilization measures with security components
iv) Extension of public and private employment services network
Greece, Italy, Portugal, Spain and Poland v) Encouragement of women’s greater participation in the labour market

low employment and The main challenges

skill mismatches in the i) Conclusion of economic restructuring processes and the convergence of the
convergent/transition economies economies with those of the EU15
ii) Introduction of new national strategies and new structures for the education
and training system
iii) Increase of labour-market flexibility
Czech Republic, Estonia, Hungary, Latvia, Lithuania,
iv) Extension of the Active Labour Market Policy
Slovakia, Cyprus, Malta, Romania and Bulgaria
v) Modernization of the social security system

Access to health services

Youth, as a category, is under particular threat of being excluded from social protection systems. Some young
people face multiple discrimination and disadvantage in terms of access to health care (8). Strategic evidence-based
information is needed to plan and monitor national programmes and promote youth-friendly policies. Experiences
and lessons learned need to be documented and widely disseminated.

In 2004, Entre Nous, the European magazine for sexual and reproductive health, dedicated an issue to the topic of
youth-friendly services in Europe. Systematic information is not available, and this issue of the magazine presents
country case studies from the Netherlands, Estonia, the Russian Federation and some other parts of Europe. These
data represent some of the few sources of information available. Cross-nationally comparable information on
the proportion of young people accessing youth-specific health services and on how young people access health
information and advice is currently lacking.

14
 young people’s health: the equality lens

1
.2

15
 A Snapshot of the Health of Young People in Europe 2009

16
 Young people in 2
the 21st century

17
 A Snapshot of the Health of Young People in Europe 2009

18
Demographic trends 2.1

Summary
• In general Eastern Europe has a higher proportion of young people
aged 0–14, whereas Western Europe has a higher concentration of
young people 14–24 years.
• An increased “age drift” in Europe will be seen over coming decades.
• Fertility rates in most of Europe are inadequate to maintain natural
replacement levels.
• Further detailed investigations of youth migration and mobility in
Europe are required.

19
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Knowledge of the present situation in relation to numbers, dispersal and population growth rates of young people
in Europe is vital in enabling an understanding of key health issues such as sexual behaviour, alcohol abuse,
socioeconomic inequalities and mental health. Demographic data describe the current situation, enable estimations
of future trends and identify “blind spots” where crucial data are missing.

What do we know?
There are apparent differences in the proportion of young people in Europe from east to west. In general, eastern
European countries with a high percentage of young people aged 0–14 years had a lower percentage of those aged
14–24 years. (Fig. 2.1.1, Fig. 2.1.2). In some countries such as the United Kingdom, Ireland and Norway, young
people aged 0–24 years account for almost a third of the total population.

The fertility rate of Europe’s youth is central to the development of populations. The fertility rate provides an
indication of the reproduction rate within a population and is calculated as the number of live births per 1000
females of a specific age group (1). For most industrialized countries, a total fertility rate of 2.1 is considered to be
the replacement level necessary to maintain the natural population (without migration) over the long term (2).

Fig. 2.1.3. presents the change in fertility rates for the EU27 population between 16 and 25 years in 1996 and 2006.
It shows that the fertility of Europe’s youth is in decline, a trend that has been evident since the 1970s. Since then,
the fertility rate for women below 30 years has declined while the rate for those above 30 has risen (3). While a
decline in fertility among 16–18-year-olds may be welcome, as it represents a decrease in teenage pregnancies, the
decrease in fertility rates for 23–25-year-olds means a shift in the age at first birth to 30 and above.

Fig. 2.1.1 Fig. 2.1.2

PERCENTAGE OF POPULATION AGED 0–14 EUROSTAT PERCENTAGE OF POPULATION AGED 14–24 EUROSTAT

15.3–17.4 18.4–27.9
13.1–15.3 16.8–18.4
12.4–13.1 15.4–16.8
11.8–12.4 14.3–15.4
10.2–11.8 13.4–14.3

* Only data for 2007 were available for the United Kingdom and Turkey.

20
 demographic trends

Fig. 2.1.3
COMPARISON OF THE FERTILITY RATE OF 16–25-YEAR-OLDS IN 1996 AND 2006 EUROSTAT

1996 2006
0.12

0.10

0.08
2.1
0.06

0.04

0.02

0.0
16 17 18 19 20 21 22 23 24 25
Age

Fig. 2.1.4 Fig. 2.1.5

COMPARITIVE RATIO: PRECENTAGE OF 0–14-YEAR-OLDS 2008 COMPARITIVE RATIO: PRECENTAGE OF 14–24-YEAR-OLDS 2008
TO PERCENTAGE OF 0–14-YEAR-OLDS 1998 EUROSTAT TO PERCENTAGE OF 14–24-YEAR-OLDS 1998 EUROSTAT

0.71–0.87 0.71–0.90
0.87–0.99 0.90–0.99
1.00 1.00
1.00–1.02 1.00–1.05
>1.02 1.05–1.14

A value less than one indicates a decrease. A value greater than one indicates an increase. A value less than one indicates a decrease. A value greater than one indicates an increase.

21
 A Snapshot of the Health of Young People in Europe 2009

What are the challenges?

Over the last ten years the percentage of young people aged 14–24 years has fallen in most countries. The population
aged 14 and under has decreased in all countries, with the exception of Denmark, suggesting that the proportion
of young people in Europe will continue to decline (Fig. 2.1.4, Fig. 2.1.5).

There are many reasons behind this, but two issues – fertility rate and socioeconomic changes – can be identified as
having significant effects. The overall key trend for the population of people between 11 and 24 years in the EU27
is that the population of those below the age of 24 will be in uninterrupted decline, while that of people over 50
years will rise (4) (Fig. 2.1.6).

At the present time, Europe’s total population is on the rise despite an overall low fertility rate (1.41 for the whole
EU) because of migration from countries outside of Europe.

Reliable statistics and comparable data about migration within Europe, particularly for those between 11 and 24
years, appear to be hard to find. Important data about the structure of Europe’s population are therefore missing,
which constitutes a serious omission given the significance of migration as a major source for the growth of Europe’s
population.

Examination of the overall age structure of migrants in the EU shows that 11–24-year-old migrants are a population
that cannot be ignored (Fig. 2.1.7). This, linked with the fact that migration is a resource for Europe’s population that
will affect its future growth, makes it necessary to compile accurate data for this population.

22
 demographic trends

Fig. 2.1.6
AGE DRIFT OF EUROPE’S POPULATION FROM 1996 TO 2006 EUROSTAT

120

110
2.1
100

90

80

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

0 to 14 years 25 to 49 years 65 to 79 years

15 to 24 years 50 to 64 years 80 years and more

Fig. 2.1.7
AGE STRUCTURE IN THE EU OF EU-BORN AND NON EU-BORN MIGRANTS EUROSTAT

EU-born Total non EU-born Non EU-born resident <

_ 7 years
90+
85–89
80–84
75–79
70–74
65–69
60–64
55–59
50–54
45–49
40–44
35–39
30–34
25–29
20–24
15–19
10–14
05–09
00–04

0 5 10 15 20 0 5 10 15 20 0 5 10 15 20
% of respective population

Note: Belgium, Denmark and Ireland excluded

23
 A Snapshot of the Health of Young People in Europe 2009

24
Education 2.2

Summary
• Gaining an understanding of school related health issues is vital for governments.
• An upward trend in enrolment rates can be seen in eastern Europe.
• Social inequalities and socioeconomic factors such as family affluence are significant
influences on academic performance, but issues such as self-efficacy are also important
in determining overall school performance.
• Findings from the HBSC survey (1) indicate high coherence between subjective
health status and the perceived school performance of students.

25
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Improving the quality of education is an issue that involves many stakeholders – students, parents, teachers and
governments. All of these stakeholders, in particular governments, need information about the overall perf-
ormance of the education system to enable them to take adequate actions to reflect changing needs and social
developments (2,3).

Central to this is the need for reliable data about the current situation and developing trends. Data on academic
performance and achievements are important indicators, but they are not sufficient in themselves to describe the
effectiveness of education systems. Modern education is not only focused on academic achievement and academic
output rates, but also concentrates on ensuring students achieve a good quality of education experience and are
enabled to cope adequately with school-related issues, such as stress, that can develop into health problems.

Health and education are linked. With, according to 2005 figures, 98.3 million students attending schools in the
EU27 at International Standard Classification of Education (ISCED) levels 1–3 (Box 2.2.1) (4,5), it is clear that gaining
an understanding of school-related health issues is vital for governments.

Box 2.2.1 International Standard Classification of Education (ISCED) levels (4)

The ISCED is as an instrument suitable for assembling, compiling and presenting statistics of education both within individual
countries and internationally. There are seven levels of defined education:
• level 0: pre-primary education
• level 1: primary education or first stage of basic education
• level 2: lower secondary or second stage of basic education
• level 3: (upper) secondary education
• level 4: post-secondary, non-tertiary education
• level 5: first stage of tertiary education (not leading directly to an advanced research qualification)
• level 6: second stage of tertiary education (leading to an advanced research qualification).

Young people experience stress to varying degrees as a product of their daily school life. School-related stress has a
significant impact on the health behaviours of young people. Those who experience high levels of pressure are at
risk through the adoption of health-compromising behaviours and are more liable to report health and psychological
complaints (6–10).

The Programme for International School Assessment (PISA) study, initiated by the Organisation for Economic Co-
operation and Development (OECD), provides an overview of academic performance of young people, while the
HBSC survey focuses on young people’s behaviours, lifestyles and social context changes as they grow through
the adolescent years. These offer valid, cross-national, comparative data sources to inform debate and decision-
making.

What do we know?
Of the students enrolled in education establishments in EU27 countries in 2005, the highest share was in the United
Kingdom, with 16.7 million; this was 2.2 million higher than the next largest student population, registered in
Germany (5).

Fig. 2.2.1–2.2.3 show the proportion of students at ISCED levels 3–5 in the education system as a percentage of all
students: all figures in the graphs are approximate.

These data from 1998 and 2006 show some significant changes in the population of students at ISCED levels 3–5.
This is especially the case in Poland, Greece, Latvia, Slovenia and the Czech Republic, with a significant change
between 1998 and 2006 in the numbers of people in education. With a few exceptions, the figures reflect an overall
upward trend.

26
 education

Fig. 2.2.1 Fig. 2.2.2

PERCENTAGE OF STUDENTS AT ISCED LEVEL 3 1998–2006 EUROSTAT PERCENTAGE OF STUDENTS AT ISCED LEVEL 4 1998–2006 EUROSTAT

2006 1998 2006 1998

United Kingdom
United Kingdom

2
Slovakia
Slovakia
Slovenia
Slovenia
Sweden
Sweden
Romania Romania .2
Portugal Portugal
Poland Poland
Estonia Estonia
Netherlands Netherlands
Malta Malta
Latvia Latvia
Luxembourg Luxembourg
Lithuania Lithuania
Italy Italy
Ireland Ireland
Hungary Hungary
Greece Greece
France France
Finland Finland
Spain Spain
Denmark Denmark
Germany Germany
Czech Repbulic Czech Repbulic
Cyprus Cyprus
Bulgaria Bulgaria
Belgium Belgium
Austria Austria
0 10 20 30 40 0 5 10
% of students at ISCED level 3 % of students at ISCED level 4

Fig. 2.2.3
PERCENTAGE OF STUDENTS AT ISCED LEVEL 5 1998–2006 EUROSTAT

1998 2006
35

30
% of students at ISCED level 5

25

20

15

10

0
Austria
Belgium
Bulgaria
Cyprus
Czech Republic
Germany
Denmark
Spain
Finland
France
Greece
Hungary
Ireland
Italy
Lithuania
Luxembourg
Latvia
Malta
Netherlands
Estonia
Poland
Portugal
Romania
Sweden
Slovenia
Slovakia
United Kingdom

27
 A Snapshot of the Health of Young People in Europe 2009

Fig. 2.2.4 shows female involvement in education between 1998 and 2006 in EU27 countries. A significant increase
can be seen in Germany, the United Kingdom, Denmark, Poland, Slovakia, Slovenia and France, but significant
declines in numbers of females in secondary education can be observed in Finland, Sweden, Austria, Hungary,
Ireland and Spain.

Examination of the numbers of young people aged 15–24 in employment (Fig. 2.2.5) shows an overall balance
between 1997 and 2007 in all countries of the EU27 (2), although a more accurate picture requires analysis of
specialized regional or national data from the labour market and education sector.

Perceived school performance

The PISA 2006 international survey offers reliable, comparable data to facilitate the evaluation of school
performance.

One of the most important influencing factors on school performance is the student’s home background.
Key findings from the HBSC survey show that gender and family affluence are significant factors in assessment of
very good school performance, with girls and those from high-affluence families more likely to report performing
well at school (1).

However, a disadvantageous home background does not automatically mean a poor school performance (2).
Students’ self-efficacy is also an important factor in determining individual school performance. Students who have
confidence in their abilities have a strong sense of self-efficacy and are willing to invest in learning to overcome
difficulties (2). Results of the PISA 2003 survey showed a significant positive association between students’ self-
efficacy in mathematics and their performance in mathematics assessments: on average, each unit increase on the
index of self-efficacy in mathematics corresponded to a performance difference of 47 points.

One major finding of the 2006 PISA survey is that students need to believe in themselves from the outset of
their education experience to enable investment in the education system to help them achieve higher levels of
performance (2). This is a significant point in relation to performance gaps, as academic performance is an important
predictor of future life chances, including education and employment opportunities (1).

Liking school
School satisfaction is considered an indicator of the emotional aspect of quality of life in the school setting. An
overall positive experience of school can be a resource for health and for a better school performance, while the
negative experience of “disliking school” constitutes a risk factor that may result in health-compromising behaviours
such as sexual risk-taking, illegal substance use and smoking (1).

When young people in the HBSC survey were asked how they feel about school at the present (possible answers
were “I like it a lot” and “I don’t like it at all”), very large cross-country differences were evident. The results show a
consistent gender difference at age 11 which narrows, along with a general decline in liking school “a lot”, between
ages 11 and 15. Neither geographical region nor family affluence is a strong predictor of liking school “a lot” (1).

Pressured by schoolwork
Students experience schoolwork-related stress, a phenomenon that is analogous to job strain in an occupational
setting, as a component of school adjustment. Stress induced by schoolwork can not only be found in individual
students; it is also characteristic of a wider context that includes the classroom or even the whole school.

Sources of school-related stress vary, but most commonly it is linked with perceived academic demands from parents
and teachers. Like any other perceived stress, high levels of school-related stress have been associated with a wide
range of health outcomes that have an influence on academic performance, such as lower self-rated health, low
quality of life and less satisfaction with school (1).

28
 education

Fig. 2.2.4 Fig. 2.2.5

COMPARISON OF FEMALES IN COMPARISON OF 15–24-YEAR-OLDS ACTIVELY
SECONDARY EDUCATION 1998–2006 EUROSTAT IN THE LABOUR MARKET IN 1997 AND 2007 EUROSTAT

1998 2006 1997 2007

United Kingdom United Kingdom

2
Slovakia Slovakia
Slovenia Slovenia
Sweden
.2
Sweden
Romania Romania
Portugal Portugal
Poland Poland
Netherlands Netherlands
Malta Malta
Latvia Latvia
Luxembourg Luxembourg
Lithuania Lithuania
Italy Italy
Ireland Ireland
Hungary Hungary
Greece Greece
France France
Finland Finland
Spain Spain
Estonia Estonia
Denmark Denmark
Germany Germany
Czech Republic Czech Republic
Cyprus Cyprus
Bulgaria Bulgaria
Belgium Belgium
Austria Austria

0 20 40 60 80 100 0 10 20 30 40 50 60 70 80
% of people between 15 and 24
% of female involvement in secondary education actively in the labour market

29
 A Snapshot of the Health of Young People in Europe 2009

Reports of feeling highly pressured by schoolwork vary between countries, from 9% among 11-year-old girls in the
Netherlands to 73% among 15-year-old girls in Portugal. The numbers indicate that girls at the age of 15 feel the
greatest pressure in most countries, although no specific geographical pattern emerges (Fig. 2.2.6, Fig. 2.2.7) (1).
Receiving recognition of effort in school has a strong impact on students’ health.

What are the challenges?

Findings from the HBSC survey show a high coherence between perceived school performance and the subjective
health of students. This finding has important implications for the future development of education systems, not
only in improving the overall school performance of students, but also in improving their perceptions of their own
health.

30
 education

Fig. 2.2.6
15-YEAR-OLD GIRLS WHO FEEL 2005/2006
PRESSURED BY SCHOOLWORK HBSC Survey

2.2

60% or more
50 to 59%
40 to 49%
30 to 39%
less than 30%

Fig. 2.2.7
15-YEAR-OLD BOYS WHO FEEL 2005/2006
PRESSURED BY SCHOOLWORK HBSC Survey

31
 A Snapshot of the Health of Young People in Europe 2009

32
 health 3
outcomes

33
 A Snapshot of the Health of Young People in Europe 2009

34
injuries and accidents 3.1

Summary
• Injuries are the leading cause of death in young people, affecting mainly males.
• Injuries prevalence increases with age (from 1 to 24 years).
• Injuries are more prevalent in middle-income countries and among lower socioeconomic
groups within countries.
• Road traffic injuries are the leading cause of death and the leading cause of injuries
in young people aged 10–24 years.
• The challenge around injury is collecting comparable data on non-fatal injuries
and injury mechanisms to prevent injuries and promote safety among young people.

35
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Injuries are the leading cause of death and disability among young people and constitute one of the leading causes
of deaths across all age groups, with more than 5 million injury deaths globally every year.

In Europe, injuries kill 800 000 people every year, accounting for 8.3% of all deaths in Europe (1,2). There are 250 000
fatalities each year in the European Union. Injuries represent the fourth major cause of death in the EU27 countries,
following cardiovascular diseases, cancer and diseases of the respiratory system (3).

For every injury-related death, it is estimated that injuries cause 30 people to be admitted to hospital and 300 others
to attend emergency departments for outpatient treatment (1,2). Injuries that do not result in death may have short-
or long-term effects on the health of the injured person, with associated burdens (including lost potential, disability,
treatment costs and rehabilitation) being substantial (4).

The World Bank and WHO have developed a measure of the impact of disease – the disability-adjusted life-year
(DALY) (Box 3.1.1) – to assess the total significance of disease to society beyond the immediate cost of treatment or
the burden of disease.

Box 3.1.1 The disability-adjusted life-year (DALY)

DALY is a summary measure that combines the impact of illness, disability and mortality on population health. The DALY combines
the amount of time lived with disability and the amount of time lost due to premature mortality, using actual data and estimates of
illness and death in a population. One DALY equals one lost year of healthy life (5). In Europe, injuries account for 14% of overall
DALYs (1) and 19% among 0–19-year-olds (6).

Injuries not only cause a significant decrease in quality of life, but are also very costly. Overall in Europe, the annual
health care costs of treating patients who subsequently die from injuries sustained are estimated to be €1−6 billion,
and those of non-fatal injuries €80−290 billion. Injuries in the home and from leisure activities (not including
workplace injury, road traffic injury and sport injury) cost about €10 billion for the EU15 countries. This accounts for
about 5.2% of total inpatient expenditure (1), with the cost of road traffic injuries being about 2% of a country’s
GDP (7). It is estimated that injuries consume approximately 10% of hospitals’ resources (3).

What do we know?

Overview: morbidity and mortality

Prevalence
Injuries are one of the leading causes of morbidity and mortality among children and young people over 12 months
(Table 3.1.1). In the EU27 countries between 2003 and 2005, injury deaths accounted for:

• 3% of deaths among those aged 0–1 years

• 27% of deaths among those aged 1–4 years
• 37% of deaths among those aged 5–14 years
• 65% of deaths among those aged 15–24 years (3).

The leading causes of fatal unintentional injuries among 0–19-year-olds in Europe were road traffic (39%), drowning
(14%), poisoning (7%), fires (4%) and falls (4%). Other causes, including suffocation, choking, strangulation, hypo-
and hyperthermia, animal encounters and natural disasters, account for 32% of all deaths (1).

Injury mortality and morbidity are not equally distributed among countries and between genders and age groups.
Injury mortality and morbidity in all age groups and from all causes are more prevalent among males. All injury types
increase with age (from age 1 to age 24), and the increase is steeper among males (3).

36
 injuries and accidents

Table 3.1.1 leading TEN causes of deaths among people aged 0–24 years in Europe WHO, 2006

Rank 10–14 years 15–19 years 20–24 years

1 Road traffic injuries Road traffic injuries Road traffic injuries
2
3
4
5
Lower respiratory infection
Drowning
Self-inflicted injuries
Leukaemia
Self-inflicted injuries
Violence
Drowning
Poisoning
Self-inflicted injuries
Violence
Poisoning
War
3.1

6 Congenital anomalies Lower respiratory infection Drowning

7 Violence Cerebrovascular disease Tuberculosis
8 Cerebrovascular disease Leukaemia Cerebrovascular disease
9 Poisoning War Falls
10 Epilepsy Falls Drug-use disorders

Injury mortality varies greatly by country, but males are at much higher risk for injury-related death in most countries
(Fig. 3.1.1). Injury rates also vary widely, with higher rates in middle-income countries than in high-income countries.
Within countries, injury fatalities, irrespective of cause, are associated with poverty, single parenthood, low maternal
education, low maternal age at birth, poor housing, large family size and parental alcohol or drug abuse. In that
sense, injuries are the leading cause of inequality in childhood death (1).

With the exception of drowning and burns, all types of injuries increase with age, and the increase is more substantial
among males (Table 3.1.2) (7).

Table 3.1.2 Injury-related mortality in European Region per 100 000 population WHO, 2008

0–4 years 5–14 years 15–29 years

Males Females Males Females Males Females
All 42.3 28.0 27.4 11.9 128.3 28.4
Road traffic injuries 3.8 4.0 4.8 3.4 29.4 7.4
Fire-related burns 3.8 4.0 0.6 0.5 1.0 1.1
Drowning 7.7 4.4 5.8 2.4 9.1 1.7
Falls 1.8 1.2 1.0 0.4 2.8 0.6
Poisoning 4.6 4.0 1.6 1.0 13.2 3.1

Road traffic injuries

Prevalence
Road traffic injury is the leading cause of death among young people aged 10–24 and, as such, requires further
attention. While young people represent 11.4% of the population, they account for 20.4% of traffic fatalities
(Fig. 3.1.2) (8).

Road transport is one of the most complex and dangerous systems people have to deal with on a daily basis (3). For
children, daily life includes travelling to school, home and play, which leaves them vulnerable to road traffic injuries.

Road traffic injuries are the leading cause of death among 5–24-year-olds in Europe, in spite of improvements in
traffic safety in many countries. They are also the leading mechanism of traumatic brain and extremities injuries and
subsequent long-term impairment (1). Most road traffic fatalities are of car passengers, followed by pedestrians and
riders of motorcycles and scooters (3).

37
 A Snapshot of the Health of Young People in Europe 2009

Fig.3.1.1
DEATHS (PER 100 000) DUE TO INJURY AND POISON AMONG 5–19-YEAR-OLDS WHO Health for all database, 2004

Males Females

Lithuania

Estonia

Romania

Finland

Slovenia

Sweden

Poland

Norway

Slovakia

Austria

Portugal

Bulgaria

Czech Republic

Greece

Iceland

Spain

Hungary

Luxembourg

Switzerland

Ireland

France

Denmark

Germany

United Kingdom

Cyprus

Netherlands

Malta

0 5 10 15 20 25 30 35 40 45

Rates per 100 000

38
 injuries and accidents

Fig.3.1.2
PROPORTION OF YOUNG PEOPLE IN POPULATION AND IN TRAFFIC FATALITIES

3.1

Inequalities
Children in middle-income countries have a 60% higher risk of dying from road traffic injuries than those in high-
income countries.

Injuries in the community

Prevalence
As part of the HBSC survey, schoolchildren were asked how many times during the last 12 months they had been
injured and had to be treated by a doctor or nurse. Overall, about 42% of 11-, 13- and 15-year-olds reported at least
one such injury. As with fatal injuries, injury prevalence increased between 11- and 15-year-olds of both genders.

Inequalities
Injury is more prevalent among boys in all countries and across all age groups. However, unlike fatal injury and severe
injury, injuries in the community are more prevalent among children from more-affluent families. Country variations
are also different for injuries in the community: injury rates are relatively higher in northern and western Europe,
while rates in eastern Europe are relatively low (Table 3.1.3).

39
 A Snapshot of the Health of Young People in Europe 2009

What are the challenges? Table 3.1.3 HBSC 2005/2006

As children grow, they become more exposed to activities
that may end in an injury. Children’s injuries receive more
attention than injury in young people, resulting in few
international reports specific to the latter age group.
Although it is known that injuries are the leading cause
of deaths among 15–24-year-olds, data are mainly
broken down for 19-year-olds and under. The age group
of 19–24 years is rarely presented separately, limiting the
ability to provide specific figures for young people.
Additionally, whereas mortality data are fairly
comprehensive, data on injury morbidity are inconsistent.
Assessing the non-fatal burden is consequently
challenging, given the variety of data systems in
Europe.

Another aspect that needs to be addressed is the

shortage of non-fatal injury data. Such data will allow
the identification of priority areas for intervention and
monitoring of their effectiveness.

It is important to recognize that injuries are preventable

and that examples of efficient prevention programmes do
exist. Lessons should be learnt from such programmes,
allowing for the development of safety promoting health
policies.

40
mental health 3.2

and well-being
Summary
• The mental health of young people in Europe is generally good, but mental disorders
are on the rise. Worldwide prevalence rates of mental disorders for those under the
age of 18 years are currently in the region of 10% to 20%.
• Well-being is a fundamental part of mental health and deserves more attention in research.
• Special attention should be paid to migrant youth, as they are especially at risk.
• Low socioeconomic status (SES) is related to poor mental health. Gender and age
differences should also be reflected in policy considerations and intervention and
prevention programmes.
• There appears to be a fundamental lack of data on the mental health
and well-being of young people aged 18−24.

41
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Mental health in young people is a topic of increasing importance in Europe. The configuration of health and illness
in young people has changed considerably over the last century. The main problems of the first half of the 20th
century, such as acute infections and high infant mortality, have diminished in importance (1), while the so-called
“new morbidity” characterized by internalizing and externalizing problems and learning disabilities came to the
fore in the middle part of the century. More recently, new phenomena such as self-harm and online game addiction
have arisen.

Facing the magnitude of the burden of disease related to young people’s mental disorders, WHO declared that
young people’s mental health was “a key area of concern” to which professionals and policy-makers must direct
their attention (2).

Although the mental health of the majority of European youth is good, psychological disorders of all kinds, such as
anxiety and phobia, post-traumatic stress disorder, learning disorders, depression, eating disorders and addictions,
are on the rise. Some of them currently have an alarming prevalence among young people in Europe. It is estimated
that the overall prevalence of mental disorders in adolescence is in the region of 10% to 20% (3), but this is
anticipated to be even higher among adolescents belonging to underprivileged and poorly integrated population
subgroups, such as migrants.

Compared to adults, young people are especially at risk of developing mental disorders as they face many new
pressures and challenges in their daily lives. For example, leaving the parental home for the first time, exams and
financial worries can cause high levels of stress, which can trigger mental ill health. Additionally, unfair denial of
employment opportunities, discrimination and difficulties in access to services, health insurance and housing, leaving
education early or underachieving, and peer and media pressure are all risk factors for, and consequences of, mental
health problems.

Besides the absence of any mental disorder, good mental health is also characterized by high levels of well-being,
including aspects of happiness, social involvement, self-esteem and sociability. WHO defined good mental health as
“a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of
life, can work productively and fruitfully, and is able to make a contribution to his or her community” (4).

Both mental health and well-being are essential for the health of young people. Happy and healthy young people
are most likely to grow into happy and healthy adults, who in turn will contribute to the health and well-being of
nations (5). On an individual level, poor mental health and low levels of well-being can have deteriorating effects on
young people’s social, intellectual and emotional development, on their family, and on their future. Decisions taken
in adolescence are often of significance for the rest of young people’s lives.

What do we know?
WHO states that the “development of a child and adolescent mental health policy requires an understanding of
the prevalence of mental health problems among children and adolescents” (6). Quantifying the burden of mental
disorders in young people in Europe is, however, a difficult task. One of the reasons for this is that psychological
and psychosocial problems in adolescence tend to be under-recognized and undertreated as they do not present as
typical and discrete entities, as they tend to in adulthood. Estimates of psychological problems and disorders may
therefore be higher than is reported by studies.

A second reason is that there is low comparability of national studies due to different definitions of mental health
being employed (including “mental health problems”, “psychosomatic complaints”, “psychiatric disorders” and
“life satisfaction”) and different data collection methods being used.

42
 mental health and well-being

Fig. 3.2.1
15-YEAR-OLD GIRLS WHO REPORT 2005/2006
HIGH LIFE SATISFACTION HBSC Survey

3.2

90% or more
85 to 89%
80 to 84%
75 to 79%
less than 75%

HBSC teams provided disaggregated data for Belgium and the United Kingdom: these data appear in the map above

Fig. 3.2.2
15-YEAR-OLD BOYS WHO REPORT 2005/2006
HIGH LIFE SATISFACTION HBSC Survey

90% or more
85 to 89%
80 to 84%
75 to 79%
less than 75%

HBSC teams provided disaggregated data for Belgium and the United Kingdom: these data appear in the map above

43
 A Snapshot of the Health of Young People in Europe 2009

Overall prevalence estimates of mental disorders

Data on the age group 18−24 years are scarce; the focus here is therefore on younger age groups.

It is estimated that 10−20% of young people in Europe have a mental or behavioural problem.

Anxiety disorders (that is, generalized anxiety disorder, panic disorder, phobias, obsessive compulsive disorder, post-
traumatic stress disorder and separation anxiety) are the most prevalent mental disorders among young people, with
an average national prevalence rate of 10.4% (although cross-national variations exist). The second most prevalent
mental disorders are conduct disorders (7.5%); while anxiety disorders are more prevalent among girls, conduct
disorders are more prevalent among boys.

Depression and depressive disorders come third, with a prevalence ranging from 4% to 8% (7). The lifetime prevalence
of major depression is about 4% in the age group 12−17 and 9% at age 18 (twice as high in females as in males).
The latest findings suggest an increase in the prevalence of adolescent depression.

Finally, hyperactivity/attention deficit disorders (ADHD) are estimated to have a prevalence rate of 4.4% among
young people, affecting more boys than girls (8). Psychotic disorders such as schizophrenia, schizoaffective disorder
and affective and atypical psychoses are rare, but the incidence of schizophrenia increases typically after puberty and
peaks in early adulthood. The prevalence of psychotic disorders is between 0.5% and 1% among young people (9).

Well-being and happiness

Well-being is a fundamental part of mental health. The HBSC 2006 survey (10) therefore measured adolescent well-
being in terms of life satisfaction. The survey showed that high life satisfaction is common among young people in
European countries: 85% of the 13-year-olds and 82% of the 15-year-olds reported high life satisfaction (Fig. 3.2.1,
Fig. 3.2.2).

Multiple health complaints

The HBSC survey measured mental health based on psychosomatic complaints experienced by young people aged
11−15 years. Psychosomatic complaints, or symptoms, are thought to be indicators of how people are responding to
stressful situations. They include somatic symptoms like headaches or backaches and psychological symptoms such as
nervousness or irritability, and can place an immense burden on the individual and on the health care system (10).

On average, 33% of the 13-year-olds and 37% of the 15-year-olds reported multiple (two or more) health complaints
more than once a week (Fig. 3.2.3, Fig. 3.2.4). There were large cross-national differences, with estimates ranging
from 13% in 11- and 15-year-old Austrian boys to 76% in 13-year-old Turkish girls. There was a significant gender
difference, with girls reporting multiple health complaints more frequently than boys. Also, young people with
low socioeconomic status were more likely to report multiple health complaints compared to those with high
socioeconomic status. With respect to geographical differences, young people in southern Europe were slightly
more likely to report multiple health complaints compared to other European regions (10).

Subclinical symptoms
The European Kidscreen study was carried out between 2001 and 2004. It measured non-clinical mental health
problems in young people aged 12−18 years in 13 European countries (Austria, the Czech Republic, France, Germany,
Greece, Hungary, Ireland, Poland, Spain, Sweden, Switzerland, the Netherlands and the United Kingdom).

The results therefore do not represent medical diagnoses, but indicate adolescents with emotional and behavioural
problems that could have an impact on their individual well-being and daily functioning.

The percentage of adolescents who showed strong signs of mental disorders varied considerably across countries,
ranging from 2.9% in Germany to 10.4% in the United Kingdom, with an average of 5.2%. An additional 9.9%
(range: 6.2% in the Netherlands to 13.8% in Greece) showed somewhat less strong, but still significant, signs of
mental disorder (11).

44
 mental health and well-being

ig
15-YEAR-OLD GIRLS WHO REPORT MULTIPLE 2005/2006
HEALTH COMPLAINTS MORE THAN ONCE A WEEK HBSC Survey

3.2

0% o o
50 to 59%
0 to 9 %
0 to 9 %
0 to 9 %
t 0%

HBSC teams provided disaggregated data for Belgium and the United Kingdom: these data appear in the map above

Fig. 3.2.4
15-YEAR-OLD BOYS WHO REPORT MULTIPLE HEALTH 2005/2006
COMPLAINTS MORE THAN ONCE A WEEK HBSC Survey

60% or more
50 to 59%
40 to 49%
30 to 39%
20 to 29%
less than 20%

HBSC teams provided disaggregated data for Belgium and the United Kingdom: these data appear in the map above

45
 A Snapshot of the Health of Young People in Europe 2009

Suicide
Suicide is one of the three most common causes of death among young people and is a public health concern in
many European countries. Suicide rates in EU27 countries in 2005 for people between 15 and 29 years were 8 per
100 000 people, with variations across countries ranking from fewer than 5 per 100 000 in some southern countries
to around 25 per 100 000 in northern and eastern Europe (12).

Data on suicide rates in EU countries are shown in Fig. 3.2.5.

Inequalities

Age differences
Generally, an increase in mental disorders with age has been reported (10,13), although not all studies have found
this effect (see, for instance, Ihle & Esser (8)). A potential increase, which appears to continue to rise in young
adulthood, may partly be explained by recurrent cases.

With respect to well-being, there is a significant decline in levels of life satisfaction between ages 11 and 15 among
girls in almost all countries, but this applies to boys only in a minority of countries.

Gender differences
In general, girls tend to suffer more from internalizing disorders, while boys have a tendency to experience more
externalizing problems. This may be related to the fact that boys and girls tend to have different reactions to stress
and trauma. Boys are more likely to respond to stress by means of aggression (either against others or against
themselves), to use physical exertion or recreation strategies and to deny or ignore stress and problems. In contrast,
adolescent girls more frequently become introverted and internalize the problems they encounter, yet are more likely
to admit they cannot cope in difficult situations and more often turn to friends to discuss their problems.

In the HBSC survey, boys generally reported higher life satisfaction and fewer psychosomatic complaints (10). These
gender differences increased with age.

Socioeconomic differences
Research on socioeconomic inequalities in mental health has shown associations between lower socioeconomic
status and impaired mental health. This has been found for mental disorders as well as for positive mental health
(10,11).

Geographical differences
Based on the 2006 HBSC data, boys in northern and western Europe are more likely to report high life satisfaction,
while those in eastern and southern Europe are significantly less likely to do so. With respect to the experience of
multiple health complaints, boys and girls in eastern and southern Europe have relatively high levels of multiple
health complaints, while those in northern and western Europe are less likely to report those complaints. Percentages
ranged from 96% in 13-year-old boys in the Netherlands to 61% in Turkish 15-year-old girls.

Life satisfaction was found to decrease with age and was higher for boys. Young people with higher socioeconomic
status tended to report greater life satisfaction.

46
 0
5
15

10
35
45

25

20
30
50

40
Fig. 3.2.5

Austria

Belgium
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
SUICIDE AND INTENTIONAL SELF HARM PER 100 000

France
Germany
Greece
Hungary
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Slovakia
SDR (15–29) MALE

Slovenia
Sweden
Switzerland
TFYR Macedonia†

United Kingdom
SDR (15–29) FEMALE
WHO Health for all Database
mental health and well-being

†
The former Yugoslav Republic of Macedonia

47
3
.2
 A Snapshot of the Health of Young People in Europe 2009

What are the challenges?

Trends in mental ill health: an increase over time?

Several studies provide evidence to support the assumption that rates of mental disorders in young people increase
over time.

Rutter & Smith (14) conclude from their review that there has been a substantial rise in the prevalence of psychosocial
disorders in many western nations over the past 50 years. Reviews by Fombonne (15) and Prosser & McArdle (16)
arrive at the same conclusion, particularly in relation to suicide, delinquency/offending behaviour, substance misuse/
addictive behaviours and depression. Collishaw et al. (17) provide comparable data, indicating a rise in conduct
problems and emotional problems over time.

Caution is warranted in interpreting these findings, as data sources are limited. There is also the suggestion in some
reports that increased media attention and heightened professional awareness are contributing to the rising number
of referrals and diagnoses (18,19). And there is now evidence to suggest that the trend may be reversing in some
countries, such as the United Kingdom (20,21).

Mental health of migrant adolescents

Membership of an ethnic minority, combined with low socioeconomic status, is a factor linked to mental disorders
and the adoption of risky behaviours in adolescents. It is believed that this issue must be mainly addressed from
the perspective of promoting and assuring school success as the only way to break the cycle of “poverty−>social
exclusion−>school failure−>health-compromising behaviours−>school dropout−> under- or unemployment−>social
exclusion−>poverty”.

Migrant status and low socioeconomic status are associated: they often coexist with a higher level of adolescent
risk behaviours. Adolescents in this situation reveal that they feel socially unsupported and unhappy. Other in-
depth studies have suggested a co-occurrence of poor physical health, risk behaviours (substance use) and poor
mental health, and stress the importance of social settings, school ethos and family−school links. They also suggest
the need for a global community intervention within adolescent contexts (family, school, community) to promote
personal and social skills adequate to their needs, the final aims being the promotion of well-being, competence,
autonomy, personal sense of responsibility, sense of belonging and personal achievement, social participation and
commitment.

Economically disadvantaged adolescents who live in deprived neighbourhoods with mainly ethnic minorities are in
greater danger of social exclusion, discrimination and stigmatization and face more severe social problems, all of
which are highly related to mental disorders.

Self-harm procedures
Self-harm procedures, without intention of suicide, are becoming more common among adolescents as a way of
regulating anxiety, depression, boredom and feelings of emptiness or lack of self-worth (22−24).

Young people who self-harm also more frequently report negative emotions, lack emotional self-regulation and
experience depression and anxiety (25).

48
 mental health and well-being

Online games addiction

Online games abuse or addiction presents a serious threat to the mental health of young people in Europe. “Massive
multiplayer online games” (MMOG) are computer games that can be played by thousand of players at the same
time.

The arising concept of online games addiction is associated with the fact that the young people who are involved
in playing the games withdraw from real life and its challenges and duties, such as attending school, sleeping and
eating properly and engaging with family life and friends; this can occur when they become increasingly intense and
3.2
frequent users of MMOG.

In the HBSC survey, the number of adolescents referring to spending several hours a day using a computer, specifically
on weekends and in countries that more recently were integrated into the EU, increased dramatically between 2002
and 2006. In some countries, withdrawal from family and school life was associated with computer use (10).

Gaps and problems with data

There is a need to collect detailed, comparable, reliable and valid data on mental health among young people in
Europe to enable political decision-making to be based on a strong scientific rationale. The mental health status of
18−24-year-olds, in particular, is not systematically measured and deserves to be the focus of future research. Data
on well-being are currently much more scarce than data on mental disorders.

49
 A Snapshot of the Health of Young People in Europe 2009

50
overweight And obesity 3.3

Summary
• Excess body weight among people in Europe poses a serious public health threat
to populations.
• Overweight is an impediment to the physical, mental and social well-being of
individuals and contributes to considerable morbidity and mortality.
• Childhood obesity is strongly associated with risk factors for cardiovascular disease
and diabetes, orthopaedic problems and impaired psychological well-being, including
eating disorders, poor social relations and educational disadvantages.
• Important trends in overweight are noted in relation to sociodemographic variables.
Overweight rates are higher in industrialized societies in individuals from lower
socioeconomic situations, while the inverse is true for countries in transition.
Overweight seems to be associated with male gender.
• The challenge lies in addressing the high prevalence of overweight
and the increasing trend of overweight in all ages, particularly
among children and young people, through a concerted effort
involving governments, industry, communities and individuals.

51
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Excess body weight poses a serious public health challenge in Europe. Overweight and obesity are omnipresent in
affluent nations and in countries in transition.

The most commonly used simple measure for assessing overweight and obesity is the body mass index (BMI). It is
defined as the weight in kilograms divided by the square of the height in metres (kg/m2).

Variable definitions have been used to define overweight in children based on BMI for age and using gender-specific
reference charts for growth. Generally, children with values in the upper extremes of the growth reference chart
(between the 85th and 95th centile) have been considered “overweight” and those in the uppermost extreme (over
the 95th or 97th centile) have been considered “obese”.

Results vary depending on the reference chart used. Care must therefore be taken to choose the growth reference
chart that is most appropriate for the population. In 2000, the International Obesity Task Force (IOTF) published
age- and gender-specific international cut-offs based on data from six different reference populations (the United
Kingdom, Brazil, the Netherlands, Hong Kong, Singapore and the United States) (1). It defined adult cut-offs of 25
kg/m2 for overweight and 30 kg/m2 for obesity. The IOTF cut-offs offer a single standard international reference
that can be used to compare the burden of overweight across populations throughout the world (2), although it is
recognized that this reference data set may not adequately represent non-western populations.

Increasingly, obesity is approached from an ecological perspective – that is, one that attributes a correlation between
rising levels of obesity with poor (high energy-density) diets and physical inactivity, rather than individual variables
such as psychological characteristics. This is sometimes referred to as an “obesogenic” environment.

Overweight and obesity present Europe with an unprecedented health challenge that has been underestimated and
is compounded by the complex multifaceted epidemiology (frequency and determinants) of overweight.

The complexity of epidemiology of overweight and obesity is not widely appreciated and tends to be under-
recognized, particularly with respect to variation in overweight prevalence in relation to age, gender, geographic
distribution and socioeconomic status across Europe.

Apart from the well-documented association of overweight with conditions comprising the metabolic syndrome
(hypertension, dyslipidaemia, glucose intolerance) and increased risk of type 2 diabetes and cardiovascular disease,
there is increasing evidence that obesity is linked to certain cancers and diseases that partly reflect mechanical stress
on the body as a result of increased body weight and fatness (such as shortness of breath, sleep apnea, back pain
and osteoarthritis). Overweight is also associated with social and psychological consequences such as social stigma,
low self-esteem, depression and a poor quality of life.

Overweight and obesity in childhood carry serious health consequences that can last into adulthood. Childhood
obesity is strongly associated with risk factors for cardiovascular disease and diabetes, orthopaedic problems and
impaired psychological well-being, including eating disorders, poor social relations and educational disadvantages
(3–6). Overweight children are more likely to become overweight adults (7,8). A high BMI in adolescence predicts
elevated cardiovascular disease and adult mortality rates, even if the excess body weight is lost.

52
 overweight and obesity

What do we know?
Various collaborative surveys conducted by WHO, the IOTF, the European Childhood Obesity Group and the European
Association for the Study of Obesity (EASO) Childhood Obesity Task Force have produced important information
on the distribution of overweight and obesity in relation to age, gender, geography and socioeconomic factors in

3
Europe.

Distribution of overweight and obesity .3

Prevalence
For children under 15 years, two kinds of information concerning overweight and obesity is available:

• information based on measured weight and height in surveys in several countries (IOTF/EASO) during
1990−2001; and
• information based on reported data on weight and height in two international studies: the HBSC survey
in 2005/2006 (9), and the pro-children study conducted in 2003 (2,10).

These studies generally indicate a high prevalence of overweight among children under 15 years in Europe of
between 10% and 20%.

Fig.3.3.1 presents geographically the prevalence of overweight in 14−17-year-old children using the IOTF cut-offs.
A clear trend of lower prevalence of overweight among children in central and eastern European countries, whose
economies suffered various degrees of recession during the period of economic and political transition in the 1990s,
is noted (11). A north−south gradient in overweight prevalence is reflected and a clear trend of higher rates of
overweight among children in southern Europe is evident, with over 20% of 14−17-year-olds who are overweight
being in southern European countries such as Spain, Italy, Greece and Malta.

Fig. 3.3.1
PREVALENCE OF OVERWEIGHT IN
14–17-YEAR-OLDS BY IOTF STANDARDS Lobstein et al (2003)

20% or more
15 to 19%
10 to 14%
less than 10%

53
 A Snapshot of the Health of Young People in Europe 2009

There is a lack of specific data on late-teenage years (15−19 years), although surveys have generally included this
age group in the category “adults”.

Prevalence of overweight and obesity among adults in Europe is shown in Fig. 3.3.2 (10).

inequalities
Although the prevalence of overweight based on reported data is generally underestimated due to overestimation of
height and underestimation of weight, cross-country and regional comparisons can nevertheless be drawn.

In the HBSC survey, higher rates of overweight (>20%) were noted in southern European countries such as Spain,
Malta, Italy and Greece, while lowest prevalence was seen in central Europe (Fig. 3.3.3, Fig. 3.3.4) (9). No clear age
patterns were observed in this survey (12).

The HBSC survey supports a significant association between male gender and overweight prevalence in most
European countries surveyed. In addition, children from low-affluence families who took part in the survey reported
higher levels of overweight and obesity, particularly in western Europe. In contrast, a positive association between
overweight prevalence and family affluence is noted in countries in transition, with high rates of overweight in
affluent families (12).

The higher rates of overweight in southern European countries and in children from disadvantaged families in
affluent countries can be linked to several elements in the “obesogenic” environment, including factors such as:

• urbanization of populations;
• concomitant changes in diet (consumption of energy-dense foods and soft drinks in place of fruit
and vegetables); and
• reduced physical activity levels (increased television viewing or the absence of safe streets,
parks, or play areas) (2).

54
 overweight and obesity

Fig.3.3.2
PREVALENCE OF OVERWEIGHT AND OBESITY AMONG ADULTS WHO, 2007

Pre-obese, measured data Pre-obese, self-reported data

Obese, measured data Obese, self-reported data

3
Boys Girls

Austria, 1999, 20+

Denmark, 2000, 16+
9.1
9.8
54.3 21.3
39.8 24.9
9.1
9.1
.3
Italy, 2003, 18+ 9.3 42.1 25.8 8.7
France, 2003, 15+ 11.4 37.4 23.7 11.3
Sweden, 2005, 16–84 12.0 41.0 26.0 11.0
Slovakia, 2002, 15+ 13.5 44.3 22.4 15.0
Belgium, 2004, 18+ 11.9 38.7 24.4 13.4
Romania, 2000, 15+ 7.7 38.1 28.6 9.5
Cyprus, 2003, 15+ 12.9 41.0 26.9 11.8
Netherlands, 2005, 20+ 9.9 40.5 28.2 11.4
Finland, 2005, 15–64 14.9 44.8 26.7 13.5
Iceland, 2002, 15–80 12.4 44.6 28.0 12.3
Estonia, 2004, 16–64 13.7 32.0 25.7 14.9
Germany, 2003, 18+ 13.6 41.1 28.9 12.3
Bulgaria, 2001, 15+ 11.3 38.8 28.8 13.5
Latvia, 2004,15–64 11.9 30.1 23.9 19.5
Lithuania, 2004,20–64 14.2 38.3 29.3 16.9
Czech Republic, 2002, 16+ 13.7 43.0 31.1 16.3
Greece, 2003, 20–70 26.0 41.1 29.9 18.2
Portugal, 1999, 15+ 13.4 41.8 32.4 15.9
Ireland, 1997–1999, 18–64 20.1 46.3 32.5 15.9
Poland, 2000, 19+ 15.7 41.0 28.7 19.9
Wales, 2003–2004, 16+ 17.0 42.0 31.0 18.0
Malta, 2002, 20–64 26.6 41.6 29.0 20.4
Hungary, 2003–2004, 18+ 17.1 41.8 31.3 18.2
England, 2003, 16+ 22.2 43.2 32.5 23.0
Turkey, 2003, 15–49 33.5 23.5
Scotland, 2003–2004, 16+ 22.4 43.0 33.7 26.0

100 80 60 40 20 0 20 40 60 80 100

55
 A Snapshot of the Health of Young People in Europe 2009

Fig.3.3.3 Fig.3.3.4
13-YEAR-OLDS WHO REPORT THAT THEY ARE 2005/2006 15-YEAR-OLDS WHO REPORT THAT THEY ARE 2005/2006
OVERWEIGHT OR OBESE ACCORDING TO BMI HBSC Survey OVERWEIGHT OR OBESE ACCORDING TO BMI HBSC Survey

¹ Malta 31 Girl % 28 Girl %

31 Malta 32
13 Boy % 18 Boy %
*Greece 27 Wales 21
11 13
*Italy 25 *Portugal 22
¹ Wales 17 11
18 *Greece 25
12 12
*Spain 19 *Iceland 22
¹ Scotland 15 10
16 *Italy 23
13 10
*Portugal 18 *Slovenia 20
11 12
*Hungary 20 *Finland 19
10 11
*Slovenia 20 *Spain 19
12 10
*Iceland 16 *Croatia 19
12 11
Czech Republic 16 *Hungary 17
11 11
*Finland 17 *Germany 16
¹ England 14 12
14 Belgium (French) 15
10 12
*Croatia 17
¹ Scotland
14
¹ Ireland 14 9
13 *Austria 19
10 7
*TFYR Macedonia† 17 *TFYR Macedonia† 19
7 8
*Bulgaria 18 *Norway 16
10 10
*Luxembourg 15
¹ *Ireland
15
¹*Belgium (French) 10 9
14 *Luxembourg 16
8 9
*Romania 15 *Czech Republic 14

*Germany 8 9
14 *Sweden 15
8 6
*Poland 14 *Bulgaria 18

*Sweden 9 8
13 *France 14
7 9
*Estonia 14 *Denmark 13
7 7
*Austria 14 *Switzerland 14
7 8
*Turkey 13
¹ *England
13
10 10
Belgium (Flemish) 10 Netherlands 10
8 5
*France 12 *Turkey 14

Norway 9 8
10 *Belgium (Flemish) 11
5 6
*Switzerland 12 *Poland 12
8 5
Netherlands 8 *Estonia 11
7 4
Denmark 9 *Slovakia 11
The former Yugoslav Republic of Macedonia

The former Yugoslav Republic of Macedonia

*Slovakia 6 Latvia 6
11 8

*Latvia 5 *Romania 4
12 10
¹*Lithuania 4 4
9 *Lithuania 8
Average (gender) 10 9
15 Average (gender)
16
Average (total) 13 Average (total) 13
†

* indicates a significant gender difference (at p<0.05) 1

indicates 30% or more missing data

56
 overweight and obesity

Body image
Around 30% of young people who took part in the HBSC survey believed they were “a bit” or “much too” fat, with
more girls (37.3%) holding this perception than boys (22.6%). This negative body image becomes more prevalent
with age in girls. “Feeling too fat” varies a lot across countries but is more common among girls living in northern

3
and western Europe (Fig. 3.3.5, Fig. 3.3.6).

There is strong correspondence between young people’s perceived and declared body weight. In France, for example, .3
77% of overweight and 89% of obese adolescents feel they are “a bit” or “much too” fat (13). However, there
are also a significicant proportion of girls who have a negative body image by reporting themselves as too fat even
though they are in normal BMI range.

What are the challenges?

The challenges in addressing the epidemic of overweight in youth and young adults are related not only to its high
prevalence, but also to the fact that trends over time show a continued increase in overweight, particularly at younger
ages. In addition, important gaps exist in the knowledge base concerning the precise estimates of overweight at
specific ages; there is therefore a need for better monitoring to establish trends over time.

Increasing trend of overweight and obesity

Not only is the prevalence of overweight and obesity high in Europe, but it is also the case that annual rates of
increase in overweight continue to rise, posing a further threat to health and emphasizing the need for public
action.

The prevalence of obesity has risen three-fold or more since the 1980s, even in countries with traditionally low rates
of overweight and obesity. The prevalence of overweight in Ireland and the United Kingdom (England and Scotland)
has risen rapidly by more than 0.8% per year based on measured data among both women and men. Based on
self-reported data, the highest annual increases in the prevalence of overweight in women and men have been
seen in Denmark (1.2% and 0.9% respectively from 1987 to 2001), Ireland (1.1% for both genders from 1998
to 2002), France (0.8% from 1997 to 2003), Switzerland (0.8% and 0.6% respectively from 1992 to 2002) and
Hungary (0.6% for both genders from 2000 to 2004). Self-reported adult obesity rates have been falling in Estonia
and Lithuania.

If no action is taken and the prevalence of obesity continues to increase at the same rate as in the 1990s, an
estimated 150 million adults will be overweight or obese by 2010 (10).

Overweight and obesity are increasing in children across Europe over time, consequently “passing” the epidemic
into adulthood and creating a growing health burden for the next generation (Fig. 3.3.7). The rise is particularly
sharp in certain countries: in Poland, for instance, the prevalence of overweight was around 8% in the late 1980s,
but it had more than doubled to 18% 10 years later (6).

This trend is mirrored in the alarming rise in the annual rate of increase in overweight in children and adolescents.
The annual increment in overweight in children is estimated to be about 5 to 10 times higher than it was in 1970.
The IOTF predicts that about 38% of school-aged children in Europe will be overweight by 2010, and that more than
a quarter of these children will be obese.

57
 A Snapshot of the Health of Young People in Europe 2009

Key gaps and priority areas for further research

The evidence reviewed here on the prevalence of overweight and obesity among children, adolescents and adults
from national and regional studies has been compiled from existing databases, published literature and information
from health agencies. Discrepancies in sampling methods, techniques used to assess body weight and height
(“measured” versus “self-reported”), sampling periods and pooling of ages (particularly late teens into adult years)
in the information available, as well as the cross-sectional nature of most surveys, mean that caution is necessary in
the interpretation of the findings.

There is a need for systematic longitudinal data to provide precise estimates of prevalence and trends for overweight
and obesity, and a need for more-specific information on the age group of 15−25 years than is currently available.
In addition, there is a need to better understand the relationship between self-declared and measured height and
weight data. If large-scale, well-designed studies were to consider age, gender, weight status and socioeconomic
factors in their design, correct weights that could be applied to future national surveys based on self-reported data
could be produced, improving the validity of estimates on overweight prevalence.

Most surveys are based on BMI which, although practical, has limitations, particularly among certain groups such
as children with growth problems and adolescents going through puberty. BMI status in relation to perceived self-
image is another important area, particularly among children and adolescents, but little is known on this issue, with
the HBSC survey the only known source of information.

It must be acknowledged that not only overweight, but also underweight, carries health risks, but little information
on underweight in the age group of interest (11−25-year-olds) was found. Future surveys should aim to examine the
prevalence of underweight in this age group.

The aetiology of overweight and obesity is complex and multifactorial. More work needs to be done to identify what
is effective (taking into consideration age, gender, socioeconomic situations and cultural differences) in combating
the increasing threat of overweight and obesity in children, adolescents and young adults.

58
 overweight and obesity

Fig. 3.3.5 Fig. 3.3.6

PERCEIVED BODY IMAGE OF BEING 2005/2006 PERCEIVED BODY IMAGE OF BEING 2005/2006
“TOO FAT” AMONG 15-YEAR-OLD GIRLS HBSC Survey “TOO FAT” AMONG 15-YEAR-OLD BOYS HBSC Survey

3.3

50% or more 50% or more

40 to 49% 40 to 49%
30 to 39% 30 to 39%
20 to 29% 20 to 29%
10 to 19% 10 to 19%
less than 10% less than 10%

HBSC teams provided disaggregated data for Belgium and the United Kingdom: these data appear in the map above

Fig.3.3.7
RISING TRENDS IN OVERWEIGHT CHILDREN International Obesity Taskforce, 2002

Ch – Switzerland; Ne – Netherlands; Sp – Spain; Po – Poland; Fr – France; Cz – Czech Republic; UK – United Kingdom

25%

Sp
20%
Ne Po
Fr
UK
Prevalence

15%
Cz

10%

Ch

5%

0%
1960 1965 1970 1975 1980 1985 1990 1995 2000

59
 A Snapshot of the Health of Young People in Europe 2009

60
 health 4
and risk
behaviours

61
 A Snapshot of the Health of Young People in Europe 2009

62
eating patterns 4.1

Summary
• Good nutrition is important for growth and development, health and well-being.
• The dietary habits of young people are not optimal in terms of maintaining health
or preventing disease.
• Data on younger children illustrate that daily fruit and vegetable intakes are below
recommended levels and daily soft drinks consumption is high, particularly in eastern
European countries. Missing breakfast is common among adolescents.
• Data on the dietary patterns and factors that influence food choice among young
people aged 17 and older are lacking.
• European-wide dietary strategies that are culturally appropriate and that are applicable
to various age groups and socioeconomic backgrounds require further exploration.

63
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Good nutrition is fundamental for healthy development and to maintain health and well-being. Food also has a role
in both causing and preventing diseases. The prevalence of unhealthy diets in European countries is of particular
concern for adults and children. Diet-related chronic diseases are a serious public health problem among adults, with
a growing incidence of these diseases among younger age groups.

Diet-related diseases
Noncommunicable diseases, which include cardiovascular disease (CVD), cancer and diabetes, are responsible for
86% of deaths and 77% of the disease burden (measured in disability-adjusted life-years ) in Europe (1). CVD is the
number one killer in Europe, causing more than half (52%) of all deaths.

Many of these conditions are linked by common risk factors. Seven leading risk factors account for almost 60% of the
disease burden in Europe, including being overweight (7.8%) and low intake of fruit and vegetables (4.4%) (1,2).

Diets high in salt and energy-dense foods also contribute to the burden of disease (3,4). One third of CVD cases are
related to poor diets (5); good nutrition could prevent about one third of cancer cases (6) and modest changes in diet
and physical activity could prevent up to 60% of diabetes cases.

Children are increasing their risk of early development of chronic diseases such as CVD, diabetes, the metabolic
syndrome, osteoporosis and some cancers through lifestyle and dietary patterns. Childhood obesity is a current
health crisis (7), resulting in young children being diagnosed with altered glucose metabolism and the metabolic
syndrome (8–10). Nutrient deficiencies are also of concern, specifically of iron and iodine, both of which affect brain
development in children (11,12).

The cost of diet-related diseases is estimated to account for some 30% of national health service costs (13). Overweight
and obesity alone are responsible for up to 6% of health care expenditure in Europe. There are other social and
economic costs beyond the health sector, with a significant proportion of the total cost of care falling on patients
and their families. Indirect costs in terms of lost lives, diminished productivity and reduced income can nearly match
or, in some cases, exceed the direct costs. It is estimated that indirect costs for overweight and obesity, for example,
are two times higher than direct health care costs.

The emergence of an “obesogenic” environment has been associated with the increasing prevalence of obesity and
diet-related chronic diseases throughout the world (14), particularly in those countries undergoing socioeconomic
transition (15,16). Policy approaches to tackle these issues have moved towards multisectoral and environmental
interventions, while also continuing to develop individual and population-based approaches.

As of 2006, one third of the European countries had developed policies on food and nutrition (17), but no country is
meeting WHO’s recommended dietary goals (3), and the burden of diet-related diseases continues to grow.

The second action plan on food and nutrition policy (17) is therefore timely. Proposed within it are a number of goals
and action areas spanning various sectors, enabling countries to target consistent priorities across national food and
nutrition policies, noncommunicable disease prevention strategies and public health policies. Implementing these
policies and evaluating their impact are key.

Good nutrition during childhood

Good nutrition and the establishment of healthy eating habits in childhood and adolescence:

• promotes optimal childhood health, growth and intellectual development;

• prevents immediate health problems such as iron deficiency anaemia, obesity, eating disorders
and dental caries; and
• may prevent long-term health problems such as CVD, cancer and osteoporosis (18,19).

64
 eating patterns

Because of both the immediate and long-term negative consequences of a poor diet, it is important to promote
good nutrition as early in life as possible, thereby reducing the number of years through which damage can occur.

Dietary habits and food choices can track from childhood and adolescence to adulthood (20,21). Consequently,

4
much work has focused on modifying dietary habits, food choice and dieting practices, often employing a settings
approach such as the family environment or school. While encouraging good nutrition as early as possible in life
through, for example, exclusive breastfeeding, good weaning practices and pre-school nutrition (17), much work .1
can also be conducted during the middle childhood years and adolescent period before adverse health behaviours
become firmly established.

The importance of good nutrition during childhood is recognized in the WHO European strategy for child and
adolescent health and development (22), with nutrition being one of the seven priority areas for action. Targets are
proposed in each of the specific life stages: preconception and pregnancy, first year of life, early childhood, late
childhood and adolescence.

The European Youth Forum has identified “nutrition and healthy lifestyles” as one of the key areas of importance
and concern for youth health and well-being (23). Factors the forum has identified as contributing to unhealthy diets
include the greater availability of energy-dense foods and drinks, larger portion sizes and an increase in the use of
restaurants and fast food outlets. Policy measures to encourage healthier food consumption and to support a healthy
body image were recommended, taking into account the needs of those from lower socioeconomic circumstances
who may be more vulnerable to poor diets. Specifically, improvements in food labelling, the production of healthier
food products for children and responsible marketing were called for, in addition to the need for schools to provide
healthy meals affordably or free of charge.

What do we know?
A number of different approaches can be taken to comparing food consumption and dietary patterns across Europe.
These include:

• nationwide surveys of individuals;

• household budget survey data, as coordinated in the Data Food Networking (DAFNE) project,
funded by the European Commission (EC) (24); and
• food balance sheets of the Food and Agriculture Organization of the United Nations (25).

There are recognized advantages and disadvantages to these methods. Some, such as national surveys which
collect individual data by life stage or age group, are more appropriate in exploring young people’s dietary habits at
European level. Other sources, such as household food availability data, are not designed to focus on young people
specifically, although statistical modelling has been used to provide data by age and gender (26).

Importantly, none of the surveys/projects mentioned have addressed issues such as the food environment (homes
and schools, for example) and food marketing and advertising (27,28); these issues are particularly relevant to young
people.

Many of the national dietary surveys among children and adolescents which have provided valuable information to
support local nutrition policy and practice have been compiled in an attempt to explore food and nutrient intakes
by European region (29–33), but differences in sampling, methodology and measurement instruments have made
comparisons difficult. In addition, the focus of these surveys has primarily been on energy and nutrients rather than
patterns of food intake (30−33).

National health and nutrition data have been compiled from 14 European countries, culminating in the European
Nutrition and Health Report (ENHR) (34). Data from an additional 11 countries are currently being added (35). The
report provides data on energy and nutrient intakes of children and adolescents, which are further expanded by data

65
 A Snapshot of the Health of Young People in Europe 2009

obtained from the literature (a total of 79 surveys of 23 countries). The primary aim was to develop dietary guidelines
for young people in Europe (36).

The data, however, are not directly comparable for a number of reasons: various collection methods were used,
age ranges varied and food composition databases differed between countries (36,37). Importantly, insufficient data
were available for any conclusion to be reached on young people’s food patterns in terms of food consumed, rather
than energy and nutrient intakes (36).

Some surveys have investigated the food habits of subgroups of young people in Europe using standardized
methodology, with a view to creating consistency and comparability across participating countries and across
successive surveys, where applicable. These include the HBSC survey and the Healthy Lifestyle in Europe by Nutrition
in Adolescence (HELENA) study, which looks at the age range 13−16 years. There appears to be a lack of published
data on the food habits and dietary patterns of young people in Europe aged 18−25 years.

HBSC survey
The HBSC survey (38) examines self-reported food habits of 11-, 13- and 15-year-olds, focusing on the frequency of
consumption of fruit and vegetables, sweets and soft drinks and breakfast consumption.

Fruit consumption
Daily fruit consumption varies between countries, but intakes decline with age and are lower among boys and those
from low-affluence families in almost all countries (Fig. 4.1.1, Fig. 4.1.2).

Vegetable consumption
Daily vegetable consumption showed similar patterns to fruit consumption, with reported intakes highest among
younger children (33%) compared to older children (28%). Once again, boys were less likely to consume vegetables
on a daily basis across all age groups and in all countries (11-year-olds: 38% among girls versus 31% among boys;
15-year-olds: 34% among girls versus 26% among boys).

Soft drinks consumption

There is considerable variation between countries in terms of non-diet soft drinks consumption, with boys and girls
in northern European countries reporting the lowest levels. Intakes generally increased with age, being significantly
higher among boys than girls at 15 years in almost all countries. Girls from low-affluence families are more likely to
consume soft drinks; this is especially evident in western and northern European countries (Fig. 4.1.3, Fig. 4.1.4).

Based on analysis from the HBSC survey, daily fruit, vegetable or soft drink consumption were not associated
with self-reports of overweight. In an investigation of television viewing among European young people, positive
associations were found for sweets and soft drinks and negative associations for fruit and vegetables, although the
latter observation was not so apparent among central and eastern European countries (39).

Breakfast consumption
The proportion of young people eating breakfast every school day varies considerably between countries, with an
approximate range of 35% to 85%, and an average of 60%.

Breakfast consumption declines with age, especially among girls. Girls aged 13 years (56%) and 15 years (51%) are
less likely to eat breakfast than boys (13 years: 66%; 15 years: 61%). This is the case in almost all countries. In most
cases, eating breakfast is associated with higher family affluence, especially in western and northern Europe.

Daily breakfast consumption was found in most countries to be positively associated with healthy lifestyle
behaviours, such as daily fruit and vegetable consumption, and negatively with unhealthy lifestyle behaviours,
such as smoking, drunkenness and daily soft drinks consumption. In the HBSC survey, irregular breakfast
habits occurred more often among children of single-parent families compared to two-parent family structures.

66
 eating patterns

Fig.4.1.1 2005/2006 Fig.4.1.2 2005/2006

13-YEAR-OLDS WHO EAT FRUIT DAILY HBSC Survey 15-YEAR-OLDS WHO EAT FRUIT DAILY HBSC Survey

51 Girl % 47 Girl %
*England 40 *Italy 37
48 Boy % 44 Boy %
*Belgium (French) 42 Belgium (French) 40

4
48 44
*Romania 40 *England 33
49 40
*TFYR Macedonia† Portugal
.1
39 36
42 46
Italy 44 *Denmark 29
45 40
Portugal 40 *Romania 30
47 41
*Denmark 36 *TFYR Macedonia† 32
46 41
*Slovenia 35 *Norway 32
46 *Switzerland 42
*Czech Republic 36 28
44 34
*Switzerland 37 Malta 35
45 41
*Norway 35 *Belgium (Flemish) 28
47 41
*Malta 33 *Luxembourg 27
44 39
*Turkey 30 *Ireland 29
40 42
*Hungary 34 *Turkey 26
42 41
*Poland 31 *Czech Republic 25
40 40
*Scotland 33 *Slovenia 26
40 36
*Germany 32 *Wales 29
37 34
Croatia 35 *Scotland 29
41 35
*Luxembourg 30 *Germany 23

Bulgaria 33 *Poland 34
37 24
37 31
*Belgium (Flemish) 32 *Croatia 26

*Ireland 38 *Sweden 34
30 22
38 33
*Austria 30 *Slovakia 22
39 *Hungary 29
*Netherlands 28 23
37 29
*Wales 29 *France 24
33 27
Slovakia 32 Bulgaria 25
35 27
*Spain 30 Spain 24
32 32
Greece 31 *Austria 18
35 30
*Estonia 28 *Netherlands 20
32 30
France 29 *Estonia 18
37 24
*Iceland 24 Greece 24
29 28
Sweden 26 *Iceland 18
The former Yugoslav Republic of Macedonia

*Latvia 28 *Finland 28
20 14

*Lithuania 27 *Latvia 26
22 15

*Finland 28 *Lithuania 23
18 15
Average (gender) 39 Average (gender) 35
32 26
Average (total) 36 Average (total) 31
†

* indicates a significant gender difference (at p<0.05)

67
 A Snapshot of the Health of Young People in Europe 2009

An analysis of 31 HBSC countries showed that daily breakfast consumption was consistently negatively associated
with overweight, with the association being stronger for boys than girls (noted in 26 and 18 of 31 countries,
respectively) across all regions.

The HELENA study

A fundamental objective of the HELENA project is to obtain data from a random sample of European adolescents
aged 13−16 years on dietary intake, food choices and preferences, anthropometry, physical activity and fitness and
on a range of blood nutritional, immunological, lipid and genetic markers. While literature on the rationale, overall
objectives, study design and tools to be used have been published (37,40–42), results on dietary patterns are currently
unavailable. Results are timely, as the need for more emphasis on adolescent nutrition was highlighted recently
(43).

What are the challenges?

Although policies on nutrition exist in almost all European countries, the burden of diet-related diseases continues to
grow, particularly as a result of the obesity epidemic (17). There is therefore a critical need to support healthy eating
and physical activity in young people. Poor eating habits, including inadequate intake of vegetables and fruit and an
excess of energy-dense snacks, play a role in immediate and long-term health, with behaviours established during
this time being likely to track into adulthood.

The difficulties of assessing food habits among children and adolescents are many (44). The challenge becomes
even greater when attempting to assess dietary patterns of young people across countries because of wide country
variations in the consumption of many food items, in food culture and portion sizes, and in food composition
databases (45).

Nevertheless, comparable data on food habits across young people in Europe should be collected. While data on a
relatively small number of food items for younger age groups are available, particularly through the HBSC survey, a
more comprehensive investigation of dietary patterns is needed.

In addition to the frequency of food items consumed, information on their portion sizes is also required. These data are
essential for surveillance purposes and as a basis for developing advice and evaluating policies and interventions.

It appears that there is a lack of data on young people’s eating patterns between 15 and 25 years. Many dietary
surveys consider young people over the age of 17 years as “adults”, limiting the potential for intervention work and
for diet and nutritional status surveillance among this age group. Young adults’ food consumption patterns, eating
styles, influences and attitudes around food are likely to differ from older adults and, indeed, from their younger
peers, and more work is warranted among this age group.

While data on food patterns need to be collected, the factors affecting food choices made by young people in
Europe, who live in very different societies and cultures, also needs further exploration. How to effect change at a
European level by investigating how environmental factors affect dietary choice across countries is also worthy of
further work.

Food supply, price and availability across Europe could be explored in terms of how they affect food choice, with
potential for intervention in the food market thereafter. Food marketing and advertising practices to young people
across Europe need continuous monitoring (25). Much work has already been accomplished in terms of establishing
an international code on marketing of foods and non-alcoholic beverages to children (27).

It is recognized that relying solely on an individualistic approach to dietary change is not appropriate. Everyone in
society has a role to play. European-wide dietary strategies that are culturally appropriate and that are applicable to
various age groups and socioeconomic backgrounds require further exploration.

68
 eating patterns

Fig.4.1.3 2005/2006 Fig.4.1.4 2005/2006

13-YEAR-OLDS WHO DRINK SOFT DRINKS DAILY HBSC Survey 15-YEAR-OLDS WHO DRINK SOFT DRINKS DAILY HBSC Survey

49 Girl % 48 Girl %
Bulgaria 53 Bulgaria 51
37 Boy % 37 Boy %
*Malta 47 *Belgium (Flemish) 52

4
36 37
*Belgium (Flemish) 46 *Netherlands 50
40 35
Romania *Malta
.1
42 49
34 38
*Netherlands 42 Romania 44
35 41
Slovakia 40 TFYR Macedonia† 38
35 36
TFYR Macedonia †
37 *Slovakia 42
31 28
Czech Republic 34 *Luxembourg 42
27 29
*Italy 38 *Belgium (French) 41
30 32
Wales 34 Hungary 38
27 33
*Belgium (French) 36 Croatia 35

Hungary 31 29
33 *Scotland 34
26 28
*Croatia 37 *Spain 34
26 25
*Scotland 34 *France 35

Poland 27 26
31 *Wales 34
24 24
*Luxembourg 32 *Czech Republic 34

*France 25 24
31 *Switzerland 34
24 25
*Switzerland 30 *Slovenia 33

Portugal 25 24
27 *Ireland 32

*Spain 22 22
28 *Poland 33

Ireland 23 22
26 *Portugal 32

*Slovenia 21 22
28 *Austria 30

*Austria 20 19
26 *Italy 31

*England 18 21
26 *England 28

*Germany 19 21
23 *Turkey 26

Turkey 19 20
21 *Germany 26

*Greece 12 14
21 *Norway 21

Lithuania 15 12
16 *Greece 24

Latvia 15 13
16 *Iceland 19

Norway 11 9
14 *Denmark 19

*Iceland 10 11
14 *Lithuania 15

*Estonia 8 Latvia 11
15 13
The former Yugoslav Republic of Macedonia

The former Yugoslav Republic of Macedonia

*Denmark 5 *Sweden 6
13 13

*Sweden 5 *Estonia 5
8 11

*Finland 4 *Finland 4
7 9

Average (gender) 23 Average (gender) 24

29 31
Average (total) 26 Average (total) 28
†

* indicates a significant gender difference (at p<0.05)

69
 A Snapshot of the Health of Young People in Europe 2009

70
Physical activity and 4.2
sedentary behaviour
Summary
• Physical activity levels decrease during adolescence. This decrease is more marked
among girls and parallels an increase in overweight and obesity.
• Adolescents’ moderate-to-vigorous physical activity has decreased over time.
• No conclusion can be drawn concerning trends in television watching; however, it clearly
constitutes the major sedentary behaviour among male and female adolescents.
• Computer use has shown an increasing trend which is concomitant with decreased use
of traditional media.

71
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Coronary heart disease, cerebrovascular diseases and chronic obstructive pulmonary disease are among the
leading causes of death throughout the world. Obesity is a risk factor for many of these chronic conditions. There
is an increasing prevalence in obesity and type 2 diabetes in children and adults, with resulting morbidity and
mortality (1,2).

The primary mechanism for overweight and obesity is an imbalance of energy intake versus energy expenditure; lack
of physical activity and excess sedentary behaviour account for one side of this equation.

Extensive reviews of the literature on children and adolescents (ages 6 through 18) indicate that moderate-to-
vigorous activity (MVPA)* is related to decreased adiposity, improvement in metabolic syndrome (abdominal obesity,
elevated blood pressure, elevated fasting glucose and reduced high-density lipoprotein), decreased triglyceride
level, increased high-density lipoprotein level, improved endothelial function, bone density, muscular strength and
endurance and aerobic fitness, and improved mental health (anxiety, depression, self-concept) (3−6).

National surveys confirm the negative relationship between physical activity and obesity (7,8). Physical activity appears
to improve both short- and long-term physical and mental health status: general health, bone health, health-related
quality of life and positive mood states have all been associated with higher levels of daily physical activity (4,9,10). In
addition, there is ample evidence that increased physical activity improves cognitive performance (6,11,12).

Physical activity also brings psychosocial benefits. In HBSC surveys, adolescents’ physical activity had positive
associations with self-image, quality of life, self-reported health status and quality of family and peer communications,
and negative associations with health complaints and, for some countries, tobacco use (13,14).

Based on their extensive review of the literature, Strong et al. (6) developed the recommendation that children
should participate in at least 60 minutes of MVPA daily for any health benefit. This recommendation is consistent
with those of governmental and professional organizations (15−17). Others suggest that longer duration of daily
MVPA is necessary to mitigate cardiovascular risk factors (18). However, many children do not meet the 60 minutes
of daily physical activity recommendations (19).

As children move into adolesence they become less likely to participate in physical activity, and there is a corresponding
increase in obesity (20−23), although HBSC data suggest that physical activity has not decreased in adolescence from
1985 to 2002 (24).

Although HBSC surveys examining relations between sedentary behaviour and physical activity have shown a weak
or no relationship (25,26), sedentary behaviour is a cardiovascular risk factor independent of physical activity levels.
Daily sedentary behaviour is associated with risk for overweight in adolescents ages 11 through 15 (27,28) and
subsequent obesity in young women (29).

The relationship between sedentary behaviour and obesity may depend on the specific activity (watching television,
playing computer/video games or using computers for homework and e-mail), gender and age (30). There is evidence
for a dose−response relationship between sedentary behaviour and prevalence of overweight (19,31,32) and a causal
relationship between sedentary behaviour and obesity is suggested by interventions demonstrating that reduction in
sedentary behaviour leads to improvements in weight status (33). In addition, there is evidence that the cumulative
effect of sedentary behaviour builds up over the course of childhood (34).

Adolescent sedentary behaviour has been related to other health problems, including neck, shoulder and lower
back pain, psychological and somatic symptoms, physical and verbal aggression, hostility, cigarette smoking, alcohol
use and illicit drug use (22,35−41). Adolescent sedentary behaviour has also been shown to be negatively related to
a number of known health promoting and protective factors: physical health status, nutrition, quality of life, body
image, self-image, school performance and quality of family communication (22,36,42).

* Defined as any activity that increases your heart rate and gets you out of breath some of the time.

72
 physical activity and sedentary behaviour

What do we know?

Physical activity

4
Prevalence
It is important that children are encouraged to participate in physical activity, in order to establish health behaviours
which will carry them through adolescense and support them into adulthood (4,43,44). .2
Findings concerning the amount and intensity of physical activity are remarkably consistent across studies and
European countries (45−48). These findings indicate that two thirds of young Europeans do not take part in sufficient
appropriate physical activity and that physical activity levels clearly decline with age.

The European Opinion Research Group analysed physical activity levels of EU countries (49). Fig. 4.2.1 refers to young
people’s participation in physical activity of different intensity, frequency and duration.

Inactivity is a problem, with 43% of the sample participating in no vigorous physical activity in the previous week and
only 17.5% reporting having participated in five or more days. Only 6.5% of the sample had participated in vigorous
physical activity on every day of the week.

Considering moderate physical activity, one third (33.1%) of the respondents reported not doing any in the past
week. Only 27.4% reported having participated in five or more days, of which 14.6% reported moderate physical
activity on every day of the past week.

Over the previous seven days, 45.3% of young people reported walking each day for at least 10 minutes, with 13%
reporting they walked for more than 60 minutes on a usual day.

European Opinion
Fig. 4.2.1 YOUNG PEOPLE’S PARTICIPATION IN PHYSICAL ACTIVITY OF DIFFERENT INTENSITY, FREQUENCY AND DURATION Research Group

Highest Percentage Lowest Percentage

VIGOROUS PHYSICAL MODERATE PHYSICAL
ACTIVITY IN THE ACTIVITY IN THE WALKING IN THE
PREVIOUS WEEK PREVIOUS WEEK PREVIOUS WEEK
Days of walking for
Days at least 10 minutes

None 43.1% 33.1% None 12.1%

1 day 9.8% 7.5% 1 day 4.4%
2 days 12.9% 12.3% 2 days 7.6%
3 days 11.8% 10% 3 days 5.9%
4 days 5.6% 6.9% 4 days 6.5%
5 days 6.3% 9.1% 5 days 10.1%
6 days 2.4% 3.7% 6 days 6.1%
7 days 6.5% 14.6% 7 days 45.3%
No data 1.5% 2.9% No data 2%
Minutes of walking
Minutes on a usual day

No activity 46.5% 38.6% None/Less than 10 minutes per day 16.7%

30 minutes or less 4.4% 13% 30 minutes or less 42.1%
31–60 minutes 17.8% 21% 31–60 minutes 21.2%
61–90 minutes 8.8% 4.2% 61–90 minutes 4.6%
91–120 minutes 14.5% 13.1% 91–120 minutes 7%
More than 120 minutes 4.8% 3.5% More than 120 minutes 1.4%
No data 3.1% 6.6% No data 7.1%

73
 A Snapshot of the Health of Young People in Europe 2009

Inequalities
Over the last few decades data indicate a decline in physical activity levels, particularly in 13−15-year-old girls (45,46).
In addition, the trend shows that boys are more active than girls across all age groups. This makes girls paticularly
vunrable to sedentary related illness (50).

Data from the 2002 HBSC survey (45) show a decrease of physical activity from age 13 to age 15. Considerable
variability across countries was observed. Results indicate a consistent drop in the proportion of respondents who
reported at least 60 minutes of MVPA a day on five or more days of the past week (Fig. 4.2.2). Only 34% of all
adolescents reported engaging in such levels of physical activity, with boys significantly more active than girls and
levels of participation decreasing across age groups for both genders. Considerable variations were observed across
countries, with proportions of children meeting the guidelines ranging from 23% of 15-year-old boys in Italy to 61%
of 15-year-old boys in Ireland, and from 11% of 15-year-old girls in France to 43% of 15-year-old girls in Ireland.

Fig. 4.2.2 2005/2006

YOUNG PEOPLE WHO REPORT AT LEAST ONE HOUR OF MVPA DAILY HBSC Survey

Maximum Minimum Average

AGE GROUP HBSC 2002 HBSC 2006

BOYS Ireland 61% Slovakia 51%

13-YEAR-OLDS

Belgium 26% Germany 19%

Average 41% Average 24%

GIRLS Ireland 43% Slovakia 35%

France 14% France 5%
Average 27% Average 14%

BOYS Czech Republic 49% Slovakia 46%

15-YEAR-OLDS

Italy 23% Sweden 11%

Average 35% Average 20%

GIRLS Netherlands 37% Slovakia 29%

France 11% 5% France/Portugal
Average 21% Average 12%

Data for 2002 did not include Slovakia, Bulgaria and Belgium (French).

Consistent with previous findings, data from the 2006 HBSC survey (46) indicate that the percentage of 13-year-olds
who reported participating in more than 60 minutes of MVPA (20%), was higher than for 15-year-olds (16%). This
pattern was identified in both males and females, but girls were found to be less active than boys across all age
groups.

Despite the fact that there has been no broader geographical pattern to the extent of MVPA, there are wide
discrepancies between countries. While Slovakia, Ireland and Bulgaria ranked consistently among the most active
countries in all age groups, Portugal, France and Norway are among the countries in which lower levels of physical
activity were reported.

The percentage of 13-year-olds who reported participating in at least 60 minutes of MVPA ranged from 5% (girls) in
France and 19% (boys) in Germany to 35% (girls) and 51% (boys) in Slovakia. In the 15-year-old group, the range
varied from 5% (girls) in France and Portugal and 11% (boys) in Sweden to 29% (girls) and 46% (boys) in Slovakia. In
more than half of the countries, young peole who reported higher family affluence also reported being more physically
active, indicating that socioeconomic status is an important determinant of adolescents’ physical activity levels.

74
 physical activity and sedentary behaviour

In a recent report from the Commission of the European Communities (51), physical activity levels and free time
tended to decrease with age. Nevertheless, 45% of the respondents aged 15−30 did some sort of physical activity
during their free time (such as going for a walk, riding a bicycle or practising sport).

Sedentary behaviour 4.2

Watching television

Prevalence
In contrast to physical activity levels which decrease during adolescence, leisure time sedentary behaviours increase
from childhood through to adolescence. These trends are complemented by a corresponding increase in childhood
obesity (20,22,23,52).

No conclusions can be drawn with respect to trends in television use in recent years (45−47). The proportion of
adolescent “permanent viewers” – viewers who spend more than four hours per weekday watching television – is
approximately 24% in EU countries. On weekend days, this proportion increases to 43.3%. This means that on an
ordinary Saturday or Sunday, nearly half of European adolescents spend a significant portion of their time watching
television. In the 2006 HBSC survey (46), about two thirds of young people engaged in television viewing two or
more hours a day during weekdays.
2005/2006
Fig. 4.2.3 PERCENTAGE OF ADOLESCENTS WHO WATCH TELEVISION HBSC Survey

Maximum Minimum Average

PERCENTAGE OF ADOLESCENTS PERCENTAGE OF ADOLESCENTS

WHO WATCH FOR FOUR OR MORE WHO WATCH FOR TWO OR MORE
AGE GROUP HOURS ON WEEKDAYS, 2002 HOURS ON WEEKDAYS, 2006

BOYS Estonia 47% Slovakia 84%

13-YEAR-OLDS

Austria 18% Luxembourg 55%

average 28% average 71%

GIRLS Portugal 41% Bulgaria 86%

Austria 15% Luxembourg 50%
average 25% average 69%

BOYS Estonia 41% Slovakia 85%

15-YEAR-OLDS

Slovenia 16% Luxembourg 59%

average 26% average 69%

GIRLS Wales 32% Bulgaria 84%

Malta 12% Slovenia 48%
average 22% average 67%

Data for 2002 did not include Bulgaria and Slovakia, data for 2006 did not include Malta

Inequalities
Time spent by adolescents watching television tends to increase as they grow older. Also boys are more likely to view
TV than girls (45–47). According to the HBSC 2006 survey (46), at age 13, 69% of girls and 70% of boys watched
two or more hours of television daily. For the age 15 and older group, the percentage was 69% for boys and 67%
for girls. For 13-year-olds, the countries with the highest percentage of television viewing time were Bulgaria (86%
for girls) and Slovakia (84% for boys). For 15-year-olds, Slovakia (85% for boys) and Bulgaria (84% for girls) rank
highest for time spent watching television (Fig. 4.2.3).

75
 A Snapshot of the Health of Young People in Europe 2009

Thirteen-year-olds in Luxembourg reported the lowest percentage (55% and 50% for boys and girls, respectively). In
15-year-olds, Luxembourg (59% for boys) and Slovenia (48% for girls) were the countries with the least time spent
watching television.

There is a higher prevalence of television viewing by boys, but gender differences may be related to regional and
socioeconomic differences. For example, western European boys reported lower percentages of television viewing
compared with eastern Europeans boys. This pattern can also be observed for girls, but the differences appear less
noticeable. High socioeconomic status was associated with television viewing in Bulgaria for both genders and in
Croatia and Romania for boys only. In contrast, lower socioeconomic status was more strongly associated with
television viewing time for girls in several countries.

Computer use

Prevalence
In contrast to time trend analyses of television use, the use of computers unambiguously increases in most parts of
Europe at the expense of the use of other media such as radio, CD and newspapers (45,47). In 2006 on average 35%
of 13-year-olds and 31% of 15-year-olds spent more than two hours on weekdays playing games on their computer
or games console. In comparison 35% of 13-year-olds and 42% of 15-year-olds use computers for emails, internet
and homework.

Inequalities
As young people become older the use of computers/consoles to play computer games declines. In contrast,
Internet use and computer use for creative work increases with age. Children from lower social groups use the
computer less.

With regard to overall time spent using computers, a greater percentage of boys reported spending two or more
hours a day during weekdays (49% versus 21% for the younger group and 46% versus 16% for the older group,
for boys and girls respectively). For use of computers and Internet for homework, the gender differences disappear
(34% versus 35% for the younger group and 42% versus 41% for the older group, for boys and girls respectively).
Fig. 4.2.4 shows the variation between the countries.
2005/2006
Fig. 4.2.4 PERCENTAGE OF ADOLESCENTS WHO USE COMPUTERS OR CONSOLE HBSC Survey

Maximum Minimum Average

ADOLESCENTS WHO PLAY COMPUTER ADOLESCENTS WHO USE COMPUTERS

OR CONSOLE GAMES FOR TWO FOR, E-MAILS, INTERNET HOMEWORK
AGE GROUP OR MORE HOURS ON WEEKDAYS FOR TWO OR MORE HOURS ON WEEKDAYS

BOYS Romania 66% the Netherlands 54%

13-YEAR-OLDS

Ireland 30% Ireland 15%

average 49% average 34%

GIRLS Romania 45% the Netherlands 58%

Ireland 11% Greece 11%
average 21% average 35%

BOYS Romania 67% the Netherlands 69%

15-YEAR-OLDS

France 26% Ireland 19%

average 46% average 42%

GIRLS Romania 39% the Netherlands 66%

France 6% Greece 11%
average 16% average 41%

76
 physical activity and sedentary behaviour

What are the challenges?

As with other areas comparable data across European countries on levels of physical activity and sedentary behaviours
is limited for the older age group referred to in this report. However data for 13 to 15 year olds tells us that in general
terms participation in physical activity is decreasing and sedentary behaviour plays a substantive part in young

4
people’s daily activities. Specifically, physical activity decreases with age and girls tend to be less active than boys
at all age levels. Decreases in physical activity start at earlier ages in girls compared to boys. Sedentary behaviours
appear to be high, with more than half of European young people spending two or more hours a day on weekdays .2
watching television. In addition, there is a trend toward increased use of computers for leisure and homework,
which increases the risk of sedentary behaviour.

Apart from the obvious need to fill the gaps in data collection for older age groups, there is a real need for further
research which helps us understand the broader determinants of young people’s ability to participate in physical
activity and to promote appropriate levels of the new and old technologies which encourage sedentary behaviour.
This is particularly important given that we already know health-related information or beliefs about lifestyles is by
itself insufficient to promote change

Current research tells us that for long-term change to occur, children and adolescents need to learn behaviour-change
skills (such as self monitoring, goal-setting, stimulus control, self-reinforcement, self-instruction and problem-solving)
to become effective self-regulators. For children and adults to establish life skills for maintaining physical activity
in changing life circumstances, they need to learn how to monitor and change their own behaviour (53,54). Policy
related research that provides us with greater details about how such factors need to be addressed in programmes
relevant for across different ages and gender is going to be most useful.

There is already some evidence to suggest that:

Physical education curricula focus on health-related activities that have the potential to be transferred to other
periods of life across the lifespan. Educators should emphasise lifespan activities and lifestyle changes in addition
to fitness (53,55). Effective school programmes include physical education, activity breaks, environmental changes
that facilitate physical activity and integrated family strategies for increasing physical activity (56).

Policies regarding neighbourhood and school environments are important for facilitating adolescent physical
activity (57,58). Sallis et al. (59) and Biddle et al. (3) provide useful reviews of work in this area, suggesting that
the key determinants of physical activity include social factors (such as encouragement from parents, siblings
and peers) and the physical environment (including the availability of facilities and programmes).

Policies that promote family involvement in physical activity have cascading benefits for the parents, their children
of all ages and future generations. Community programmes and facilities that provide opportunities for physical
activity have been shown to be related to increased physical activity. “Walkable” communities with safe streets
and reasons to walk (shops, parks, restaurants, recreational venues) provide environments that are conducive to
physical activity being built into daily life.

77
 A Snapshot of the Health of Young People in Europe 2009

78
alcohol, drugs 4.3
and tobacco
Summary
• Substance use is associated with a large number of interacting factors.
• There are wide variations across countries in relation to tobacco, alcohol and drug use.
• Substance use increases substantially with age, and alcohol and cannabis use are more
common among boys.
• Cannabis use increased markedly in almost all EU countries during the 1990s but is
currently stabilizing in many countries.
• The number of reported drug law offences in EU countries increased by an average
of 36% between 2001 and 2006.
• A special focus on emerging trends (online shops, new psychoactive substances,
combined use of substances) is required.
• Investigations point to the importance of programmes being tailored for different
problem behaviours, being school-based and using a whole-school approach, and
being focused on building competences and alternative lifestyles.

79
 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Tobacco is still the leading cause of preventable death in the world.

Adolescence is a period of major vulnerability to substance use and substance use disorders. Some adolescents start
engaging in substance use early, a behaviour that is associated with a higher risk of adult dependence.

To understand substance use, it is necessary to consider a large number of interacting factors. Five levels of influence
are proposed to explain individual behaviour that endorses substance use:

• intrapersonal level (individual characteristics such as knowledge, attitudes, beliefs and personality traits);
• interpersonal level (interactions between family, peers and friends);
• institutional level (rules and regulations within institutions such as schools and workplaces)
• community level (influences from social networks and norms within the community); and
• public policy level (regulations and laws at national or regional level) (1–3).

Perceived peer group norms are crucial in explaining young people’s substance use (4). Adolescence is a time in
which peer pressure can incline young people to engage in substance use (5), encouraging the development of
particular substance use cultures which can be interpreted as “rites of passage” for some young people.

Low parental supervision or families with a coercive social interaction style seem to be a risk factor for substance use
in children and adolescents (6).

It is essential to understand the “potentialities” and perceived benefits of substance use from a young person’s
viewpoint. These include relaxation, tension and stress reduction, heightened sexual contact, enhanced social
relationships and an antidepressant effect (7).

The literature notes that substance use is frequently associated with multiple health risks and with violence
and injury (such as road accidents and suicide attempts) (8). A study examining the relationship between the early
initiation of cannabis use and other high-risk behaviours with psychosocial and health-related correlates in 15-
year-old adolescents in six European countries showed that the early initiation (≤13 years of age) of tobacco (and
alcohol) use was associated with the early use of cannabis and with frequent use of tobacco, alcohol and cannabis at
age 15 (9).

As substance use among young people in Europe has increased substantially since the 1990s, and because of the
many short- and long-term consequences of substance use, there is an urgent need to recognize and understand
such trends.

What do we know?

Tobacco

Prevalence rates
Data from the HBSC survey show that smoking rates in European countries average 5% at age 13, with the average
increasing to 19% at age 15 (Fig. 4.3.1, Fig. 4.3.2). The most striking feature is the increase of weekly smoking
between ages 13 and 15 and the emerging variations in rates across countries (10). Estonia has the largest proportion
of smokers who started smoking at age 13 or younger (65% for boys and 43% for girls), while the lowest proportion
was found in the former Yugoslav Republic of Macedonia (15% and 11% respectively) (Fig. 4.3.3).

Data from the 2007 European School Survey Project on Alcohol and other Drugs (ESPAD) survey* show that on
average, 58% of students aged 16 had tried cigarettes at least once and 29% had used cigarettes during the last

* Data includes countries outside the EU27

80
 alcohol , drugs and tobacco

Fig.4.3.1 Fig.4.3.2
13-YEAR-OLDS WHO 2005/2006 15-YEAR-OLDS WHO 2005/2006
SMOKE AT LEAST ONCE A WEEK HBSC Survey SMOKE AT LEAST ONCE A WEEK HBSC Survey

10 Girl % 36 Girl %
Latvia 11 *Bulgaria 28
11 Boy % 30 Boy %
Malta 9 *Austria 24

4
12 28
*Wales 6 Croatia 24
7 23
*Estonia *Latvia
.3
11 30
11 19
*Bulgaria 7 *Estonia 27
9 21
Czech Republic 8 Finland 23
5 21
*Lithuania 10 Hungary 22
7 18
Austria 8 *Lithuania 26
8 23
England 6 Czech Republic 20
6 24
Luxembourg 6 Malta 19
7 20
Germany 5 Italy 20
8 22
*Scotland 4 *Germany 17

Finland 7 Ireland 20
5 19
6 21
Ireland 6 *Luxembourg 17
5 21
Italy 6 *France 17

Hungary 6 *Scotland 23
5 14
4 Netherlands 21
Slovakia 7 16

Belgium (French) 5 Slovenia 16

6 20
5 17
France 5 Belgium (Flemish) 18

Poland 5 *Wales 23
5 12

Croatia 5 *Spain 20
5 14

Netherlands 4 Slovakia 15
4 18

Belgium (Flemish) 4 Greece 16

4 17

Portugal 4 *Poland 14
4 19

*Denmark 3 Belgium (French) 17

5 14
2 *England 18
*Romania 5 13

Spain 4 Switzerland 15
3 15
3 Denmark 15
Switzerland 4 15
3 *Romania 12
Slovenia 3 20

Sweden 3 TFYR Macedonia† 14

1 14

Iceland 2 Iceland 13
3 14

TFYR Macedonia† 2 Portugal 12

2 9
The former Yugoslav Republic of Macedonia

The former Yugoslav Republic of Macedonia

2 Norway 12
Norway 1 9

Greece 2 Sweden 9
2 8

6 19
Average (gender) 5 Average (gender) 18
Average (total) 5 Average (total) 19
†

* indicates a significant gender difference (at p<0.05).

81
 A Snapshot of the Health of Young People in Europe 2009

30 days (11). An early smoking debut (age 13 or younger) is correlated (at country level) with high levels of use in
the past month. On average, 7% of the 15−16-year-old students in the survey said that they started smoking daily
at age 13 or before.

For the 15−34 age group, Sweden and Slovakia are the countries with the lowest daily smoking prevalence. In both
countries, less than 20% of the population aged between 15 and 34 are daily smokers. In contrast, Bulgaria has the
highest percentage of daily smokers (31% for the population aged 15−24 and half of the population aged 25−34),
followed by Estonia, where two thirds of men aged 25−34 are regular smokers. Ireland is the only country where
the share of smokers decreases with age (12).

inequalities
No clear pattern of gender differences can be found among 15-year-olds in most countries (10). In Poland, Latvia,
Lithuania, Romania and Estonia, significantly more boys than girls are weekly smokers, while in the United Kingdom,
Spain, France, Luxembourg, Germany, Austria and Bulgaria, the opposite prevails.

A study by Hublet et al. (12) looked at smoking trends between 1990 and 2002. Three different trends were
observed among boys and girls, each showing the same geographical pattern. Among boys, Nordic countries
showed a declining or stabilizing smoking trend; in western countries, an initial increase was followed by a decrease
in daily smoking; and in eastern European countries, an increase was followed by stabilization in smoking prevalence
between 1998 and 2002. Similar daily smoking trends could be found among girls, with only a few exceptions. No
country showed a continuous decline in daily smoking prevalence among girls; indeed, Austria and Hungary showed
an increasing smoking trend in girls, at the same time as boys’ rates were stabilizing.

For the older age groups (those 15 years and older), males are more likely to be smokers. Only in Sweden and the
United Kingdom is the percentage of female smokers aged 15−24 found to be higher than that of males (12).

Family affluence is not strongly associated with early smoking initiation, but is significantly related to weekly smoking
in girls in half of the EU countries (10). Girls with low family affluence are more likely to be weekly smokers; in boys,
this relationship was less pronounced.

HBSC data about tobacco initiation and weekly smoking in 13−15-year-old adolescents are presented in Fig. 4.3.1
and Fig. 4.3.2.

Alcohol

Prevalence
Overall, alcohol is the most consumed psychoactive substance by young people in the EU. At least two thirds of
the 16-year-olds students in the ESPAD survey had tried alcohol at least once during their life. Eighty-two per cent
drank alcohol in the last 12 months and 61% in the past 30 days. On average, 40% of the alcohol consumed on the
latest drinking day was beer. The next most important beverage type was spirits, contributing 30% of total alcohol
consumption. Wine and “alcopops” contributed 13% and 11% respectively (11).

“Early drunkenness” is defined in the HBSC study as having been drunk by the age of 13 or younger (as reported by
young people when 15). There are considerable variations between countries in the prevalence of early drunkenness,
from 3% of girls in Italy to 35% of boys in Estonia (Fig. 4.3.4). There are also very large differences between countries
in the prevalence of 15-year-olds having been drunk on two or more occasions (Fig. 4.3.5).

In one third of the countries participating in the ESPAD study, at least half of the 15−16-year-old olds had consumed
at least one glass of alcohol at the age of 13 or younger, and 14% had been drunk at that same age Only 14% of
students stated that at present, they never drink alcohol. In countries where students reported a relatively high level
of alcohol use in the past 30 days, they also, by contrast, reported lower volumes of consumption on their latest

82
 alcohol , drugs and tobacco

Fig.4.3.3
15-YEAR-OLDS WHO REPORT FIRST 2005/2006
SMOKING AT AGE 13 OR YOUNGER HBSC Survey

43 Girl %
*Estonia 65
49 Boy %
Austria 48

4
38
*Latvia 51
41
Czech Republic
*Lithuania 34
45

49
.3
39
Luxembourg 37
39
Germany 35
38
Bulgaria 35
32
*Slovakia 40
32
*Finland 38
33
Hungary 35
31
Switzerland 35

*Poland 27
39
32
Netherlands 31
33
Ireland 29

*Croatia 28
35
34
*Wales 26
30
Belgium (French) 30
34
*Scotland 25

France 29
27
25
Slovenia 30

Spain 28
22
28
Malta 22

Portugal 23
26
24
Denmark 24

Sweden 25
23

Belgium (Flemish) 24
22
27
*England 19
22
Norway 22

Italy 20
23
15
*Romania 25
13
Greece 16
The former Yugoslav Republic of Macedonia

*Iceland 12
15

*TFYR Macedonia† 11
15

29
Average (gender) 31
Average (total) 30
†

* indicates a significant gender difference (at p<0.05).

83
 A Snapshot of the Health of Young People in Europe 2009

drinking day. In some countries (such as Greece), students drank more often, but in smaller quantities, while in
others (including the Nordic countries), alcohol was consumed less often but in larger quantities (11).

In most European countries, more than 80% of young people aged 17−18 years have consumed alcohol over the past
12 months, with Denmark and the Czech Republic registering the highest prevalence (95%). The lowest prevalence
of young people having consumed alcohol over the past 12 months was found in Portugal (74%), with Sweden
on 77% (12).

In around half of the countries for which data are available, more than 50% of young Europeans aged 17−18 have
been drunk at least once in the past 12 months. Denmark accounted for the highest rates of drunkenness among
young people (82%), while only 25% of young people in Cyprus and 29% in France admitted to having been drunk
in the past 12 months (12).

inequalities
There are large cross-national differences in the prevalence of weekly alcohol consumption among 13−15-year-olds
as measured in the HBSC survey. In all countries (but one), rates increased between 13 and 15 for both boys and
girls. There is a general tendency for weekly drinking and drunkenness to be more common among boys. Young
people in northern Europe have relatively high rates of drunkenness and those in southern Europe relatively low
rates. These geographic patterns are stronger for girls than boys.

Wide variations were found between countries in reports of early drunkenness (at 13 years or younger) among
15-year-olds. Young people in southern Europe have relatively low prevalence of early drunkeness. The opposite is
true for northern Europe, where girls are generally as likely as boys to report this behaviour (10).

Recent trend research suggests that alcohol prevalence among 15-year-olds increased over time in some countries
and decreased in others between 1998 and 2006, but that the increase was more prevalent among girls.

Family affluence does not appear to be an important predictor for any alcohol variables.

Cannabis

Prevalence
Cannabis is the most popular drug among young people aged 15−34. The highest levels of use are generally being
reported among 15−24-year-olds. Estimates suggest that around 23 million European adults have used cannabis in
the last year (14).

Data from the 2006 HBSC survey show large variations in lifetime and last 30 days prevalence of cannabis use by
15-year-olds across Europe (Fig. 4.3.7) (10). Recent use (30-day use) is virtually unreported in some countries, while
others report up to 15% of cannabis use at the high end of the range.

inequalities
Among the 15-year-olds, boys usually report a higher prevalence of cannabis use, with a significant gender difference
in around half of countries. The differences can be very high between countries, from 15% of both boys and girls in
Spain, to 1% of boys (and <0.5% of girls) in Romania (10). The difference in reported prevalence between genders
is small or even absent in some of the countries with the highest prevalence estimates. Family affluence does not
appear to be linked to cannabis use.

National survey data reported to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) (14)
show that cannabis use increased markedly during the 1990s in almost all countries, particularly among young
people and school students. Around the year 2000, lifetime prevalence of cannabis use among the 15–34 age group
increased to levels in excess of 30% in nine countries and around 40% in two cases, while last-year prevalence

84
 alcohol , drugs and tobacco

Fig.4.3.4 Fig.4.3.5
15-YEAR-OLDS WHO REPORT 2005/2006 15-YEAR-OLDS WHO HAVE BEEN 2005/2006
EARLY DRUNKENNESS HBSC Survey DRUNK AT LEAST TWICE HBSC Survey

21 Girl % 56 Girl %
*Estonia 35 Denmark 59
19 Boy % 50 Boy %
*Lithuania 29 *Lithuania 57

4
22 54
Austria 26 Wales 52
24 42
England *Estonia
.3
23 57
21 50
Wales 25 England 44
19 42
*Bulgaria 27 *Bulgaria 51
22 44
Finland 23 Finland 47
23 48
Scotland 21 *Scotland 43
18 39
*Latvia 25 *Latvia 50
19 36
Denmark 21 Austria 41
16 29
*Slovakia 22 *Croatia 48
15 32
*Czech Republic 21 *Hungary 40
13 27
*Croatia 24 *Slovenia 43

*Ireland 15 31
20 *Slovakia 39

*Slovenia 10 27
19 *Poland 42
9 31
*Belgium (French) 18 Ireland 36

*Romania 8 30
21 *Czech Republic 36
10 32
*Switzerland 15 *Iceland 31

*Poland 8 Spain 33
17 29
10 28
*Hungary 15 *Germany 31

Netherlands 11 *Romania 19
13 45

*Luxembourg 9 23
14 *Belgium (Flemish) 33

Germany 11 32
12 *Norway 25
10 21
Belgium (Flemish) 12 *Belgium (French) 31

Malta 9 26
11 Sweden 26
10 21
Sweden 10 *Netherlands 30
10 20
Norway 8 *Luxembourg 27

Iceland 8 18
10 *France 29

Spain 8 18
9 *Switzerland 29

Portugal 8 18
10 *Portugal 25
6 18
*France 11 Italy 22

*TFYR Macedonia† 3 17
11 Greece 21
The former Yugoslav Republic of Macedonia

*Greece 5 *TFYR Macedonia† 12

9 25

*Italy 3 *Malta 15
6 18

13 31
Average (gender) 17 Average (gender) 36
Average (total) 15 Average (total) 34
†

* indicates a significant gender difference (at p<0.05).

85
 A Snapshot of the Health of Young People in Europe 2009

reached 15–20% in seven countries and last-month prevalence 8–15% in six. Information from recent national
surveys suggests that cannabis use is stabilizing in many countries.

A comparison of HBSC data between 2002 and 2006 (15) shows a stable or decreasing trend in both lifetime and
more-frequent cannabis use among 15-year-old students in most countries.

Other drugs

Prevalence
The ESPAD study examines (11), illicit drug use other than cannabis, including: ecstasy, amphetamines, LSD or other
hallucinogens, cocaine and heroin. On average, 7% of the 15−16-year-olds report the use of illicit drugs other than
cannabis. Fig. 4.3.6 shows the variation between the countries.

The most widely used illicit drugs for 15−16-year-olds are amphetamines, ecstasy and cocaine (3% on average).
A summary of substance use among young people in Europe is shown in Fig. 4.3.8.

Fig. 4.3.6 ILLICIT DRUGS OTHER THAN CANNABIS ESPAD 2007

Lowest-prevalence countries Highest-prevalence countries

SUBSTANCE
(AGE GROUP) LIFETIME BOYS GIRLS
(15–16 YEARS)
ILLICIT DRUGS OTHER
THAN CANNIBIS

EUROPEAN AVERAGE 7 8.5% 6%

RANGE 3–11% 3–14% 2–11%

LOWEST-PREVALENCE Romania 3% Finland 3% Cyprus 2%

COUNTRIES Finland 3% Romania 3% Greece 2%

HIGHEST-PREVALENCE Austria 11% Latvia 14% Ireland 10%

COUNTRIES France 11%
Latvia 11%

Data for UK does not include Isle of Man, data for Denmark does not include Faroe Islands. Averages are of EU27

In the general population, cocaine remains the second most-used substance after cannabis, with national prevalence
rates between 0.4% and 7.7%. The EMCDDA report states that cocaine use is mainly concentrated among young
adults (15–24 years): last-year prevalence of cocaine use is estimated at 2.6%. It is estimated that between 0.4%
and 11.2% of young adults have used it at least once. On average, 1.2% have used cocaine in the past month, but
there is much variation between the countries.

Among young adults (15–34 years), lifetime prevalence of amphetamine use varies considerably between countries,
from 0.2% to 16.5% (the European average is around 5%) (14). Last-year use of amphetamines in this age group
ranges from 0.1% to 2.9%, with the majority of countries reporting prevalence estimates of between 0.7% and
1.9%. Bulgaria and the Mediterranean countries such as Greece, Cyprus and Malta accounted for the lowest
levels of drug consumption in Europe (14). It is estimated that on average, 1.3% of young Europeans have used
amphetamines in the last year.

86
 alcohol , drugs and tobacco

Fig.4.3.7
15-YEAR-OLDS WHO HAVE USED 2005/2006
CANNABIS IN THE LAST 30 DAYS HBSC Survey

15 Girl %
Spain 15
11 Boy %
*France 14

4
10
*Netherlands 15
11
Switzerland
.3
13
11
Scotland 13
11
Wales 12
9
Belgium (French) 12
7
*Luxembourg 13
9
Italy 11
7
*Ireland 11
9
Czech Republic 10
8
England 10
6
*Belgium (Flemish) 12

*Estonia 5
10
9
Malta 6

Croatia 6
7

Bulgaria 5
7

*Poland 4
8

*Latvia 2
8

*Slovenia 4
7

*Germany 4
6

*Slovakia 2
7

Denmark 3
6

Austria 4
4

*Portugal 2
6

Hungary 3
4

*Lithuania 2
5

Iceland 3
4

*Finland 1
3

Greece 1
3

Sweden 1
2

TFYR Macedonia† 1
2
The former Yugoslav Republic of Macedonia

<0.5
*Romania 1

6
Average (gender) 8
Average (total) 7
†

* indicates a significant gender difference (at p<0.05)

87
 A Snapshot of the Health of Young People in Europe 2009

Ecstasy consumption is also more prevalent among young adults (15–34 years) compared to older age groups (14).
Lifetime prevalence estimates for 15−34-year-olds ranged at national level from 0.5% to 14.6%, with between
0.4% and 7.7% of this age group reporting using the drug in the last year. Consumption remained high in the
Czech Republic and the United Kingdom.

Lifetime prevalence estimates of LSD use among this same age group are a little higher than is found in older age
groups. In the few countries providing comparable data, the use of LSD is often exceeded by that of hallucinogenic
mushrooms, where lifetime prevalence estimates for young adults range from 1% to 9% and last-year prevalence
estimates are between 0.3% and 3% (14).

Inequalities
Use of cocaine is particularly high among young males (15–34 years). The female to male prevalence ratio for last-
year use ranged between 1.1 and 1.13 for adolescents and young adults in different countries. Weighted averages
for the EU as a whole suggest that, among cocaine users aged 15–34, the male to female ratio was nearly 4 to 1
(3.8 males for each female) (14).

Trends analysis reveals stabilization or even a decrease in amphetamine and ecstasy consumption in Europe following
a general increase in the 1990s, although not in all countries (14).

Substance use and criminality

Although data on drug-related crime are rare or patchy, it is clear from research that there is a positive relationship
between substance use and criminal activity (16). The available data from the EMCDDA 2008 report (which includes
subjects from 15- to 64-years-old) show that overall, the number of reported drug law offences in EU countries
increased by an average of 36% between 2001 and 2006. Most European countries reported that the majority
of the offences were related to drug use or possession for use. In 2006, cannabis continued to be the illicit drug
most often involved in reported drug law offences in most European countries. Drug law offences related to heroin
dropped by an average of 14% in the EU over the period 2001–2006.

In adolescents younger than 16 years, delinquency problems (such as physical fighting, robbery or theft and getting
into trouble with the police) are related to alcohol use (11). Physical fighting associated with alcohol use was reported
by 13% (on average) of the 15−16-year-olds. The country scoring highest in this group of problems is the United
Kingdom (12%), with Greece and Portugal lowest at around 3%. There were substantial gender differences, with
twice as many boys as girls (11% versus 5%) involved in physical fighting.

What are the challenges?

Areas for further research

Cannabis use increased markedly during the 1990s in almost all EU countries, particularly among young people and
school students. Information from recent national surveys, however, suggests that cannabis use is stabilizing in many
countries. Such trends need to be confirmed and monitored.

Special attention is needed to monitor emerging trends concerning psychoactive products and behaviours related
to them. Young people can access over 200 psychoactive products and controlled substances such as LSD, ecstasy,
cannabis and opioids through online shops on the Internet. Besides these substances, new psychoactive substances
were notified for the first time through the early-warning system to the EMCDDA and Europol (a total of 15 during
2007). New patterns in the use of combinations of substances require more detailed study; the simultaneous use
of Viagra™ and ecstasy when going out seems to be a new trend that has been noted among young people (Blay,
unpublished observations, March 2009).

The EMCDDA 2008 report presents data on this topic on individuals from 15 to 64 years. Specification by age groups
and gender would be helpful in clarifying the involvement of adolescents in these risk behaviours.

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 alcohol , drugs and tobacco

Fig. 4.3.8
ILLICT DRUG USE OTHER THAN CANNABIS EMCDDA, 2008

Lowest-prevalence countries Highest-prevalence countries

4
SUBSTANCE
(AGE GROUP) LIFETIME LAST YEAR

ESTIMATED NUMBER OF USERS 7 MILLION 2 MILLION

.3
(15–34 YEARS)
AMPHETAMINES

EUROPEAN AVERAGE 5.1% 1.3%

RANGE 0.2–16.5% 0.1–2.9%
LOWEST-PREVALENCE Greece 0.2% Greece 0.1%
COUNTRIES Romania 0.5% France 0.2%
Malta 0.7% Cyprus 0.3%
Cyprus 0.8% Portugal 0.4%
HIGHEST-PREVALENCE United Kingdom 16.5% Estonia 2.9%
COUNTRIES Denmark 12.7% United Kingdom 2.7%
Spain 5.3% Latvia 2.4%
Latvia 5.3% Denmark 2.2%

ESTIMATED NUMBER OF USERS 7.5 MILLION 2.5 MILLION

(15–34 YEARS)
ECSTACY

EUROPEAN AVERAGE 5.6% 1.8%

RANGE 0.5–14.6% 0.4– . %
LOWEST-PREVALENCE Romania 0.5% Greece 0.4%
COUNTRIES Greece 0.6% Italy 0.7%
Malta 1.4% Poland 0.7%
Lithuania 2.1% Denmark 0.9%
Poland 2.1% Lithuania 0.9%
Portugal 0.9%
HIGHEST-PREVALENCE Czech Republic 14.6% Czech Republic 7.7%
COUNTRIES United Kingdom 13.0% United Kingdom 3.9%
Ireland 9.0% Estonia 3.7%
Slovakia 8.4% the Netherlands 2.7%
Slovakia 2.7%

ESTIMATED NUMBER OF USERS 3 MILLION 2 MILLION

(15–24 YEARS)
COCAINE

EUROPEAN AVERAGE 4.5% 2.6%

RANGE 0.4–11.2% 0.2–6.1%
LOWEST-PREVALENCE Romania 0.4% Greece 0.2%
COUNTRIES Greece 0.6% Poland 0.3%
Lithuania 0.7% Czech Republic 0.4%
Malta 1.1% Latvia 0.6%
Poland 1.1%
HIGHEST-PREVALENCE United Kingdom 11.2% United Kingdom 6.1%
COUNTRIES Spain 8.7% Spain 5.8%
Denmark 8.0% Ireland 3.8%
Ireland 7.0% Denmark 3.3%
Italy 3.3%

ESTIMATED NUMBER OF USERS 7.5 MILLION 3.5 MILLION

(15–34 YEARS)
COCAINE

EUROPEAN AVERAGE 5.4% 2.3%

RANGE 0. – 12. % 0.2–5.4%

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 A Snapshot of the Health of Young People in Europe 2009

Policy and tailored preventive interventions

The implementation of clusters of programmes tailored to address different problem behaviours is an important
aspect of prevention. School-based interventions should follow a systematic approach to ensure they address the
many challenges within the school setting. A focus on the positive aspects of life is encouraged, as is reinforcement
of the autonomy, responsibility and social participation of young people.

Recent studies point to the need for selective and more intense interventions on small identified risk groups, taking
“surgical” care of selective risk factors and situations. These focus on times and events in which substances may
be available to young people (17). Some currently recommended tobacco control policies (especially price and tax
increases) may help decrease smoking prevalence in 15-year-old adolescents, but have a greater influence on boys
than girls (18). Similarly, research into alcohol use shows a greater increase in alcohol consumption among girls,
suggesting more research is needed to examine national effects of alcohol marketing practices and preventive
measures with a particular focus on the possibility that changes in the social roles of adolescent girls may make them
more susceptible to drinking (19).

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sexual health 4.4

Summary
• The gender gap between age at first sexual intercourse is narrowing in the EU,
mostly among the youngest and those in western and northern Europe.
• Condoms are widely used, more by males than females, and more than before.
Among 15-year-olds, the contraceptive pill is used more commonly in western Europe.
• There are dramatic differences in abortion rates between the different regions of Europe,
with very high rates in eastern Europe.
• Overall in Europe, young people are not the main population affected by human
immunodeficiency virus (HIV), with 11% of cases occurring among 15−24-year-olds
in EU countries.
• The challenges around sexual health are in collecting comparable data that can be broken
down by age at country level and in developing common indicators to meet the challenge
of improving sexual and reproductive health in Europe.

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 A Snapshot of the Health of Young People in Europe 2009

Why is this issue important to young people?

Sexual and reproductive health is an integral part of holistic health. It consists of the promotion of safe and healthy
sexual behaviour, including reproductive choice. Sexual and reproductive health has a substantial contribution
to make towards meeting the United Nations Millennium Development Goals, as it is fundamental to human well-
being (1).

Sexual health is rooted in lifelong sexual development, spanning from early childhood throughout adulthood. It is a
process, not a destination.

Sexual health is a central component of health for all sections of the population, but the challenges in maximizing
the sexual health of young people are substantial. Addressing the sexual health of young people by raising their
commitment to safer sex has become a major issue in many countries (1−3).

There are, however, substantial disparities between EU countries on factors linked to sexual and reproductive heath:
different cultural and religious backgrounds, different policies on issues such as family planning and accessibility
and affordability of contraception and abortion, different policies relating to youth-friendly services, and different
education systems dealing differently with issues like gender, health education and sexual education. Such differences,
among others, explain the large discrepancies found in, for instance, levels of condom and contraceptive pill use,
rates of abortion and teenage pregnancies and numbers of sexually transmitted infections (STIs).

Overall, reproductive health outcomes contribute to the general health and social well-being of a population. Even
if in many countries the average age of first sexual intercourse had been decreasing (4), no universal trend towards
earlier sexual intercourse is seen. Rather, there seems to be a shift towards later marriage leading to higher rates of
premarital sex (5). While the risk profile may be changing, early and poorly protected sexual intercourse remain of
central relevance to public health (6−9).

Early sexual activity, particularly when associated with inconsistent or non-use of contraception, has serious short-
and long-term health-compromising consequences. Early sex has implications for self-perception, well-being, social
status and future health behaviour (10), including sexual behaviour (11). Early sexual initiation can be seen as part
of broader risk-behaviour clusters that include substance use and unprotected sex (12−15). Unprotected or poorly
protected intercourse bring the risk of unintended pregnancy, abortion and early motherhood. Teenage pregnancy
and early parenthood can lead to poor educational achievement, poor physical and mental health, poverty and social
isolation for the young mothers and their children (16−18).

For those not employing barrier methods of protection, the risk of STIs, including HIV transmission, is also present.
Reported condom use at last high-risk sexual contact (penetrative sex with a nonmarital, noncohabitating partner)
has been identified by UNAIDS (the Joint United Nations Programme on HIV/AIDS) and REPROSTAT (part of the
Health Monitoring Program of the European Commission) as 1 of 13 core reproductive health indicators for HIV
prevalence among young people (19).

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 sexual health

Table 4.4.1 Avery

What do we know? Average age of first intercourse in 16−20-year-olds et al, 2007

Age at first
Sexual experience Country intercourse

4
Prevalence Iceland 15.7
Experience of sexual intercourse as reported by 15-year- Germany 16.2
olds in the 2006 HBSC survey varies considerably across Austria
Netherlands
16.3
16.4
.4
countries, from 12% in Slovakia to 38% in Bulgaria and
Sweden 16.4
Denmark.
Denmark 16.5
Finland 16.5
In 2004, the average age at first sexual intercourse was Norway 16.5
16.5 years, ranging from 15.7 in Iceland to 18.0 in United Kingdom 16.7
Slovakia (2) (Table 4.4.1). Bulgaria 17.1
France 17.1
Inequalities Belgium 17.2
The HBSC survey emphasises that although in general TFYR Macedonia† 17.2
boys are more likely to report sexual intercourse, this Slovenia 17.2
pattern is reversed in a few countries. This could mean Hungary 17.3
that gender stereotypes in which boys are considered to Switzerland 17.3
Czech Republic 17.5
be more sexually active and to commence sexual activity
Ireland 17.5

The former Yugoslav Republic of Macedonia

earlier are eroding in the majority of EU countries.
Croatia 17.6
Italy 17.6
There is some evidence of geographical patterns, Spain 17.7
particularly among girls. The highest rates of sexual Greece 17.8
intercourse for girls are in northern Europe, while girls in Poland 17.9
southern and western Europe have relatively low rates of Slovakia 18.0
reported sexual intercourse.

†
Family affluence is generally not a strong predictive factor, except for boys in eastern Europe, where more boys from
high-affluence families report having had sexual intercourse.

International comparisons of age of initiation of sexual activity show that in industrialized countries, the observed
decline in age of first having sex (2,4) is slowing down, but that the gender gap is narrowing, with girls initiating
earlier than before (20). This leads to a profile observed in Nordic countries, where girls initiate slightly earlier than
boys (21,22).

Bozom & Kontula (4), drawing on data from an integrated European comparative study, found that only in a
few countries (Denmark, Germany and Norway) did more females than males in the younger cohorts report first
intercourse prior to 18 years. This pattern was not observed among the older cohorts (except in Denmark). In his
analysis of trends in sexual initiation between 1960 and 1995, Teitler (20) found that patterns of youth sexual
behaviours are converging across industrialized countries. The variation within and between countries in the age of
sexual debut is narrowing, while the influence of social class is becoming less predominant.

Condom use

Prevalence
From HBSC data, condoms are the most commonly used form of contraception among 15-year-olds at their last
sexual intercourse, with wide variations between countries (from 65% in Sweden to 89% in Spain) (23,24).

In many countries and in many studies, the data on contraception use does not specify what type of contraception
was used. A typical statement is that “condoms are the most commonly used type of contraception worldwide” (2),
particularly among adolescents (7), yet no comparative data on the consistency with which condoms are used are
offered (5).

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 A Snapshot of the Health of Young People in Europe 2009

inequalities
Among 15-year-olds, as found in the HBSC survey, boys are more likely to report condom use at last intercourse.
There are no clear geographical patterns and family affluence is not a major factor in condom use at last intercourse
in this population.

Overall, the proportion of 15−24-year-old sexually active young people reporting condom use is higher among males
than among females. Rates of condom use are usually higher in industrialized countries, especially among females.
Condom use has increased in recent years in most countries (5,7).

Contraceptive pill use

Prevalence
Reports of contraceptive pill use at last sexual intercourse among 15-year-old respondents to the HBSC survey show
great variations, ranging from 4% in Spain to 52% in the Netherlands.

Oral contraceptives are the most popular method of pregnancy prevention in industrialized countries. The data on
contraception use in many countries and in many studies do not specify what type of contraception was used, so
they will inevitably encompass traditional and nontraditional methods and those that are efficient and less (or not)
efficient (2).

inequalities
According to the HBSC data, girls are more likely to report contraceptive pill use at last sexual intercourse. There are
strong geographical patterns, with those from western Europe being most likely to report such use and those from
eastern and southern Europe being least likely (23,24). No associations with family affluence could be detected, as
the numbers were too small to detect meaningful differences.

Overall, there has been an increase in the use of contraception by young people at first intercourse in European
countries. Until the late 1980s, this rise was due to the use of contraceptive pills, but there has been a dramatic increase
in the use of condoms in Europe since the 1990s (although this is less substantial in the United Kingdom) (20).

A summary of contraceptive use as presented in the HBSC survey is shown in Fig. 4.4.1.

Unintended pregnancy

Prevalence
Fertility trends over recent decades in Europe show a sharp decline in the total fertility rate, far below the replacement
level of 2.1 children per woman. There has also been an increase during the period 1995−2005 in the mean age of
mothers at first births; the mean age overall in the EU is now around 27 years (25).

Evidence suggests the rates of adolescent pregnancy have been decreasing in the last 20 years (2).

More than 40% of pregnancies of that occur in industrialized countries are unintended and 28% end in induced
abortion (26).

Data on unintended pregnancies among young women are scarce, but the assumption is that at least in industrialized
countries, most teenage pregnancies are unintended (18).

inequalities
There are large differences within Europe on levels of pregnancies among young women, from approximately 12
pregnancies per 1000 women aged 15−19 in Italy to approximately 59/1000 in Bulgaria. Lower levels are found in
western and central Europe (with the exception of the United Kingdom), while moderate rates (40−60 per 1000) are
found in eastern Europe (Fig. 4.4.2).

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 sexual health

Fig. 4.4.1 2005/2006

CONTRACEPTIVE USE AT LAST INTERCOURSE HBSC Survey

Boys
Pill Condom Dual All Girls
Country only only use protected

4
6.7 50.3 35.0 92.0%
Netherlands 20.9 33.5 40.1 94.5%

Switzerland
3.2
15.6
62.2
54.7
26.3
21.1
91.7%
91.4% .4
20.8 47.4 21.2 91.9%
Denmark 28.7 43.6 18.2 90.4%
6.0 49.8 35.3 88.7%
Germany 20.1 38.5 34.7 93.4%
0.7 79.9 3.2 83.8%
Spain 1.1 91.3 3.6 96.0%
2.2 73.3 14.5 90.0%
France 9.2 62.5 17.1 88.8%
1.7 44.0 34.9 88.0%
Belgium (Flemish) 15.8 34.1 33.0 90.8%
1.3 76.5 9.4 87.2%
Portugal 7.0 63.7 20.4 91.1%
2.7 68.5 15.8 87.0%
England 6.8 64.5 16.4 87.7%
3.5 71.3 14.4 89.1%
Austria 11.9 58.4 17.8 88.1%
0.5 74.0 13.7 88.2%
Estonia 3.4 70.2 10.7 84.3%
8.2 64.5 15.3 88.0%
Finland 20.7 53.8 10.4 84.9%
5.9 58.4 23.8 88.1%
Wales 11.0 50.4 21.0 82.4%
2.3 69.5 12.7 84.4%
Scotland 9.5 58.2 15.9 83.6%
1.5 84.4 3.4 89.7%
Greece 0.8 61.5 4.6 66.9%
0.8 80.2 5.8 86.8%
Latvia 3.2 69.4 8.1 80.6%
0.0 74.2 7.5 81.7%
Croatia 0.7 76.6 7.1 84.4%
0.6 77.8 8.0 86.3%
Bulgaria 0.4 69.2 6.6 76.2%
14.1 57.6 9.8 81.5%
Sweden 18.9 52.3 8.2 79.4%
0.9 78.7 4.4 84.0%
Lithuania 0.9 64.9 9.9 75.7%
5.0 56.0 14.2 75.2%
Slovenia 5.4 64.6 19.2 89.2%
2.5 70.2 8.3 81.0%
Hungary 3.9 66.9 8.7 79.5%
The former Yugoslav Republic of Macedonia

1.0 77.6 3.2 81.7%

TFYR Macedonia† 58.7 6.5 65.2%
1.2 79.3 1.6 82.0%
Romania 1.7 53.3 7.5 62.5%
1.3 56.6 7.9 65.8%
Slovakia 1.4 65.2 1.4 68.1%
†

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 A Snapshot of the Health of Young People in Europe 2009

Abortion

Prevalence
In 2007, Sedgh et al. (25) published a worldwide study on abortion rates from 1995 to 2003. On average, they found
that there were 31 abortions for every 1000 live births worldwide in 2003. The rate was lowest in western Europe
(12 per 1000). Rates in northern (17 per 1000) and southern Europe (18 per1000) were also quite low. The rate was
highest in eastern Europe (44 per 1000).

inequalities
Overall, abortion rates have been decreasing over time in the EU. The induced abortion rate in Europe in 2003 was
28 per 1000 women aged 15−44 years, down from 48 per 1000 in 1995 (25). Based on recent data (27), it can be
concluded that this decrease has continued in most countries until today.

Yet it needs to be stressed that even though rates in eastern European countries have fallen substantially since
1995, abortion rates in eastern Europe have remained higher than in any other region of Europe. This might be due
to limited availability and high cost of appropriate contraceptives and to lack of counselling services in central and
eastern Europe (25).

Abortion rates in young women (under age 20) are higher in northern Europe. In 2005, the highest rate was found
among Swedish girls (Fig. 4.4.3). It is worth emphasizing that abortion data are not readily available for those under
15 years in many countries, meaning caution should be exercised when interpreting such data (2).

Sexually transmitted infections (STIs) (including HIV)

Prevalence
Worldwide, it is believed that the largest proportion of STIs occurs in people younger than 25 years (7). The main
studied and monitored STIs in the EU are syphilis, gonorrhoea and chlamydia infection. It should be noted that due
to the fact that underreporting is common for such diseases, especially in the adolescent population (because of
accessibility issues), the figures given are minimum estimates (2).

Chlamydia is the most common sexually transmitted bacterial infection in many EU countries. Syphilis rates are
considered a good indicator of the trends in all sexually transmitted diseases.

HIV/AIDS is still considered a serious health concern across the EU. In 2006, 26 220 newly diagnosed cases of HIV
infection were reported, a rate of 67.2 per million. The highest rates of HIV in Europe are found in Estonia and
Portugal. Rates of more than 100 newly diagnosed cases of HIV infection were observed in the United Kingdom
(149), Latvia (130) and Luxembourg (119) in 2006. Of these, 11% were reported in young people (15−24-years-old)
and 34% were female (28).

inequalities
The eastern part of Europe suffered an epidemic-like increase in the incidence of syphilis in the 1990s, but now the
rates are declining in all western and central European countries.

HIV epidemics in Spain, Italy, France and the United Kingdom continue to be the largest in Europe. The annual
number of newly diagnosed HIV infections has more than doubled in the United Kingdom, from 4152 in 2001 to
8925 in 2006. In eastern Europe, the number of newly diagnosed HIV infections in 2006 surpassed 100 in only three
countries: Poland (750), Turkey (290) and Romania (180). Elsewhere, the epidemics are comparatively small. Injecting
drug use is the most-reported mode of HIV transmission in the three Baltic states (Estonia, Latvia and Lithuania),
where the epidemics appear to have stabilized (28,29).

The characteristics of newly diagnosed cases of HIV reported in Europe are summarized in Table 4.4.2 and
Table 4.4.3.

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 sexual health

Fig. 4.4.2
ADOLESCENT PREGNANCY OUTCOMES, PER 1000 WOMEN AGED 15-19 Avery et al, 2007

Induced
Birth Rate Abortion Rate

4
Switzerland
Italy
.4
Greece
Slovenia
Belgium
Malta
Germany
Austria
Netherlands
Croatia
Spain
Czech Republic
Denmark
Albania
France
Finland
Lithuania
Norway
Slovakia
TFYR Macedonia†
Sweden
Latvia
Iceland
Hungary
Estonia
United kingdom
Romania
The former Yugoslav Republic of Macedonia

Bulgaria

0 10 20 30 40 50 60

Pregnancy outcome per 1000 women

†

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 A Snapshot of the Health of Young People in Europe 2009

Table 4.4.2 Characteristics of newly Table 4.4.3 Characteristics of newly

diagnosed cases of HIV infection reported Euro HIV, diagnosed cases of HIV infection reported Euro HIV,
in western europe, 2006 2007 in eastern europe, 2006 2007

Number of HIV cases 25 241 Number of HIV cases 1 805

Rate per million population 82.5 Rate per million population 9.4
Percentage of cases: Percentage of cases:
aged 15–24 years 10% aged 15–24 years 17%
female 35% female 26%
Prodominant transmission mode Heterosexual Prodominant transmission mode Heterosexual

*Missing data: Italy, Monaco, Spain

Human papilloma virus (HPV) vaccination

HPV vaccination is relatively new. There is wide variation in how countries choose to integrate vaccination into their
national health programmes. Many are attempting to establish the vaccine’s impact against cost−effectiveness.

Preliminary data suggest that vaccine uptake is highest when delivered through a school-based programme, such
as in United Kingdom (Scotland) (92% for first dose, 88% for second) and participating Spanish regions (>90%).
Uptake is less than 50% in Spanish regions where the on-demand vaccination is not supported by a campaign to
increase participation. Similarly, only 9% of the Greek population has accepted the option of receiving the vaccine
(30).

What are the challenges?

The overall trend seems to be towards fewer gender differences in sexual behaviour in the EU, starting among the
youngest (as shown in the HBSC survey) and in western and northern Europe.

Contraception use (mainly condoms) is more frequent among young people: partially linked to this, abortion rates
are declining.

Substantial differences are found between regions of the EU, however, emphasizing the need to improve access for
all young people in Europe to adequate reproductive and sexual health resources.

Reproductive health indicators currently used in the EU differ, making it difficult or impossible to compare between
countries (even more so since the age cut-offs also vary). This has been underlined by the REPROSTAT programme
and ought to be addressed to improve understandings of changes around the issue of sexual and reproductive
health in the EU. These understandings are crucial to the design and evaluation of interventions to improve the
sexual health of young people and, as a consequence, their overall health and well-being.

The specificity of data collected around sexual health needs to be recognized. For understandable social reasons,
questions on sexual behaviour are more susceptible to misreporting, with underreporting on issues such as STIs to
be expected. Some data are difficult to gather at country level. Overall, the common age range studied in the field
of sexual and reproductive health is 15−44 years, making it difficult to work on more specific age categories or on
specific problems (such as abortion rates for under 15s).

Finally, it needs to be underlined that most of the indicators collected around sexual and reproductive health are
linked to negative outcomes of unsafe sex rather than sexual behaviour in general.

On the whole, little is known about patterns of sexual behaviour in the EU, with only some countries, such as France,
conducting recent population surveys (31). In addition, available data are usually not comparable.

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 sexual health

Fig. 4.4.3
ABORTION RATES PER 1000 LIVE BIRTHS
AMONG WOMEN UNDER AGE 20 WHO Health for all database

4.4

2000 or more
1500 to 1999
1000 to 1499
500 to 999
less 500

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 A Snapshot of the Health of Young People in Europe 2009

100
references

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 A Snapshot of the Health of Young People in Europe 2009

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Network. London, National Institute for Health and Clinical Excellence, 2007 (http://www.who.int/social_determinants/
resources/mekn_final_report_102007.pdf, accessed 16 June 2009).
13. Esping-Andersen G. Three worlds of welfare capitalism. Cambridge, Policy Press, 1990.
14. Ferrera M. The “southern model” of welfare in social Europe. Journal of European Social Policy, 1996, 6:17−37.
15. Pathways to work: current practices and future needs for the labour market integration of young people. Rome, Istituto per
lo Sviluppo della Formazione Professionale [Institute for the Development of Vocational Training], 2008 (http://ec.europa.eu/
social/main.jsp?langId=en&catId=89&newsId=448&furtherNews=yes, accessed 16 June 2009).

2.1 Demographic trends

1. O’Keeffe S, et al. Crisis Pregnancy Agency statistical report 2006: teenage pregnancy data. Dublin,
Crisis Pregnancy Agency, 2006 (http://www.crisispregnancy.ie/pub/statistical_report2006.pdf, accessed 19 June 2009).
2. Europe in figures. EUROSTAT yearbook 2008. Luxembourg, Office for Official Publications of the European Communities,
2008 (http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-CD-07-001-SPOT/EN/KS-CD-07-001-SPOT-EN.PDF,
accessed 19 June 2009).
3. Policy paper on youth & migration. Brussels, European Youth Forum, 2008 (http://www.youthforum.org/sites/youthforum.
org/files/_old_website_yfj_files/Downloads/policy_docs/human_rights/1069-07_Migration_FINAL.pdf, accessed 19 June 2009).
4. European Commission. Employment in Europe 2008. Luxembourg, Office for Official Publications of the European
Communities, 2008 (http://ec.europa.eu/social/main.jsp?langId=en&catId=113&newsId=415&furtherNews=yes,
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2.2. Education
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from the 2005/2006 survey. Copenhagen, WHO Regional Office for Europe, 2008 (Health policy for children and adolescents
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2. Organisation for Economic Development and Co-operation. PISA 2006. Science competencies for tomorrow’s world. Volume
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3. Organisation for Economic Development and Co-operation. Education at a glance 2008. OECD indicators. Paris, OECD
Publishing, 2008 (http://www.oecd.org/dataoecd/23/46/41284038.pdf, accessed 19 June 2009).
4. International standard classification of education 1997 [web site]. Paris, United Nations Educational, Scientific and
Cultural Organization (UNESCO), 1997 (http://www.unesco.org/education/information/nfsunesco/doc/isced_1997.htm,
accessed 19 June 2009).
5. Europe in figures. EUROSTAT yearbook 2008. Luxembourg, Office for Official Publications of the European Communities,
2008 (http://epp.eurostat.ec.europa.eu/cache/ITY_OFFPUB/KS-CD-07-001-SPOT/EN/KS-CD-07-001-SPOT-EN.PDF, accessed
19 June 2009).
6. Gådin KG, Hammarström A. Do changes in the psychosocial school environment influence pupils’ health development?
Results from a three-year follow-up study. Scand J Public Health, 2003, 31:3:169−177.
7. Hjern A et al. School stressors, psychological complaints and psychosomatic pain. Acta Paediatr, 2008, 97:1:112−117.
8. Samdal O et al. Students’ perception of school and their smoking and alcohol use: a cross-national study.
Addiction Research, 2000, 8:2:141−167.
9. Torsheim T et al. Sense of coherence and school-related stress as predictors of subjective health complaints in early
adolescence: interactive, indirect or direct relationships? Social Science & Medicine, 2001, 53:603−614.
10. Torsheim T, Wold B. School-related stress, school support, and somatic complaints: a general population study.
Journal of Adolescent Research, 2001, 16:3:293−303.

3.1 Injuries and accidents

1. Sethi D et al. Injuries and violence in Europe: why they matter and what can be done. Copenhagen, WHO Regional Office for
Europe, 2006 (http://www.euro.who.int/InformationSources/Publications/Catalogue/20050907_1, accessed 19 June 2009).
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(http//whqlibdoc.who.int/publications/924156220X.pdf).
8. EU youth report. Brussels, Commission of the European Communities, 2009.

3.2 Mental health and well-being

1. Palfrey JS et al. Introduction: addressing the millennial morbidity – the context of the community.
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4. Herman H et al. Promoting mental health: concepts, emerging evidence, practice. Summary report. Geneva, World Health
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5. Rao M. Promoting children’s emotional well-being: a book review. Journal of Public Health Medicine, 2001, 23:2:168.
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7. Prevention of mental disorders: effective interventions and policy options. Summary report of the World Health Organization
Department of Mental Health and Substance Abuse in collaboration with the Prevention Research Centre of the Universities
of Nijmegen and Maastricht. Geneva, World Health Organization, 2004 (http://www.who.int/mental_health/evidence/en/
prevention_of_mental_disorders_sr.pdf, accessed 19 June 2009).
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Geschlechtsunterschiede. Psychologische Rundschau, 2001, 53:4:159−169.
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from the 2005/2006 survey. Copenhagen, WHO Regional Office for Europe, 2008 (Health policy for children and adolescents
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15. Fombonne E. Increased rates of psychosocial disorders in youth.
European Archives of Psychiatry and Clinical Neuroscience, 1998, 248:14−21.
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17. Collishaw S et al. Time trends in adolescent mental health.
Journal of Child Psychology and Psychiatry, 2004, 45:8:1350−1362.
18. Maughan B et al. Time trends in child and adolescent mental disorders. Current Opinion in Psychiatry, 2005, 18:381−385.
19. Reigstad B et al. Changes in referrals to child and adolescent psychiatric services in Norway 1992−2001.
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20. Levin KA et al. Mental well-being and subjective health of 11−15-year-old boys and girls in Scotland, 1994−2006.
European Journal of Public Health, in press (advanced access published April 21 2009 [DOI:10.1093/eurpub/ckp046]).
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23. Castille K et al. The early maladaptive schemas of self-mutilators: implications for therapy.
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25. Klonsky E, Muehlenkamp J. Self-injury: a research review for the practitioner.
Journal of Clinical Psychology, 2007, 63:1045−1056.

3.3 Overweight and obesity

1. Cole TJ et al. Establishing a standard definition for child overweight and obesity worldwide: international survey.
British Medical Journal, 2000, 320:1240–1243.
2. Lobstein T et al. Obesity in children and young people: a crisis in public health. Obes Rev, 2004, 5:Suppl. 1:4−85.
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Saint-Denis, INPES, 2008.

4.1 Eating patterns

1. Gaining health. The European strategy for the prevention and control of noncommunicable diseases. Copenhagen,
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Oxford, British Heart Foundation Health Promotion Research Groups, 2000.
6. Food, nutrition, physical activity, and the prevention of cancer: a global perspective. Washington, DC, World Cancer Research
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7. WHO European Ministerial Conference on Counteracting Obesity. Conference report. Copenhagen,
WHO Regional Office for Europe, 2007 (http://www.euro.who.int/document/E90143.pdf, accessed 20 June 2009).
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9. Weiss R et al. Prediabetes in obese youth: a syndrome of imparied glucose tolerance, severe insulin resistance, and altered
myocellular and abdominal fat partitioning. The Lancet, 2003, 363:951−957.
10. Cook S et al. Prevalence of a metabolic syndrome phenotype in adolescents. Findings from the Third National Health and
Nutrition Examination Survey, 1988−1994. Arch Pediatr Adolesc Med, 2003, 157: 821−827.
11. Benton D. Micronutrient status, cognition and behavioral problems in childhood.
European Journal of Nutrition, 2008, 47:Suppl. 3:38−50.
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Thyroid, 2003, 17:9:829−835.
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18. Centers for Disease Control and Prevention. Guidelines for school health programs to promote lifelong healthy eating.
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4.2 Physical activity and sedentary behaviour

1. Smyth S, Heron A. Diabetes and obesity: the twin epidemics. Nature Medicine, 2006, 12:75−80.
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Medicine and Science in Sports and Exercise, 2006, 38:919−925.
30. Burke V et al. Television, computer use, physical activity, diet and fatness in Australian adolescents.
International Journal of Pediatric Obesity, 2006, 1:248−255.
31. Crespo CJ et al. Television watching, energy intake, and obesity in US children.
Archives of Pediatric and Adolescent Medicine, 2001, 155:360−365.
32. Gortmaker SL et al. Television viewing as a cause of increasing obesity among children in the United States, 1986−1990.
Archives of Pediatric and Adolescent Medicine, 1996, 150:356−362.
33. DeMattia L et al. Do interventions to limit sedentary behaviours change behaviour and reduce childhood obesity?
A critical review of the literature. Obesity Reviews, 2007, 8:69−81.
34. Hancox RJ, Poulton R. Watching television is associated with childhood obesity: but is it clinically important?
International Journal of Obesity, 2006, 30:171−175.
35. Aarnio M et al. Associations of health and related behaviour, social relationships, and health status with persistent physical
activity and inactivity: a study of Finnish adolescent twins. British Journal of Sports Medicine, 2002, 36:360−364.
36. American Academy of Pediatrics. Children, adolescents and television. Pediatrics, 2001, 107:423−426.
37. Berkey CS et al. Weight gain in older adolescent females: the internet, sleep, coffee and alcohol.
The Journal of Pediatrics, 2008, 635−645.
38. Hakala PT et al. Frequent computer-related activities increase the risk of neck-shoulder and low back pain in adolescents.
European Journal of Public Health, 2006, 16:536−541.
39. Kuntsche E et al. Television viewing and forms of bullying among adolescents from eight countries.
Journal of Adolescent Health, 2006, 39:6:908−915.
40. Kuntsche E et al. Television viewing, computer use and hostile perception of classmates among adolescents from 34 countries.
Swiss Journal of Psychology, 2008, 67:2:97−106.
41. Steptoe A, Butler N. Sports participation and emotional wellbeing in adolescents. The Lancet, 1996, 347:1789−1792.
42. Punamäki R-L, et al. Use of information and communication technology (ICT) and perceived health in adolescence.
The role of sleeping habits and waking-time tiredness. Journal of Adolescence, 2007,30:569−585.
43. Kelder SH et al. Longitudinal tracking of adolescent smoking, physical activity, and food choice behaviors.
Journal of Public Health, 1994, 84:1121−1126.
44. McMurray RG et al. Tracking of physical activity and aerobic power from childhood through adolescence.
Medicine & Science in Sports & Exercise, 2003, 35:1914−1922.
45. Currie C et al., eds. Young people’s health in context. Health Behaviour in School-aged Children (HBSC) study: international
report from the 2001/2002 survey. Copenhagen, WHO Regional Office for Europe, 2004 (Health policy for children and
adolescents No. 4; http://www.euro.who.int/Document/e82923.pdf, accessed 16 June 2009).
46. Currie C et al., eds. Inequalities in young people’s health. Health behaviour in school-aged children: international report
from the 2005/2006 survey. Copenhagen, WHO Regional Office for Europe, 2008 (Health policy for children and adolescents
No. 5; http://www.euro.who.int/datapublications/Publications/Catalogue/20080616_1, accessed 16 June 2009).
47. Brettschneider W et al. Study on young people’s lifestyles and sedentariness and the role of sport in the context of education
and as a means of restoring the balance.  Paderborn, University of Paderborn, 2004 (http://www.sportdevelopment.info/
attachments/507_sporteducating.pdf, accessed 20 June 2009).
48. Global strategy on diet, physical activity and health. Geneva, World Health Organization, 2004 (http://www.who.int/
dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf, accessed 20 June 2009).
49. Special Eurobarometer 183-6/Wave 52.8. Physical activity. Luxembourg, European Opinion Research Group, 2003
(http://ec.europa.eu/public_opinion/archives/ebs/ebs_183_6_en.pdf. accessed 20 June 2009).
50. Brodersen NH et al. Trends in physical activity and sedentary behaviour in adolescence: ethnic and socioeconomic differences.
British Journal of Sports Medicine, 2007, 41:140−144.
51. EU youth report. Brussels, Commission of the European Communities, 2009.
52. Hardy LL et al. Changes in sedentary behavior among adolescent girls: a 2.5-year prospective cohort study.
Journal of Adolescent Health, 2007, 40:158−165.

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53. Corbin CB. Physical activity for everyone: what every physical educator should know about promoting lifelong physical activity.
Journal of Teaching in Physical Education, 2002, 21:128−144.
54. Sallis JF et al. The effects of a 2-year physical education program (SPARK) on a physical activity and fitness in elementary
school students. American Journal of Public Health, 1997, 87:1328−1334.
55. Biddle J et al. Young and active? Young people and health-enhancing physical activity–evidence and implications.
London, Health Education Authority, 1998 (http://www.nice.org.uk/niceMedia/documents/youngandactive.pdf,
accessed 20 June 2009).
56. Salmon J et al. Promoting physical activity participation in children and adolescents.
Epidemiologic Reviews, 2007, 29:144−159.
57. Calmeiro L, Matos MG. Psicologia do exercício e da saúde [Psychology of exercise and health]. Lisboa, Omniserviços, 2004.
58. Mota J et al. Perceived neighborhood environments and physical activity in adolescents. Prev Med, 2005, 41:5−6:834−836.
59. Sallis JF et al. Correlates of physical activity in a national sample of girls and boys in grades 4 through 12.
Health Psychology, 1999, 18:410−415.

4.3 Alcohol, drugs and tobacco

1. Gilvarry E. Substance abuse in young people. Journal of Child Psychology and Psychiatry, 2000, 41:55−80.
2. Simões C et al. Alcohol use and abuse in adolescence: proposal of an alternative analysis.
Child: Health, Care and Development, 2008, 34:3:391−401.
3. Sallis JF, Owen N. Ecological models of health behavior. In: Glanz K et al., eds. Health behavior and health education.
Theory, research and practice. San Fransisco, CA, John Wiley and Sons, Inc., 2002:462−484.
4. Verkooijen A. Youth crowds and substance use: the impact of perceived norm and multiple group identification.
Psychology of Addictive Behaviors, 2007, 21:1:55–61.
5. D’Amico E, McCarthy D. Escalation and initiation of younger adolescents’ substance use: the impact of perceived peer use.
Journal of Adolescent Health, 2006, 39:481–487.
6. Connel A et al. An adaptive approach to family intervention: linking engagement in family-centred intervention to reductions
in adolescent problem behavior. Journal of Consulting and Clinical Psychology, 2007, 75:4:568–579.
7. Wills T. Coping dimensions, life stress and adolescent substance use. Journal of Abnormal Psychology, 2001, 110:2:309−323.
8. Kandel DB. Persistent themes and new perspectives on adolescent substance use: a lifespan perspective. In: Jessor R, ed.
New perspectives on adolescent risk behaviour. New York, NY, Cambridge University Press, 1998:43−89.
9. Kokkevi A et al. Early initiation of cannabis use: a cross-national European perspective.
J Adolesc Health, 2006, 39:5:712−719.
10. Currie C et al., eds. Inequalities in young people’s health. Health behaviour in school-aged children: international report from
the 2005/2006 survey. Copenhagen, WHO Regional Office for Europe, 2008 (Health policy for children and adolescents No.
5; http://www.euro.who.int/datapublications/Publications/Catalogue/20080616_1, accessed 16 June 2009).
11. Hibell B et al. The 2007 ESPAD report − substance use among students in 35 European countries. Stockholm, The Swedish
Council for Information on Alcohol and Other Drugs, 2009 (http://www.espad.org/documents/Espad/ESPAD_reports/2007/
The_2007_ESPAD_Report-FULL_090617.pdf, accessed 20 June 2009).
12. EU youth report. Brussels, Commission of the European Communities, 2009
13. Hublet A et al. Smoking trends among adolescents from 1990 to 2002 in ten European countries and Canada.
BMC Public Health, 2006, 6:280.
14. Annual report 2008: the state of the drugs problem in Europe. Lisbon, European Monitoring Centre for Drugs and
Drug Addiction, 2008 (http://www.emcdda.europa.eu/publications/annual-report/2008, accessed 20 June 2009).
15. Kuntsche E et al. Decrease in adolescent cannabis use from 2002 to 2006 and links to evenings out with friends in
31 European and North American countries and regions. Arch Pediatr Adolesc Med, 2009, 163:2:119−125.
16. Fergusson DM et al. Cannabis use and psychosocial adjustment in adolescence and young adulthood.
Addiction, 2002, 97:1123−1135.
17. Valmain J. Current work of the European Commission (driving licences and research activities).
Report presented at Pompidou Group Seminar on Road Traffic and Drugs, Strasbourg, July 2006.
18. Hublet A et al. Association between tobacco control policies and smoking behaviour among adolescents in 29 European
countries, Addiction, in press.
19. Simons-Morton et al. Gender Specific trends in alcohol use: cross-cultural comparisons from 1998 to 2006 in 24
countries and regions, International Journal of Public Health, in press (advanced online access published July 18, 2009
[10.1007/s00038–009–5411–y]).

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4.4 Sexual health

1. Public choices, private decisions: sexual and reproductive health and the Millennium Development Goals. New York, NY,
United Nations Millennium Project, 2006 (http://www.unmillenniumproject.org/documents/MP_Sexual_Health_screen-final.
pdf, accessed 20 June 2009).
2. Avery L, Lazdane G. What do we know about the sexual and reproductive health of adolescents in Europe?
European Journal of Contraception and Reproductive Health Care, 2007, 13:58−70.
3. Global strategy for the prevention and control of sexually transmitted infections: 2006−2015. Geneva, World Health
Organization, 2007.
4. Bozon M, Kontula O. Sexual initiation and gender in Europe: a cross-cultural analysis of trends in the twentieth century.
In: Hubert M et al., eds. Sexual behaviour and HIV/AIDS in Europe. London, UCL Press, 1998:37−67.
5. Wellings K et al. Sexual behaviour in context: a global perspective. The Lancet, 2006, 368:1706–1728.
6. Santelli JS et al. Explaining declines in adolescent pregnancy in the United States: the contribution of abstinence and
improved contraceptive use. American Journal of Public Health, 2007, 97:150−156.
7. Bearinger LH et al. Global perspectives on the sexual and reproductive health of adolescents: patterns, prevention and
potential. The Lancet, 2007, 369:1220−1231.
8. Anderson JE et al. Trends in adolescent contraceptive use, unprotected and poorly protected sex, 1991−2003.
Journal of Adolescent Health, 2006, 38:734−739.
9. Wellings K et al. Sexual behaviour in Britain: early heterosexual experience. The Lancet, 2001, 358:1843−1850.
10. Magnusson C, Trost K. Girls experiencing sexual intercourse early: could it play a part in reproductive health in middle
adulthood? Journal of Psychosomatic Obstetrics and Gynaecology, 2006, 27:237−244.
11. Fergus S et al. Sexual risk behavior in adolescence and young adulthood.
American Journal of Public Health, 2007, 97:6:1096−1101.
12. Parkes AP et al. Explaining association between adolescent substance use and condom use.
Journal of Adolescent Health, 2007, 40:3:180.e1−180.e18.
13. Eaton DK et al. Youth risk behavior surveillance − United States, 2005. MMWR Surveill Summ, 2006, 55:1-108.
14. Cooper ML. Alcohol use and risky sexual behaviour among college students and youth: evaluating the evidence.
Journal of Studies on Alcohol, 2002, 14:Suppl:101−117.
15. Poulin C, Graham L. The association between substance use, unplanned sexual intercourse and other sexual behaviours
among adolescent students. Addiction, 2001, 96:607−621.
16. Ellison MA. Authoritative knowledge and single women’s unintentional pregnancies, abortions, adoptions, and single
motherhood: social stigma and structural violence. Medical Anthropology Quarterly, 2003, 17:322−347.
17. The European health report 2005. Public health action for healthier children and populations. Copenhagen,
WHO Regional Office for Europe, 2005 (http://www.euro.who.int/document/e87325.pdf, accessed 20 June 2009).
18. Imamura M et al. Factors associated with teenage pregnancy in the European Union countries: a systematic review.
Eur J Public Health, 2007, 17:6:630−636.
19. Temmermaan M et al. Reproductive health indicators in the European Union: the REPROSTAT project.
Eur J Obstetrics and Reproductive Biology, 2006, 126:3−10.
20. Teitler JO. Trends in youth sexual initiation and fertility in developed countries: 1960−1995.
Annals of the American Academy of Political and Social Science, 2002, 580:134−152.
21. Bajos N et al. Reproductive health behaviour of young Europeans. Vol.1. Strasbourg, Council of Europe, 2003 (Population
Studies, No. 42).
22. Nikula M et al. Sexual health among young adults in Finland: assessing risk and protective behaviour through a general health
survey. Scand J of Public Health, 2007, 35:298−305.
23. Godeau E et al. Contraceptive use by 15-year-old students at their last sexual intercourse − results from 24 countries. Archives
of Pediatric and Adolescent Medicine, 2008, 162:1:66−73.
24. Nic Gabhainn S et al. and the HBSC Sexual Health Behaviour Focus Group. How well protected are sexually active
15-year-olds across Europe and Canada? Data from the 2006 WHO/HBSC study. International Journal of Public Health,
in press.
25. Sedgh G et al. Induced abortion: estimated rates and trends worldwide. The Lancet, 2007, 370:9595:1338–1345.
26. Facts on induced abortion worldwide. New York, NY, Guttmacher Institute, 2008
(Fact sheet: http://www.guttmacher.org/pubs/fb_IAW.pdf, accessed 20 June 2009).
27. European health for all database [online database]. Copenhagen, WHO Regional Office for Europe, 2009
(http://www.euro.who.int/hfadb, accessed 20 June 2009).

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28. HIV/AIDS surveillance in Europe. End-year report 2006, no. 75. Saint-Maurice: EuroHIV, 2007
(http://www.eurohiv.org/reports/report_75/pdf/report_eurohiv_75.pdf, accessed 20 June 2009).
29. 07 AIDS epidemic update. Geneva, UNAIDS, 2007
(http://data.unaids.org/pub/EPISlides/2007/2007_epiupdate_en.pdf, accessed 20 June 2009).
30. HPV vaccination across Europe. Brussels, European Cancer Association, 2009.
31. Bajos N, Bozon M, eds. Enquête sur la sexualité en France. Pratiques, genre et santé (Survey on sexuality in France behaviours,
gender and health). Paris, Editions la Découverte, 2008.

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The WHO Regional Office for Europe A snapshot of the health of young people in Europe

The World Health Organization (WHO) This report has been prepared by the WHO Regional Office for Europe for the European
is a specialized agency of the United Commission conference, Youth health initiative: be healthy, be yourself, held in Brussels,
Nations created in 1948 with the primary Belgium on 9 and 10 July 2009.
responsibility for international health
matters and public health. The WHO The conference reflects the high priority given to youth health by the European

A snapshot of the health of young people in Europe

Regional Office for Europe is one of six Commission. This is a vital commitment, because securing the health and well-being of
regional offices throughout the world,
each with its own programme geared young people today is an essential investment in securing the health, well-being and
to the particular health conditions of prosperity of the Europe of tomorrow.
the countries it serves.
The report provides a “snapshot” of the health of young people in Europe rather than
Member States a more comprehensive account.
Albania An editorial board was formed to oversee production of the report, and expert writers
Andorra were commissioned to make specific contributions. Their expertise and knowledge of
Armenia the underpinning issues makes for an authoritative yet succinct overview of the health
Austria
Azerbaijan issues that are important to Europe’s young people now and for the future, including:
Belarus
Belgium
• mental health
Bosnia and Herzegovina • overweight and obesity
Bulgaria • physical activity and sedentary behaviour
Croatia • substance misuse
Cyprus
Czech Republic • sexual health.
Denmark
Estonia
Finland
France
Georgia
Germany
Greece
Hungary
Iceland
Ireland
Israel
Italy
Kazakhstan
Kyrgyzstan
Latvia
Lithuania
Luxembourg
Malta
Monaco
Montenegro
Netherlands
Norway
Poland
Portugal
Republic of Moldova
Romania
Russian Federation
San Marino
Serbia
Slovakia
Slovenia
Spain
Sweden
Switzerland
A snapshot of the health
Tajikistan
The former Yugoslav
Republic of Macedonia
of young people in Europe
Turkey
Turkmenistan
Ukraine a report prepared for the european commission conference on
United Kingdom youth health, brussels, belgium, 9–10 July 2009
Uzbekistan

World Health Organization

Regional Office for Europe
Scherfigsvej 8, DK-2100 Copenhagen Ø, Denmark
Tel.: +45 39 17 17 17.
Fax: +45 39 17 18 18.
E-mail: [email protected]

Web site: www.euro.who.int