Setting the scene: controversies on trends in mental health among adolescents in the Nordic countries

At present there are different positions regarding trends in adolescent mental health. Can we trust trend data on the mental health among adolescents in the Nordic countries? Some question the trustworthiness of adolescent self-reports, which describe ordinary daily hassles as health complaints, which cannot be interpreted as signs of mental disorders. In addition, today there is a more open climate for talking about mental issues, which can lead to an overestimation of the prevalence of mental disorders.

Statistics on mental health services statistics report increased psychopharmaceutic prescriptions as well as consumption of professional care. Such data argues for increased governmental investment in adolescent mental health services. Is this pattern due to increased availability of mental health services and/or increased prevalence of mental health problems in the adolescent population?

A concern is that data availability influences policymaking and allocation of resources. If there is an emphasis on self-reported data from adolescents that may an increased risk of medicalization of young people's dealing with their daily lives. If on the other hand the reported problems among young people is disregarded, this would be against the UN Child Convention.

The survey data has important qualities especially if the data is analysed and reported properly. The validation of survey measure has been done both regarding psychometric quality and content validity. Advanced analysis of the data can draw a more nuanced picture. Moreover, some screening instruments have been developed as a first step towards making diagnosis. Instead the HBSC surveys ask boys and girls about their health and well-being, social environment and health behaviours. HBSC uses findings at national and international levels to gain new insights into young people's health and wellbeing, understand the social determinants of health, and inform policy and practice to improve young people's lives.

Trends in social inequality in loneliness among adolescents 1991-2014

BACKGROUND

Loneliness and social inequality in health are important public health concerns. We examined (i) trends in loneliness among adolescents from 1991 to 2014 in Denmark and (ii) trends in social inequality in loneliness.

METHODS

Study population: 11-15-year olds in random samples of schools in 1991, 1994, 1998, 2006 and 2014, n = 19 096. Loneliness was measured by a single item and social background by parents' occupational social class (OSC). We calculated absolute (%) differences in loneliness between high and low OSC and relative differences by odds ratio for loneliness.

RESULTS

Across all surveys, 6.3% reported feeling lonely. The prevalence increased from 4.4% in 1991 to 7.2% in 2014. The prevalence of loneliness in high, middle and low OSC was 5.8, 5.9 and 8.0%. The increase in loneliness was more pronounced in higher than lower OSC, resulting in a decreasing absolute social inequality in loneliness. The statistical interaction between OSC and survey year was significant, P = 0.0176, i.e. the relative social inequality in loneliness also decreased from 1991 to 2014.

CONCLUSION

The prevalence of loneliness increased from 1991 to 2014. The social inequality in loneliness decreased in both absolute and relative terms because of a rising prevalence of loneliness among children from high OSC.

Short communication: Persistent socio-economic inequality in frequent headache among Danish adolescents from 1991 to 2014

BACKGROUND

The association between socio-economic status (SES) and headache among adolescents is an understudied issue, and no study has examined whether such an association changes over time. The aim was to examine trends in socio-economic inequality in frequent headache among 11- to 15-year-olds in Denmark from 1991 to 2014, using occupational social class (OSC) as indicator of SES.

METHODS

The study applies data from the Danish part of the international Health Behaviour in School-aged Children (HBSC) study. HBSC includes nationally representative samples of 11-, 13- and 15-year-olds. This study combines data from seven data survey years from 1991 to 2014, participation rate 88.6%, n = 31,102. We report absolute inequality as per cent difference in frequent headache between high and low OSC and relative inequality as odds ratio for frequent headache by OSC.

RESULTS

In the entire study population, 10.4% reported frequent headache. There was a significant increase in frequent headache from 8.0% in 1991 to 12.9% in 2014, test for trend, p < 0.0001. This increasing trend was significant in all OSCs. The prevalence of frequent headache was significantly higher in low than high OSC, OR = 1.50 (95% CI: 1.34-1.67). This socio-economic inequality in frequent headache was persistent from 1991 to 2014.

CONCLUSION

There was a significant and persistent socio-economic inequality, i.e. increasing prevalence of frequent headache with decreasing OSC. The association between socio-economic position and headache did not significantly change over time, i.e. the statistical interaction between OSC and survey year was insignificant.

SIGNIFICANCE

The prevalence of frequent headache among adolescents increases with decreasing SES. This socio-economic inequality has been persistent among adolescents in Denmark from 1991 to 2014. Clinicians should be aware of this social inequality.

Process evaluation of a multi-component intervention to reduce infectious diseases and improve hygiene and well-being among school children: the Hi Five study

The Hi Five study was a three-armed cluster randomized controlled trial designed to reduce infections and improve hygiene and well-being among pupils. Participating schools (n = 43) were randomized into either control (n = 15) or one of two intervention groups (n = 28). The intervention consisted of three components: (i) a curriculum (ii) mandatory daily hand washing before lunch (iii) extra cleaning of school toilets. The aim of this study was to evaluate the implementation and to identify challenges to program implementation. Several data sources were used, including observations of school toilets, semi-structured interviews with school coordinators (n = 4), focus groups with pupils (n = 6) and teachers (n = 5), and questionnaires among pupils (n = 5440), teachers (n = 387) and school coordinators (n = 28). This study indicates that the curriculum was successfully implemented at most schools, and that teachers and pupils reacted positively to this part of the intervention. However, daily hand washing before lunch seems to be difficult to implement. Overall, the implementation process was affected by several factors such as poor sanitary facilities, lack of time and prioritization and objections against the increasing tendency to place the responsibility for child-rearing tasks on schools. This study reveals the strong and weak parts of the Hi Five study and can guide program improvement.

Timing of motor milestones achievement and development of overweight in childhood: a study within the Danish National Birth Cohort

BACKGROUND

Overweight may hinder achievement of gross motor milestones and delayed achievement of milestones may increase the risk of later overweight for reasons involving physical activity and the building of lean body mass.

OBJECTIVE

To investigate whether increased birth weight and body mass index (BMI) at 5 months is associated with the achievement of the ability to sit up and walk and whether delayed achievement of these milestones is associated with overweight at age 7 years.

METHODS

We used data from the Danish National Birth Cohort on 25,148 children born between 1998 and 2003. Follow-up took place from 2003 to 2010. Mean age at follow-up was 7.04 years. We used logistic and linear regression analyses.

RESULTS

Birth weight and BMI at 5 months were marginally associated with earlier achievement of the ability to sit up and walk (regression coefficients between -0.027 months; [CI -0.042; -0.013] and -0.092 months [CI -0.118; -0.066]). Age in months of sitting and walking were not associated with overweight at age 7 years (ORs between 0.97 [CI 0.95-1.00] and 1.00 [CI 0.96-1.04]). Later achievement of sitting and walking predicted lower BMI at age 7 years (ln-BMI -z-scores between -0.023 [CI -0.029; -0.017] and -0.005 [CI -0.015; 0.005)).

CONCLUSIONS

All observed associations were of negligible magnitude and we conclude that birth weight or BMI at age 5 months and motor milestones appear largely independent of each other and that timing of achievement of motor milestones seems not to be associated with later overweight or increased BMI.

Socioeconomic position, macroeconomic environment and overweight among adolescents in 35 countries

OBJECTIVE

It is important to understand levels and social inequalities in childhood overweight within and between countries. This study examined prevalence and social inequality in adolescent overweight in 35 countries, and associations with macroeconomic factors.

DESIGN

International cross-sectional survey in national samples of schools.

SUBJECTS

A total of 11-, 13- and 15-year-olds from 35 countries in Europe and North America in 2001-2002 (N=162 305).

MEASUREMENTS

The main outcome measure was overweight based on self-reported height and weight (body mass index cut-points corresponding to body mass index of 25 kg/m(2) at the age of 18 years). Measures included family and school affluence (within countries), and average country income and economic inequality (between countries).

RESULTS

There were large variations in adolescent overweight, from 3.5% in Lithuanian girls to 31.7% in boys from Malta. Prevalence of overweight was higher among children from less affluent families in 21 of 24 Western and 5 of 10 Central European countries. However, children from more affluent families were at higher risk of overweight in Croatia, Estonia and Latvia. In Poland, Lithuania, Macedonia and Finland, girls from less affluent families were more overweight whereas the opposite was found for boys. Average country income was associated with prevalence and inequality in overweight when considering all countries together. However, economic inequality as measured by the Gini coefficient was differentially associated with prevalence and socioeconomic inequality in overweight among the 23-high income and 10-middle income countries, with a positive relationship among the high income countries and a negative association among the middle income countries.

CONCLUSION

The direction and magnitude of social inequality in adolescent overweight shows large international variation, with negative social gradients in most countries, but positive social gradients, especially for boys, in some Central European countries. Macroeconomic factors are associated with the heterogeneity in prevalence and social inequality of adolescent overweight.

High agreement on family affluence between children's and parents' reports: international study of 11-year-old children

OBJECTIVE

To examine the agreement between parents' and children's reports on four items of family affluence: number of cars, own bedroom, number of family holidays and number of computers, and to analyse predictors of disagreement.

DESIGN

Cross-sectional child-parent validation study of selected items from an internationally standardised questionnaire.

SETTING

Survey conducted in schools in Denmark, Germany, Hungary, Italy, Poland and Scotland.

PARTICIPANTS

972 11-year-old children and their parents responded to the questionnaires.

RESULTS

The child item response rates were high (above 93%). The per cent agreement was low for holidays spent with family (52.5%), but high for the other three items of family affluence (76.2-88.1%). The kappa coefficients were good or excellent for all items (between 0.41 and 0.74) and the gamma coefficients were strong for all items (between 0.56 and 0.96). Children from single-parent families were more likely to over-report family affluence (OR 2.67; CI 1.83 to 3.89).

CONCLUSIONS

Young adolescents' self-reports of family affluence are fairly valid across the six countries. This finding suggests that the variables measured can be used in epidemiological studies that aim at ranking children according to socioeconomic position.

Personal, social and environmental predictors of daily fruit and vegetable intake in 11-year-old children in nine European countries

OBJECTIVE

To investigate potential personal, social and physical environmental predictors of daily fruit intake and daily vegetable intake in 11-year-old boys and girls in nine European countries.

SUBJECTS

The total sample size was 13 305 (90.4% participation rate).

RESULTS

Overall, 43.2% of the children reported to eat fruit every day, 46.1% reported to eat vegetables every day. Daily fruit intake and daily vegetable intake was mainly associated with knowledge of the national recommendations, positive self-efficacy, positive liking and preference, parental modeling and demand and bringing fruit to school (odds ratio between 1.40 and 2.42, P<0.02). These factors were associated fairly consistently with daily fruit intake across all nine European countries, implying that a rather uniform intervention strategy to promote fruit can be used across Europe. For vegetables, the pattern was, however, less consistent. Differences between countries in cooking and preparing vegetables might be responsible for this larger diversity.

CONCLUSIONS

This study showed that especially a combination of personal and social factors is related to daily fruit and vegetable intake in schoolchildren. This shows that a comprehensive multilevel intervention strategy based upon a series of individual and social correlates will be most promising in the promotion of daily fruit and vegetable intake in children.

Prevalence of obesity in Denmark

There has been a pronounced, distinctive increase of the prevalence of obesity within almost all age groups of the Danish population, during the last 25-30 years. The largest increase has been documented in studies based on objective data from total populations and the latest data show the increase will continue. The Danish studies show heterogeneity in the development of the obesity epidemic. A close association with birth cohorts indicates a need for further aetiological research, not only into behavioural factors, but also into early life factors that may explain some of this developmental pattern.

Reliability and validity of a questionnaire to measure personal, social and environmental correlates of fruit and vegetable intake in 10–11-year-old children in five European countries

Objectives

To investigate the internal consistency of the scales and the test–retest reliability and predictive validity of behaviour theory-based constructs measuring personal, social and environmental correlates of fruit and vegetable intake in 10–11-year-old children.

Design

Test–retest with one-week interval.

Setting

Five European countries: Norway, Spain, Denmark, Portugal, Belgium.

Subjects

Three hundred and twenty-six children completed the questionnaire during class hours.

Results

For the total sample across all countries, the test–retest reliability was good to very good (intra-class correlation coefficient (ICC) >0.60) for 12 out of the 15 fruit constructs and also for 12 out of the 15 vegetable constructs. Acceptable ICCs, ranging between 0.50 and 0.59, were found for the remaining constructs. Test–retest reliability was comparable across countries. Only in Portugal were some significantly lower ICCs found for some constructs (knowledge and barriers related to fruit, general self-efficacy related to fruit and vegetables) compared with the other countries. Cronbach'sαvalues were moderate to high (range 0.52 to 0.89) with the exception of the general self-efficacy scale, which had a value below 0.50 for both fruit (α= 0.42) and vegetables (α= 0.49). Spearman correlations with intake ranged between -0.16 and 0.54 for personal determinants and between 0.05 and 0.38 for environmental determinants. Compared with other studies, predictive validity can be considered moderate to good.

Conclusions

The questionnaire provides a reliable, valid and easy-to-administer tool for assessing personal, social and environmental factors of potential influence on fruit and vegetable intake in 10–11-year-olds.

Socioeconomic health inequalities among a nationally representative sample of Danish adolescents: the role of different types of social relations

STUDY OBJECTIVE

To investigate the role of different types of social relations in adolescent health inequalities.

DESIGN

Cross sectional study. Measures included family social class, indices of social relations to parents, friends, teachers, and school.

SETTING

Random sample of 55 schools in Denmark.

PARTICIPANTS

Nationally representative sample of 5205 students from grades 5, 7, and 9.

MAIN OUTCOME MEASURES

Self reported physical and psychological symptoms.

RESULTS

Adolescents from families of lower socioeconomic position reported more physical and psychological symptoms. This ranged from 40% increased odds for multiple physical symptoms among less advantaged girls, to 90% increased odds of multiple psychological symptoms for less advantaged boys. Relationships with friends or teachers showed small social class differences, while strong and consistent social class differences were found in the ways adolescents reported their own and their parents relations to school. For example, girls from families of lower socioeconomic position were more than four times as likely to report their parents unwilling to attend school meetings (odds ratio=4.54, 95% confidence intervals: 2.68 to 7.69). Poorer relations with parents, peers, teachers, and school were all associated with worse health. Patterns of parent-child relations with the school were the greatest contributors to socioeconomic differences in physical and psychological symptoms.

CONCLUSIONS

The school is one of the first important social institutions directly experienced by children and socioeconomic differences in how adolescents and their parents relate to the school may be part of the cascade of early life influences that can lead to later social and health disadvantage.

Socioeconomic position in early life, birth weight, childhood cognitive function, and adult mortality. A longitudinal study of Danish men born in 1953

OBJECTIVE

To examine the relation between socioeconomic position in early life and mortality in young adulthood, taking birth weight and childhood cognitive function into account.

DESIGN

A longitudinal study with record linkage to the Civil Registration System and Cause of Death Registry. The data were analysed using Cox regression.

SETTING

The metropolitan area of Copenhagen, Denmark.

SUBJECTS

7493 male singletons born in 1953, who completed a questionnaire with various cognitive measures, in school at age 12 years, and for whom birth certificates with data on birth and parental characteristics had been traced manually in 1965. This population was followed up from April 1968 to January 2002 for information on mortality.

MAIN OUTCOME MEASURES

Mortality from all causes, cardiovascular diseases, and violent deaths.

RESULTS

Men whose fathers were working class or of unknown social class at time of birth had higher mortality rates compared with those whose fathers were high/middle class: hazard ratio 1.39 (95% CI 1.15 to 1.67) and 2.04 (95% CI 1.48 to 2.83) respectively. Birth weight and childhood cognitive function were both related to father's social class and inversely associated with all cause mortality. The association between father's social class and mortality attenuated (HR(working class)1.30 (1.08 to 1.56); HR(unknown class)1.81 (1.30 to 2.52)) after control for birth weight and cognitive function. Mortality from cardiovascular diseases and violent deaths was also significantly higher among men with fathers from the lower social classes.

CONCLUSION

The inverse association between father's social class at time of birth and early adult mortality remains, however somewhat attenuated, after adjustment for birth weight and cognitive function.

Exposure to teachers smoking and adolescent smoking behaviour: analysis of cross sectional data from Denmark

OBJECTIVE

To determine whether adolescent smoking behaviour is associated with their perceived exposure to teachers or other pupils smoking at school, after adjustment for exposure to smoking at home, in school, and best friends smoking.

DESIGN

Logistic regression analysis of cross sectional data from students in Denmark.

SUBJECTS

1515 grade 9 students (mean age 15.8) from 90 classes in 48 Danish schools.

OUTCOME MEASURE

Self reported smoking behaviour; daily smoking and heavy smoking, defined as those smoking more than 20 cigarettes per week.

RESULTS

Of the students in this study, 62% of boys and 60% of girls reported being exposed to teachers smoking outdoors on the school premises. The proportion of boys and girls reporting to have been exposed to teachers smoking inside the school building were 86% and 88%, respectively. Furthermore, 91% of boys and 92% of girls reported that they had seen other students smoking outdoors on the school premises. Adolescents' perceived exposure to teachers smoking outdoors on the school premises was significantly associated with daily smoking, having adjusted for sex, exposure to teachers smoking indoors at school and pupils smoking outdoors at school, as well as the smoking behaviour of mother, father, and best friend (odds ratio (OR) 1.8, 95% confidence interval 1.2 to 2.8). Adolescents' perceived exposure to teachers smoking inside the school building was not associated with daily smoking (OR 0.9, 95% CI 0.5 to 1.6) and perceived exposure to pupils smoking outdoors was not associated with daily smoking (adjusted OR 1.5, 95% CI 0.5 to 4.4). There were similar findings with heavy smoking as the outcome variable.

CONCLUSIONS

Teachers smoking during school hours is associated with adolescent smoking. This finding has implications for future tobacco prevention strategies in schools in many countries with liberal smoking policies where it might provide support for those working to establish smokefree schools.

Stability and change in structural social relations as predictor of mortality among elderly women and men

In a follow-up study of 70-95 years old women and men (n = 911) we studied the association between change and stability in three structural aspects of social relations (contact frequency, contact diversity, cohabitation status) from 1986-1990 and mortality after the next four years in 1994. Women aged 70-74 years who developed low contact frequency or developed small contact diversity showed significantly higher mortality, adjusted ORfreq: 3.78 (1.08-13.20), adjusted ORdiv: 3.79 (1.24-11.58). Women aged 70-74 years with continuously low contact frequency showed an increased mortality compared to women constantly experiencing high contact frequency, adjusted OR: 2.75 (1.04-7.26). A tendency in the same direction for sustained small contact diversity was found, adjusted OR: 1.98 (0.70-5.61). Among women aged 75+ years no impact of frequency and diversity was demonstrated, whereas continuously living alone was a significant predictor of mortality, when compared to women continuously living with somebody, adjusted OR: 2.57 (1.29-5.09). In men, we found a significantly increased mortality among those who developed high contact frequency and developed large contact diversity ORfreq: 3.91 (1.02-14.94) and ORdiv: 6.04 (1.30-28.03). In summary, we found rather larger age differences in the strength of the association between change in structural social relations and mortality. Furthermore, the associations seemed stronger among women than men, which may however mainly be explained by the small number of men in our cohort.

Social relations: network, support and relational strain

We introduce a conceptual framework with social relations as the main concept and the structure and the function of social relations as subconcepts. The structure of social relations covers aspects of formal relations and social network. The function of social relations covers social support, social anchorage and relational strain. We use this conceptual framework to describe social relations in the Danish population, with questionnaire data from the Danish Longitudinal Health Behaviour Study including a random sample of each of the age groups 25-, 50-, 60-and 70-year olds, N = 2,011. The postal questionnaires were answered by a random sample in each of the age groups. The results show marked age and gender differences in both the structure and the function of social relations. The social network, measured as weekly contacts, weakens with age and so does instrumental support. Emotional support is unrelated to this decline in contact frequency and appears to be at the same level for younger and older individuals. Relational strain, measured as conflicts, declines with age for all kinds of social relations. The weakening of the social network with age does not seem to affect the level of emotional support and in turn seems to be partly compensated for by a simultaneous decline in relational strain.

Old persons' contact with general practitioners in relation to health: a Danish population study

The study describes health, social situation, and contact with general practitioners in a random sample of non-institutionalized persons 70-95 years old in Denmark. There was a strong correlation between health and contact with general practitioners. A small group, 3% of the respondents, had no health problems, but had been in contact with a general practitioner within the previous month. This group was characterized by a strong social network and a high degree of life satisfaction. Another small group, including 3% of the respondents, had extensive health problems, but had nevertheless not been in contact with a general practitioner within the previous year. This group was characterized by a weak social network and a low degree of life satisfaction.

[Diet and health behaviour in Danish children aged 11-15 years]

A total of 1,671 school children aged 11, 13 and 15 years answered a questionnaire on diet, other health behaviour, social background, social network, health and life satisfaction. The proportions who ate fruit, vegetables, and rye bread every day were 77%, 64% and 94%. Moreover, 78% had fibre-containing breakfast every day and 79% had a regular lunch meal every day. 26% of the children received an optimal diet containing all of these five components every day, and 19% received less than three of these components every day. The proportions who consumed five unhealthy diet components every day (candy, chips, French fries, sausages/hamburgers, and sweet long-drinks) were 32%, 12%, 5%, 5% and 18%. 39% received at least one of these unhealthy diet components every day. There was no association between intake of healthy and intake of unhealthy diet components. We found no age differences among boys regarding the healthy diet components but an increasing consumption of unhealthy components with increasing age. Among girls we found a decreasing consumption of both healthy and unhealthy components with increasing age. Healthy diet was associated with high social class, good health, positive life satisfaction, positive school assimilation, and positive health behaviour.

[TV and video watching among 11-15-year old children--a sociomedical perspective]

A material of 1,671 schoolchildren replied to a questionnaire about health, time spent watching television, the demographic and social situation, social network, and life satisfaction. These pupils spend two hours daily watching television and one tenth of this time is spent on video programmes. 48% of the children spend 0-10 hours weekly watching television, 35% 11-27 hours, 15% 28-37 hours and 3% more than 37 hours. Boys spend more time watching television than girls, younger pupils more than older and children from lower social classes more than children from higher social classes. The time spent watching television increases with increasing degree of urbanisation. Children who spend many hours watching television have more problems in life satisfaction, health and social network compared with children who spend a few hours watching television.

[Diet and health behavior in Danish children aged 11-15 years]

A total of 1,671 school children aged 11, 13 and 15 years answered a questionnaire on diet, other health behaviour, social background, social network, health and life satisfaction. The proportions who ate fruit, vegetables, and rye bread every day were 77%, 64% and 94%. Moreover, 78% had fibre-containing breakfast every day and 79% had a regular lunch meal every day. 26% of the children received an optimal diet containing all of these five components every day, and 19% received less than three of these components every day. The proportions who consumed five unhealthy diet components every day (candy, chips, French fries, sausages/hamburgers, and sweet longdrinks) were 32%, 12%, 5%, 5%, and 18%. 39% received at least one of these unhealthy diet components every day. There was no association between intake of healthy and intake of unhealthy diet components. We found no age differences among boys regarding the healthy diet components but an increasing consumption of unhealthy components with increasing age. Among girls we found a decreasing consumption of both healthy and unhealthy components with increasing age. Healthy diet was associated with high social class, good health, positive life satisfaction, positive school assimmilation, and positive health behaviour.

[Social inequalities in child health status]

The article describes the health situation in relation to demographic and social class variables in a sample of 1,671 schoolchildren aged 11, 13 and 15 years in Denmark. The proportions assessing their health as excellent, good, fair, or poor were 47%, 39%, 13%, and 1%, respectively. 22% reported daily symptoms and 74% weekly symptoms (20% one symptom a week, 54% two or more symptoms). During one week, 50% suffered from bad moods, 37% insomnia, 30% depression, 26% headaches, 22% nervousness, 19% back pain, 14% abdominal pain, and 12% vertigo. 37% had used medical drugs during the last month, most frequently for headaches (25%), colds (11%), coughs (9%) and abdominal pain (8%). Girls showed poorer self-assessed health than boys, more symptoms and more use of medication. The youngest pupils had the most frequent symptoms and the oldest least. There were no health differences when place of residence or family composition were considered, but there were clear social class differences. Pupils from the lowest social class and pupils whose parents were not included in the social class classification (e.g. disability pensioners) had the poorest self-assessed health, the most frequent symptoms and the highest use of medication.

[Smoking habits among children aged 11-15 years in 1988. A study of smoking habits and their connection with social background factors, health, satisfaction and social networks]

A total of 1,671 schoolchildren aged 11, 13 and 15 years answered an anonymous questionnaire in 1988 on their social backgrounds, social networks, health, life satisfaction and health behaviour. The proportions who had tried to smoke were 24%, 51%, and 66% in the three age groups; the proportions of smokers were 3%, 8%, and 29%, and the proportions of daily smokers were 0%, 2% and 6%. More girls than boys were smokers but there was almost no difference if place of residence, social class, or family type were considered. Almost the entire variation could be explained by best friends' smoking habits and by the number of smokers at home. Smoking was associated with poor health, fatigue, school tiredness, school performance below the average, frequent contacts with friends outside school and at night, difficulties in discussion with parents, ease in discussions with friends, and with having close friends. The proportion of smokers, among children has been steadily declining since the first Danish nationwide survey was carried out in 1959.

[Quality of life, health and social contacts in elderly people unable to go out-of-doors]

The study includes 1,261 individuals aged 70-95 years old selected at random in four Danish communes with varying degree of urbanization. In October-November, 1986 they answered a mailed questionnaire on health and, social situation, quality of life, and utilization of health and social services. The object of the article is to describe elderly persons with reduced ability to leave their homes. The proportion with difficulty in leaving their home is 13% and 7% need help to get outdoors. The proportion with mobility problems is larger among women and increases with increasing age. Mobility is not associated with urbanization, household composition, housing situation, floor, stairs and social class. Mobility problems are more frequent among elderly with the lowest incomes and the most extensive health problems. Mobility problems are associated with reduced quality of life, negative self-esteem reduced social network and poor "means of communication" (hearing and sight). Elderly persons with mobility problems use more health and social services than those with unrestricted mobility. However, the use of services from the primary health services are more frequent among those who can get outdoors with some difficulty than among those who cannot get outdoors on their own. Lack of engagement toward the problems of this group of elderly must be anticipated to lead to great health and social requirements in this group in the years to come.