school manchester sven bremberg
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Children and adolescents: health protective factors in education
Sven Bremberg
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Education and health
Health education
Health behaviour
Health
Problems with the educational approach to adolescent public health
• Few school education programmes demonstrate behaviour effects: alcohol, tobacco, drugs, nutrition, exercise
• Individual behaviour is determined by social context
• Low long term stability of health behaviours during adolescence
Educational approach to adolescent sexual health
• Systematic reviews of RCT:s • Behaviour effects (contraceptive use)• DiCenso 2002
– 7 studies, pooled estimate: males ns, females ns.– 1 study in favour of controls in males
• Bennett 2005– 10 studies, 5 in favour of intervention– 2 studies in favour of controls in females
Public health policy
EconomyLife
chancesLifestyle -
environmentHealth QoL
General politics
Social policy
Public health policy
Health promotion Health care
Upstream Downstream
Swedish national public health targets
• Mainly structural targets focusing institutions• 11 targets approved by the parliament in 2003• Structural targets
– Democracy - participation– Economic and social security
– Positive conditions during childhood and adolescence
– Healthier working life– …
• Some downstream targets– Reduced use of tobacco and alcohol– …
Determinants of U-5 female child mortality rate in 118 nations - t-values. Total model R2=0.79 (Safaei 2006)
-6,3-5,52
-2,65 -2,65
3,04
1,69
-7
-6
-5
-4
-3
-2
-1
0
1
2
3
4
Education GNP Democracy
Health (public) Health (private)Gini
Effects of education on adult health - a natural experiment (Spasojevic 2003)
• Compulsory schooling was extended in Sweden from 7 to 9 years; decided at municipal level, 1950 -
• Men born 1945-1955. Health 1981-91 - control for SES
• One extra year of schooling: 19% less risk of ill health, 12% less obesity
Effects of education on adult health -other natural experiments (Feinstein et al 2006) - effects demonstrated on
• Mortality• Hospital care• Management of chronic
diseases• Depression• Smoking• Physical activity
Determinants of adolescent health
Alcohol, tobacco Mental health
Obesity Unsafe sex
Literacy Levels by Physical, Mental or Other Health Conditions – USA (Quantitative)
0
10
20
30
40
50
60
1 2 3 4 5
Per
cen
t
Level NALS, p. 44, 2002
Health Problems
Mental or Emotional Problems
Long-term Illness
Competences include abilities …(after Martha Nussbaum)
to solve problems
to attach to other people
to take part in social life
to reflect critically
to form a concept of what is good
…
Association between mortality and cognitive ability at age 10 in men born in Malmö 1928, hazard ratio, crude and adjusted for parental income and class (Lager 2008)
CrudeAdjusted for parents’ income 1933 Adj. for parents’ income 1933 and parents’
class 1938
Hazard Ratio Confidence Interval Hazard Ratio Confidence Interval Hazard Ratio Confidence Interval
Highest quartile 1.00 Reference 1.00 Reference 1.00 Reference
Second highest quartile 1.40 1.00-1.95 1.29 0.92-1.81 1.31 0.93-1.84
Second lowest quartile 1.56 1.13-2.17 1.44 1.04-2.01 1.48 1.07-2.07
Lowest quartile 1.95 1.42-2.69 1.67 1.21-2.32 1.72 1.23-2.40
Table 1. Cognitive ability and mortality. Men (n=834, 349 deceased)
Remains
Education and health
Health Ability to adaptCompetencies
Time sequence for problematic health behaviours (after Roe)
Year 1 Year 4 Year 7 Year 10
Antisocial behaviour/depression
Problematic health behaviour
School failure
Emphasis on health promotion or effective schools - municipalities in Stockholm county (Guldbrandsson 2005)
Effective schools
Healt
h p
rom
oti
on
Potential contribution to schools from the health sector
• Programmes that facilitates learning
• Programmes with direct effects on health or determinants of health
• Programmes with demonstrable effects
Measures for schools proposed by the Swedish National Institute of Public Health
• Social and emotional training (SET) • Prevention of bullying• Aggression preventive programmes • Programmes based on cognitive psychology• Local quality assurance programmes using
both educational and health data• Parental support programmes
Effects of SET in Botkyrka grades 4-9 controlled trial (Kimber 2008)
Variable Effect size
Body image 0,48
Psychological well-being 0,33
Aggressiveness 0,33
Bullying 0,39
Alcohol (grade 7-9) 0,26
Narcotics (grade 7-9) 0,23
Prevention of bullying– Olweus’ model– Three controlled
trials • 40% reduction
– Four levels• Students• Teachers• Headmasters• Parents
Programmes preventing behaviour problems including aggression in the classroom: effect at follow up (Wilson 2007)
ACT - a preventive programme based on cognitive psychology
• Third generation CBT programme
• Year 10-12 students - 3*3 hours (Livheim, 2006)
• Reduced anxiety after 2 years
Self asContext
Contact with the Present Moment
Defusion
Acceptance
Committed Action
Values
ACT modellen
Structured methods for parents of children age 3-9 years, based on methods like PMT, COPE etc. adapted for universal use in
Sweden…
• Parental groups • Starting with
videotaped problem situations
• Modelling • Role play
Education and sexual health
Sexual health Ability to adaptCompetencies
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