Development of health and depressive symptoms among Danish adolescents—Socioeconomic differences and effects of life-style

doi:10.4236/ojpm.2013.31013

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Vol.3, No.1, 104-110 (2013) Open Journal of Preventive Medicine

http://dx.doi.org/10.4236/ojpm.2013.31013

Development of health and depressive symptoms

among Danish adolescents—Socioeconomic

differences and effects of life-style

Johan Hviid Andersen1, Merete Labriola1,2*, Thomas Lund1,3, Claus D. Hansen1,4

1Danish Ramazzini Centre, Department of Occupational Medicine, Regional Hospital Herning, Herning, Denmark;

*Corresponding Author: [email protected]

2Department of Clinical Social Medicine, Public Health and Quality Management, Central Denmark Region and Section of Clinical

Social Medicine & Rehabilitation, School of Public Health, University of Aarhus, Aarhus, Denmark

3National Centre for Occupational Rehabilitation, Rauland, Norway

4Department of Sociology & Social Work, Aalborg University, Aalborg, Denmark

Received 19 November 2012; revised 20 December 2012; accepted 28 December 2012

ABSTRACT

While the existence of social inequality in health

in childhood as well as among adults is well es-

tablished, research of mechanisms underlying

this inequality is still sparse. The study aim was

to report on the development of self-rated health

and depressive symptoms from age 15 to18

years in a cohort study of Danish adolescents.

Methods: The cohort comprised 3,681 individu-

als born in 1989, 3058 individuals answered the

baseline questionnaire in 2004, and 2400 re-

sponded to a follow-up questionnaire in 2007,

with 2181 individuals participating in both rounds

(59% of the original cohort). Social background

information of the participants was derived from

a national register. For the analysis two vari-

ables indicating change in the two health indi-

cators was computed by subtracting the 2007

levels of the variables from the levels experi-

enced in 2004. Results: After 3 years, mean

self-rated health (SRH) deteriorated slightly in

adolescents (−0.24; 95% CI = −0.28 to −0.19)

across all socioeconomic status (SES) groups

and depressive symptoms increased (0.64; 95%

CI = 0.52 to 0.75). High household income was

protective for decrease in SRH (0.62; 0.43 - 0.91).

Negative life-style changes were associated with

poorer SRH and more depressive symptoms.

Conclusions: Self-rated health and depressive

symptoms changed to the worse among Danish

adolescents from age 15 to 18 years. Negative

changes in several lifestyle factors were found

to accompany the deterioration of health. This

result stresses the intrinsic relationship be-

tween lifestyle changes and health and the pos-

sible positive effect of maintaining and enhanc-

ing positive lifestyle factors.

Keywords: Longitudinal Cohort Study; Lifestyle;

Self-Rated Health; Depressive Symptoms

1. INTRODUCTION

Whilst social inequality in childhood and adult health

is well established, research into the mechanisms under-

lying this inequality is essential if we are to understand

how social and economic factors are related to health and

where interventions will be effective. Assessments of

individual overall health status have been widely studied

by means of self-rated health (SRH), originally devel-

oped for the ShortForm-36 (SF-36) and SF-12. In adult

populations, this single self-perception measure has re-

vealed systematic associations with later morbidity,

mortality and disability [1,2]. Despite a large body of

work examining adult SRH, only a few studies have

evaluated the role of SRH among adolescents as a meas-

ure of actual health status.

Among US adolescents’ self-rated health was found to

be moderately stable and was characterized as an endur-

ing self-concept among adolescents [3]. The Norwegian

young-Hunt study followed adolescents aged 13 - 19

years for 4 years and found that SRH was a relatively

stable construct during adolescence and that it was re-

lated to both general well-being and disability as well as

to use of healthcare, and health-compromising behav-

iours. The study, however, lacked information on family

income and parents’ educational level rendering socio-

economic comparisons impossible [4].

The German Bella-study [5] found children from

lower social status homes to report a lower health-related

quality of life compared to children from middle social

J. H. Andersen et al. / Open Journal of Preve ntive Medicine 3 (2013) 104-110 105

status homes, who, in turn, were surpassed by children

with a high family social status. Various mechanisms

that could explain the relationship between socioeco-

nomic status, and the well-being and health-related qual-

ity of life of children and adolescents are being widely

discussed in the literature [6-10]. Many of the hypothe-

sized mechanisms refer to differences in access to mate-

rial and social resources or to reactions to stress-induced

conditions to which children and adolescents are exposed.

One of the most prominent explanations of social ine-

quality of health is the behavioural/cultural explanation

that hypothesize that the observed health differentials are

primarily the result of social class differences in health

related lifestyle behaviours [6].

Depression is another commonly studied measure of

health and wellbeing among adolescents and young

adults [11-15]. First onset is usually in adolescence

[11-12]. Depression early in life can have serious impli-

cations for the individuals’ school performance, school

absence and dropout and later professional careers [14].

Furthermore, depression in adolescence can increase use

of tobacco and alcohol [15]. Other studies have shown a

moderate association between physical activity and de-

pression amongst adolescents [16,17]. However, due to

cross sectional designs, the causal relation between de-

pression and physical activity is unclear.

This study reports on the development of self-rated

health and depressive symptoms, from age 15 to 18, in a

prospective cohort study among Danish adolescents. The

aim was to study life-style related predictors for health

change among children with different social backgrounds

defined by household income and parents’ education.

2. METHODS

2.1. Study Population

Data were gathered as part of the ongoing West Jut-

land Cohort Study (VestLiv), which is a survey follow-

ing a complete regional cohort of adolescents in the

Western part of Denmark, gathering comprehensive in-

formation on the occurrence, severity and impact of

manifold symptoms of physical and mental health prob-

lems—both self-reported and register-based [18]. Infor-

mation on socioeconomic status of parents is from offi-

cial registers.

The cohort comprised of 3681 individuals born in

1989, of which 3058 answered the baseline questionnaire

in 2004, resulting in a response rate of 83%. Everyone

who had not opted out of the study (N = 3293) was sent

the second round questionnaire in 2007, and 2400 an-

swered the questionnaire resulting in a response rate of

73%; 2181 individuals participated in both rounds (59%

of the original cohort). These 2181 individuals constitute

the basis of analysis in this study.

Information on the social background of the partici-

pants (e.g. household income, parents’ highest education

etc) derived from a national register in Statistics Den-

mark by using information from the Central Office of

Civil Registration (CPR) in which the respondents are

linked to their legal parents or guardians via a personal

identification number given to everyone in Denmark at

birth (or upon entry for immigrants).

Ethical approval: The study has been notified to and

registered by Datatilsynet (the Danish Data Protection

Agency). According to Danish law, questionnaire and

and scientific committees, nor informed consent.

2.2. Health Indicators

This study examines two aspects of adolescents’

health status: self-rated health (SRH), and psychological

health. For SRH the question was “In general, how

would you rate your health?” with response options from

1 “Poor” to 5 “Excellent.” Psychological health was

measured using the Center for Epidemiological Studies

Depression Scale for Children (CES-DC), 4-item version

[19]. Responses were scored 0 “Not At All”, 1 “A Little”,

2 “Some”, 3 “A Lot”.

2.3. Independent Variables

Socioeconomic status (SES) was defined according to

household income and parents’ educational level in the

year before baseline (2003). Household income was di-

vided into quartiles, and parents’ highest education was

divided into four levels: under 10 years, 10 - 12 years, 13

- 15 years and >15 years of education.

Life-style factors were measured by a series of ques-

tions on leisure-time and sporting activities, smoking

habits, time spent watching television and using a com-

puter, and eating habits at age 15 and 18 years. We con-

structed dichotomous variables for a change in life-

style indicating a potentially negative change versus no

change/change to a healthier life-style during the 3-year

follow-up period e.g. starting smoking versus continuing

to smoke/stopping smoking. Characteristics of the study

population at baseline 2004 are described in Table 1.

2.4. Statistics

Adolescents who participated in both waves of the

study (2004 and 2007) were eligible for data analysis (n

= 2181). For the analysis, two variables indicating a

change in the two health indicators was computed by

subtracting the 2007 levels from the level reported in

2004. These are the dependent variables. A decrease of at

least one scale point on a scale from 1 to 5 was consid-

ered a relevant change for SRH, and for CES-DC scale,

which runs from 0 to 12, a change of at least 3 scale-

J. H. Andersen et al. / Open Journal of Preve ntive Medicine 3 (2013) 104-110

106

Table 1. Characteristics of study population at baseline 2004 and at follow up 2007, and changes in negative direction for included

variables from 2004 to 2007.

2004 2007 2004/2007

Variable Level N (%) N (%) N (%)

Gender Female 1180 (54.1)

Male 1001 (45.9)

Self-rated health (SRH) Excellent 645 (29.8) 477 (22.5)

Very good 999 (46.1) 909 (42.8)

Good 442 (20.4) 608 (28.6)

Fair 76 (3.5) 138 (6.5)

Poor 6 (0.3) 21 (1.0)

Poorer SRH at follow-up Decrease of ≥1 point 780 (35.8)

Depress. symptoms (score 0 - 12) 0 - 3 1665 (78.5) 1446 (67.1)

4 - 12 455 (21.5) 708 (32.9)

More depressive at follow up Increase of ≥3 point 465 (24.3)

Parental educational level <10 yrs 214 (9.8)

10 - 12 yrs 1107 (50.8)

13 - 15 yrs 709 (32.5)

>15 yrs 138 (6.3)

Household income, EURO <60,000 473 (21.7)

60 - 75,000 533 (24.4)

75 - 90,000 573 (26.3)

>90,000 590 (27.1)

Participation in sports, hrs/week 0 32 (1.5) 99 (4.6)

Approx. 0.5 84 (3.9) 102 (4.7)

Approx. 1 214 (9.8) 295 (13.6)

Approx. 2 - 3 565 (25.9) 668 (30.7)

Approx. 4 - 6 756 (34.7) 649 (29.8)

7 or more 511 (23.4) 360 (16.6)

Reduction in sports 338 (15.5)

Smoking habits Non smoker 1889 (89.2) 1555 (73.5)

<Once/week 94 (4.4) 158 (7.5)

Not daily, but >once/week 39 (1.8) 98 (4.6)

Daily 94 (4.4) 305 (14.4)

Begun to smoke 386 (17.7)

TV/video and computer use <2 hrs/day 913 (42.3) 470 (22.0)

2 hrs +/day 1246 (57.7) 1668 (78.0)

More TV and computer use 1435 (65.8)

Fruit/vegetable intake Once/day or more 849 (39.2) 310 (14.6)

Once or more/week 727 (33.5) 752 (35.4)

<Once/week 589 (27.2) 1061 (50.0)

Less fruit/vegetable 1,106 (33.7)

Wholegrain bread intake Once/day or more 645 (30.4) 667 (31.5)

Once or more/week 956 (45.0) 798 (37.6)

<Once/week 523 (24.6) 653 (30.9)

Less full grain bread 535 (24.5)

J. H. Andersen et al. / Open Journal of Preve ntive Medicine 3 (2013) 104-110 107

points, corresponding to 1 standard deviation, was used

to indicate change. Logistic regression analyses were

conducted with the two measures of SES, life style fac-

tors, and gender as the independent variables. Results are

reported as odds ratios (OR) with 95% confidence inter-

vals (95% CI) for developing poorer self-rated health and

more depressive symptoms in the 3-year follow-up pe-

riod. Baseline levels of the two outcomes and all the

life-style factors were included in the models in order to

adjust for baseline levels. The Hosmer-Lemeshow Good-

ness-of-fit test was used for each of the logistic regres-

sion models.

3. RESULTS

Assessments of health behaviour at baseline 2004 and

at follow up 2007 show changes in negative direction for

all included variables (Table 1).

Furthermore, mean self-rated health (SRH) deterio-

rated slightly in adolescents from 15 to 18 years (−0.24;

95% CI = −0.28 to −0.19) across all SES groups (Table

2) and depressive symptoms increased (0.64; 95% CI =

0.52 to 0.75) during the 3 years (Table 3)

Parental education level was not associated with a de-

terioration in SRH or increase in depressive symptoms

among adolescents from 15 to 18 years of age, whereas

there was a tendency for adolescents from lower income

homes to develop poorer SRH: Higher household income

was protective against reporting poorer SRH after 3

years (OR = 0.62; 95% CI 0.43 - 0.91), but had no effect

on the development of depressive symptoms. Female

adolescents had a two-fold risk of developing worse

SRH and more symptoms of depression in the 3-year

period compared to males (Table 4).

Changes in several of the life-style factors were asso-

ciated with poorer SRH in the follow-up period. Adoles-

cents who reduced their sporting activities (OR=1.97;

1.46 - 2.66) or decreased their intake of fruit and vegeta-

bles (1.36; 1.06 - 1.73) had poorer SRH after 3 years.

More than two thirds of the respondents (65.8%) had

increased their time with television and computer use,

and this was associated with poorer SRH (OR = 1.58;

1.23 - 2.02). A reduction in fruit and vegetable intake

and of whole-grain bread were each associated with a

48% increased risk of reporting more depressive symp-

toms after 3 years, whereas the association between

eating habits and SRH after 3 years was smaller (Tabl e

4). Finally, reducing sports activities was associated

with poorer SRH and more symptoms of depression

from age 15 to 18. Those who begun to smoke reported

poorer SRH (OR = 1.81; 1.36 - 2.42) at follow-up (Ta-

ble 4).

4. DISCUSSION

In general, development in self-rated health and de-

pressive symptoms were in a negative direction among

Table 2. Self-Rated Health (SRH) at baseline (2004) and follow-up (2007). N = 2140.

Follow-up 2007

Self-rated health*

Excellent Very good Good Not very goodPoor Total

Excellent 261 (12.2%) 262 (12.2%) 99 (4.6%) 14 (0.7%) 2 (0.1%) 638 (29.8%)

Very good 174 (8.1%) 479 (22.4%) 282 (13.2%) 41 (1.9%) 10 (0.5%) 986 (46.1%)

Good 34 (1.6%) 145 (6.8%) 191 (8.9%) 61 (2.9%) 5 (0.2%) 436 (20.4%)

Not very good 4 (0.29%) 18 (0.8%) 29 (1.4%) 20 (0.9%) 4 (0.2%) 75 (3.5%)

Poor 1 (0.1%) 1 (0.1%) 2 (0.1%) 1 (0.1%) 0 5 (0.2%)

Baseline 2004

Total 474 (22.2%) 905 (42.3%) 603 (28.2%) 137 (6.4%) 21 (1.0%) 2140 (100%)

*Mean change estimate; 95% CI, t-test p-value, All: −0.24; −0.28 to −0.19, p < 0.000. Scale range 1 - 5, Boys/girls: 0.06; −0.03 to 0.14, p = 0.09.

Table 3. Depressive symptoms at baseline (2004) and follow-up (2007). N = 2120.

Follow-up 2007

Depressive symptoms*

Scale score 0 to 3 Scale score 4 to 12 Total

Scale score 0 to 3 1197 (56.5%) 468 (22.1%) 1,665 (78.5%)

Scale score 4 to 12 227 (10.7%) 228 (10.8%) 455 (21.5%)

Baseline

2004

Total 1424 (67.2%) 696 (32.8%) 2120 (100%)

*Mean change estimate; 95% CI, t-test p-value; All: 0.64; 0.52 to 0.75, p < 0.000. Scale range 0 - 12; Boys/girls: 0.30; 0.07 to 0.52, p = 0.005.

J. H. Andersen et al. / Open Journal of Preve ntive Medicine 3 (2013) 104-110

108

Table 4. Parental socioeconomic status (SES) and change in life-style factors-effects on the risk of developing poorer general health

and more depressive symptoms in a 3-year follow up period amongst Danish adolescents. Logistic regression with odds ratios (OR)

with 95% confidence interval (CI). N = 2181.

Poorer self-rated health More depressive symptoms

Variable Level N (%)

Partly adjusted*

OR; 95% CI

Fully adjusted**

OR; 95% CI

Partly adjusted*

OR; 95% CI

Fully adjusted**

OR; 95% CI

Up to 10 yrs 214 (9.9%) 1.00 1.00 1.00 1.00

10 - 12 yrs 1107 (51.1%) 0.89;

0.63 - 1.26

0.88;

0.59 - 1.31

0.87;

0.59 - 1.28

0.89;

0.58 - 1.37

13 - 15 yrs 709 (32.7%) 1.04;

0.72 - 1.50

1.07;

0.70 - 1.63

1.02;

0.68 - 1.55

1.13;

0.71 - 1.79

Educational level

>15 yrs 138 (6.4%) 1.10;

0.66 - 1.83

1.22;

0.69 - 2.17

1.36;

0.78 - 2.36

1.39;

0.71 - 2.61

<60,000 473 (21.8%) 1.00 1.00 1.00 1.00

60,000 - 75,000 533 (24.6%) 0.73;

0.52 - 1.02

0.67;

0.46 - 0.98

1.07;

0.73 - 1.56

1.18;

0.77 - 1.81

75,000 - 90,000 573 (26.4%) 0.78;

0.56 - 1.09

0.79;

0.54 - 1.14

1.07;

0.73 - 1.56

1.15;

0.75 - 1.76

Household income,

quartiles—EURO

>90,000 590 (27.2%) 0.62;

0.44 - 0.88

0.62;

0.43 - 0.91

0.87;

0.59 - 1.28

0.94;

0.61 - 1.46

Gender Female 1180 (54.1%) 1.66;

1.36 - 2.02

1.76;

1.38 - 2.24

2.03;

1.63 - 2.53

2.37;

1.79 - 3.13

Reduction in sport 338 (15.5%) 1.97;

1.46 - 2.66 1.51;

1.09 - 2.11

Begun to smoke 386 (17.7%) 1.81;

1.36 - 2.42 1.25;

0.93 - 1.69

More TV and PC time 1435 (65.8%) 1.58;

1.23 - 2.02 1.09;

0.96 - 1.24

Less fruit and vegetables 1106 (33.7%) 1.36;

1.06 - 1.73 1.48;

1.12 - 1.94

Less wholegrain bread 535 (24.5%) 1.19;

0.91 - 1.55 1.47;

1.10 - 1.97

*Adjusted for parents’ educational level, household income, baseline self-rated health or depressive symptoms and gender, **Adjusted for parents’ educational

level, household income, baseline self-rated health or depressive symptoms, gender and life-style changes.

Danish adolescents from age 15 to 18 years. The risk of

reporting poorer SRH after 3 years was lower in house-

holds with higher income, whereas parental educational

level was not associated with the development in SRH or

depressive symptoms. Adolescents who had adjusted

certain life-style factors in a negative direction from the

age of 15 to 18 reported poorer SRH and more depres-

sive symptoms. These results are consistent with what

has been observed in other longitudinal studies of health

related lifestyle among adolescents [20,21].

Despite the relatively high average household income

in this region of Denmark adolescents from households

within the lowest quartile of incomes had a statistically

significant increased risk of reporting poorer SRH after

the three-year period. SRH is a measure of perception of

general health rather than a measure of “true health”, but

such a measure seems indeed impossible to pinpoint [22].

Explanations for the effect of household income on

health have been hypothesized as the direct effects of

material living conditions (absolute deprivation) as well

as to social comparisons and experiences of relative dep-

rivation. The results from a meta-analysis and several

other studies among adults suggest a moderate adverse

effect of income inequality on health, but the population

impact might be large [23,24]. A British study found that

low household income was associated with lower SRH

and a number of other indicators of poor health among

children aged 5 - 15 years [25].

The discrepancy in findings related to the two measure

of SES (household income and parents’ highest educa-

tion) emphasize that these are two different indicators of

social status emphasizing different aspects—material

versus cognitive dimensions of socioeconomic status

[18]. From our results it seems that material circum-

stances better predict developments in SRH compared to

parental educational level.

Developing more health-compromising habits from

age 15 to 18 years was consistently associated with re-

J. H. Andersen et al. / Open Journal of Preve ntive Medicine 3 (2013) 104-110 109

porting both poorer SRH and, to a lesser extent, more

depressive symptoms in this group of adolescents. Even

though the study was prospective there could be reverse

causation in that, for example, a reduction in sporting

activities could be due to developing poorer SRH and

more depressive symptoms in the 3-year period. We

tested for an association between changes in health-

compromising habits as the outcome variables using

SRH and depressive symptoms as explanatory variables,

and found several significant associations indicating that

causation was bidirectional. The protective effect of

positive health behaviour is in line with similar findings

suggested in previous cross sectional studies [16,26,27].

Health-compromising behaviors and a lack of sporting

activity and exercise were also found to be risk factors

for deterioration in SRH in the Young-Hunt-Study,

which benefits from a 4-year observation period [4]. We

conclude that health risk behaviours, such as lack of lei-

sure time sporting activity and smoking may contribute

to later poor self-rated health. This has also been found

to be true over a follow-up period of 25 years [28]. But

in addition, developing more depressive symptoms and

experiencing a deterioration in SRH may also result in

health-compromising behaviours. This study benefits

from using register-based information on parents educa-

tion and household income. Comparing non-responders

at baseline and dropouts in the follow-up period it can be

seen that there were more non-responders and dropouts

from households with low income and the least parental

educational. This selection would tend to bias the results

towards the null.

From a public health perspective, this study supports

the idea that increasing sporting activities and providing

better opportunities for healthy nutrition in schools will

improve chances for the successful prevention of the

development of poorer health among adolescents. A re-

cent Cochrane review [29] found that there is some evi-

dence of positive effects on lifestyle behaviors and

physical health status measures, and that ongoing physi-

cal activity promotion in schools is recommended.

The study also points to the importance of giving spe-

cial attention to adolescents who develop more depres-

sive symptoms or experience a deterioration in SRH: this

group may be at greater risk of developing a health com-

promising lifestyle to put their health at further risk.

This research received no specific grant from any

funding agency in the public, commercial, or not-for-

profit sectors.

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