Child and adolescent health and wellbeing: evidence review
Maps available national data on child health and wellbeing against the SHANNARI domains, to produce a full and detailed picture of ‘where we are now’ on child health and wellbeing in Scotland.
9. Included
9.1 Elements within the Included domain
The Included domain is defined as 'Having help to overcome social, educational, physical and economic inequalities, and being accepted as part of the community in which they live and learn'. The key indicators identified here are around economic inclusion in terms of income and housing, teenage pregnancy, peer relations and neighbourhood relationships.
Economic inclusion
The socioeconomic context in which children and young people grow up impacts on their experiences and their health and wellbeing, both indirectly, through association between socio-economic position and other factors discussed in the preceding chapters, and independently, through a direct link between household incomes and health and wellbeing outcomes.
Child poverty and material deprivation is associated with both immediate and long term health issues; cognitive, social, emotional and behavioural development concerns; as well as a negative impact on young people's future life prospects ( lxxxiv). Child poverty has been shown to affect mortality, health at birth, growth, physical morbidity, blood pressure, body mass and psychological and developmental disorders ( lxxxv). It has also been linked to poor self-regulatory behaviours ( lxxxvi), which have long term effects into adulthood, as children and young people who experience a lack of control over their own lives are less likely to develop good habits ( e.g. diet, exercise, positive coping strategies) which can act as protective factors against negative health and wellbeing outcomes ( lxxxvii).
Many health issues emerging in childhood are irreversible and continue on into adulthood. Adverse childhood socioeconomic position is associated with a poorer health profile in mid-adulthood (45 years), independent of adult social position and across diverse measures of disease risk and physical and mental functioning ( lxxxviii). One of the potential explanations for this link focuses on the role of chronic stress in early life causing a propensity to develop chronic diseases in later life, even when individuals appear to have successfully coped and adapted to a later adult role. Research also suggests that the duration of childhood spent in poverty may determine the long term impact on morbidity and mortality in later adulthood ( lxxxix).
Where poor child health results in poor educational attainment, low self-esteem and disaffection with society, it may limit earning capacity and increase the risk of continued poverty throughout the lifespan ( xc). OECD research has suggested that children's social background is a stronger predictor of attainment than school systems ( xci).
In the short term, one of the most immediate impacts of poverty is through housing quality. Children and young people living in damp, mouldy homes are more prone to respiratory problems, potentially leading to sleep loss and restrictions on children's daily activities. Housing quality also affects mental health, increasing children's chances of experiencing stress, anxiety and depression. The space available within a home can also have an impact. Overcrowding has been linked to stress, tension and sometimes family breakup, anxiety and depression, a lack of privacy (particularly for adolescents) and disrupted sleep patterns. Housing quality can also impact on educational attainment, for example if there is insufficient quiet, warm space for children to do their homework ( xcii).
Teenage pregnancy
One group that faces multiple barriers in terms of economic and other forms of inclusion is teenage mothers, and teenage pregnancy has therefore been included in this section. Pregnancy in young people is often both a cause and a consequence of social exclusion. Young people who are at higher risk of becoming parents tend to have poorer health and social outcomes compared with older parents ( xciii), and these are generally intensified as a result of becoming a parent. Early pregnancy is a significant predictor of negative outcomes in the transition from school to work and young mothers are more likely to have lower educational qualifications and employment levels, and a higher risk of poverty ( xciv). Young mothers also experience poorer mental health than older mothers ( xcv).
In terms of outcomes for the baby, and linked to the Healthy domain, although young mothers have generally positive pregnancies and births ( xcvi), birth weight is lower and infant mortality higher among babies born to teenage mothers than those born to older mothers. Teenage mothers also tend to have higher rates of smoking and lower rates of breastfeeding, which means their babies are less likely to benefit from the associated positive health outcomes ( xcvii).
Peer relationships
Another aspect of the Included domain relates to peer relationships. Peer relationships become increasingly important during adolescence and support from peers can help young people cope with changes in their bodies, emotions, social relationships and school environment ( xcviii). Peers can offer alternative attitudes, norms and behaviours to those conveyed by family ( xcix), and may have both positive or negative impacts on health and wellbeing outcomes. In terms of positive influences, social support from peers has been linked with higher levels of physical activity ( c) and fewer negative mental health outcomes ( ci). The ACEs literature also highlights the importance of peer support (alongside family and community support) in mitigating the negative effects of childhood adversity ( cii). School friendships, particularly those developed through structured extracurricular activities may also increase educational engagement and lead to higher educational aspirations. Such benefits have been found to accrue unevenly for those who can afford to enrol in these activities and who are intrinsically motivated or encouraged by parents to do so ( ciii).
Peers may also have a negative influence in terms of spreading negative attitudes towards school and school work. Some peer groups may also encourage risky health behaviours, such as early onset of alcohol consumption and binge-drinking ( civ), smoking ( cv), risky sexual behaviour ( cvi), eating disorders ( cvii) and snacking and sugary drink consumption ( cviii). However, the direction of influence between peer relationships and health behaviours is not always clear - peer norms may influence behaviour, but equally young people may choose their friends based upon pre-existing shared behaviours ( e.g. smoking ( cix) or disordered eating ( cx)).
Neighbourhood relationships
As noted previously, children and adolescents who have a wider range of - or higher quality - social support networks have been found to benefit in terms of having better general health, quality of life and/or wellbeing, and fewer reports of negative health outcomes ( cxi). This includes parental, peer and school relationships, as discussed in preceding sections, but also wider relationships within the neighbourhood.
Consultation with children and young people shows the value they place on being included within their community, interacting with, and being treated well by, those in the local area, such as shopkeepers and neighbours. Such positive relationships are described as a prerequisite for health and wellbeing by young people themselves ( cxii). Better relationships and trust within the community also increase feelings of safety, and where this is lacking this may lead to young people not taking advantage of the opportunities their physical neighbourhood environment offers, such as greenspace or recreational facilities ( cxiii).
9.2 Current position
| Indicator |
Headline figure |
Date |
Data source |
Next data |
Time trend |
Key inequalities |
International comparisons |
|---|---|---|---|---|---|---|---|
| Economic inclusion |
|||||||
| Percentage of children living in relative poverty (living in households whose equivalised income is below 60 per cent of inflation adjusted median income) after housing costs |
24% |
2014/15 - 2016/17 |
FRS |
2015/16 - 2016/17 2017/18 |
The rate fell from 32% in 1995/96 - 1998/99 to a low of 21% in 2011/12 - 2013/14, but has since started rising again |
* Family structure 41% of lone parent households were in poverty, compared with 19% of couple households with children * Economic status 65% of children in poverty lived in a household with at least one person working. 58% of economically inactive households with children were in poverty, compared with 8% of households were all adults were in full time work * Age of mother 50% of children in households where the mother was under 25 were in poverty, compared with 22% where the mother was 25 or over * Disability children in households with a disabled person were more likely to be in poverty (30%) than in other households (21%) * Family size The rate was highest (31%) among households with three or more children and lowest among households with two children (19%) * Ethnicity (2013/14 - 2015/16 data) The rate was higher (37%) among minority ethnic households |
/ |
| Percentage of children living in absolute poverty (living in families with incomes less than 60% of inflation adjusted 2011-12 median income) after housing costs |
22% |
2014/15 - 2016/17 |
FRS |
2015/16 - 2016/17 2017/18 |
The rate fell from 40% in 1998/99 - 2000/01 to 22% in 2009/10 - 2011/12, and has not changed since |
(2013/14 - 2015/16 data) * Family structure the rate was higher (34%) among lone adult households * Age of mother the rate was higher (44%) among households where the mother was under 25 * Disability the rate was higher (29%) among households with a disabled person * Family size the rate was higher (29%) among households with three or more children * Ethnicity The rate was higher (37%) among minority ethnic households |
/ |
| Percentage of children in combined material deprivation (based on a suite of questions in the Family Resources Survey) and low income (below 70% of UK median income) after housing costs |
12% |
2014/15 - 2016/17 |
FRS |
2015/16 - 2016/17 2017/18 |
The percentage has fluctuated but not changed in a meaningful direction since 2010/11 - 2012/13 |
(2013/14 - 2015/16 data) * Family structure the rate was higher (27%) among lone adult households * Age of mother the rate was higher (35%) among households where the mother was under 25 * Disability the rate was higher (17%) among households with a disabled person * Family size the rate was higher (22%) among households with three or more children * Ethnicity The rate was higher (16%) among minority ethnic households |
/ |
| Percentage of children in families who have been in relative poverty for three out of the past four years |
10% |
2012/13 - 2015/16 |
Understanding society |
2013/14 - 2016/17 |
Slightly lower than in 2011-2012 to 2014-2015 (14%) |
* Family structure the rate was higher (29%) among lone adult households * Age of mother the rate was higher (26%) among households where the mother was under 25 * Disability the rate was higher (22%) among households with a disabled person * Family size the rate was higher (22%) among households with three or more children * Ethnicity The rate was higher (15%) among minority ethnic households |
The rate is lower in Scotland than in England (18%), Northern Ireland (16%) and Wales (20%). |
| Percentage of children, in primary 4 and above, registered for free school meals |
37.4% |
2018 |
EAS |
2019 |
Down from 38.7% in 2015. Prior to that not comparable as pre universal P1-P3 provision |
/ |
/ |
| Percentage of households with children living in homes that fail the SHQS |
40% |
2016 |
SHCS |
2017 |
Fluctuating, but general downwards trend from 2010 (57%) |
* Family structure Single parent families were less likely to live in a house that fails the standard (30%) than other family types (43%). This might be a result of single parents being more likely to live in social sector housing, where the standard is mandatory, unlike the private rented and owner occupier sectors * SIMD Those in the 15% most deprived areas were slightly more likely (44%) to live in a house that doesn't meet the standard than those elsewhere (39%) |
/ |
| Percentage of households with children living in fuel poverty (required fuel costs >10% of income) |
12% |
2016 |
SHCS |
2017 |
The percentage stayed mostly stable between 2010 and 2014 at around 20%, but has dropped since |
* Family structure Single parent families were substantially more likely to live in fuel poverty (23%) than those in other family types (8-11%) * SIMD Those in the 15% most deprived areas were more likely to be in fuel poverty (26%) than those in the rest of Scotland (9%) |
/ |
| Teenage pregnancy |
|||||||
| Pregnancies in under 20-year-olds; crude rate per 1,000 females aged 15-19 years |
31.6 /1000 |
2016 |
ISD |
17 |
Rates have dropped consistently from a peak of 57.7 per 1,000 women in 2007, a 45.1% fall |
* SIMD Pregnancy rates were five times higher in SIMD1 than SIMD5 (58.9 compared with 11.8 per 1,000), although the gap narrowed as rates from SIMD1 fell more. Teenagers from deprived areas were more likely to deliver, while those in the least deprived areas were more likely to terminate their pregnancy |
No international comparisons available for pregnancy rates (conceptions), but data for live births in Scotland are higher than in the rest of Western Europe. In 2014, the UK had one of the highest rates of teenage births in Europe at 15.5/1000. This compares with 3.6/1000 in Denmark (the lowest). Comparable NRS data for Scotland showed a rate of 16.1/1000. |
| Peer relations |
|||||||
| Percentage of S2 and S4 pupils who have three or more close friends |
81% |
2015 |
SALSUS |
2018 |
The percentage declined slightly between 2006 and 2015 (from 86-88%) for all groups except for S4 boys |
* Age Little difference by school year (83% S2; 80% S4) * Gender At S4, boys were slightly more likely than girls to have three or more close friends (78% vs 81%). There was no gender difference at S2 |
/ |
| Percentage of S2 and S4 pupils who see their friends at least three evenings a week |
61% |
2015 |
SALSUS |
2018 |
The percentage spending 3 to 5 evenings out remained stable since 2000, while the percentage spending 6 or 7 nights out with their friends a week declined since 2004 (26% to 15%) |
Little difference by school year or gender |
/ |
| Percentage of 13 and 15 year olds who find it easy ('easy' or 'very easy') to talk to their best friend about things that really bother them |
88% |
2014 |
HBSC |
2018 |
The percentage has not changed in a meaningful way |
* Gender Percentage was higher among girls than boys (92% vs 85%) |
Scotland only question |
| Percentage of 11, 13 and 15 year olds with a high level of peer support (composite measure of My friends really try to help me / I can count on my friends when things go wrong / I have friends with whom I can share my joys and sorrows / I can talk about my problems with my friends (Very strongly disagree = 1 to Very strongly agree = 7)) |
57% |
2014 |
HBSC |
2018 |
No time series, new question |
* Gender Girls at all ages were more likely than boys to report high peer support (65% vs 49%). * Age There was little difference in perceived peer support between the ages of 11 and 13, but lower levels at 15 (from 67-70% to 60% for girls; from 51-52% to 43% for boys) |
Scotland performed above average for 13 year old girls, average for 13 year old boys and below average for 15 year olds. |
| Percentage of 11, 13 and 15 year olds who agree that their classmates are kind and helpful |
62% |
2014 |
HBSC |
2018 |
Percentage declined from (70%) in 2002. Since 2010, there has been no change in boys' perception of classmate support, but for girls there has been a slight decrease from 65% to 61%. |
* Age The percentage declined with age, from 74% at 11 to 57% at 13 and 54% at 15 * Gender No gender difference |
Scotland performed below average in international comparison |
| Percentage of 11, 13 and 15 year olds who report never feeling left out of things |
17% |
2014 |
HBSC |
2018 |
The percentage increased between 1998 and 2010 (from 14% to 17% for girls; and 22% to 17% for boys), but then declined back to 1998 levels |
* Gender Boys were more likely than girls to never feel left out (21% vs 13%). * Age The likelihood of never feeling left out decreased with age. Among girls, the decrease was largest between 11 and 13 (18% vs 10%), whereas for boys, the greatest change occured between 13 and 15 (22% vs 16%). |
Scotland only question |
| Neighbourhood relations |
|||||||
| Percentage of 13 and 15 year olds who agree that people say hello and talk to each other in the street |
72% |
2014 |
HBSC |
2018 |
The percentage has declined from 79% in 2002 |
* Gender At age 15, 63% of boys agreed compared with 73% of girls. There was no gender difference at age 13 |
Scotland only question |
| Percentage of 13 and 15 year olds who agree that they can trust people in their local area |
66% |
2014 |
HBSC |
2018 |
The percentage has not changed in a meaningful way |
* Gender Boys had more positive perceptions than girls (67% vs 64%) * Age For boys, the percentage declined between ages 13 and 15 (71% to 63%), but there was no difference for girls |
Scotland only question |
| Percentage of 13 and 15 year olds who agree that they can ask for help from neighbours |
68% |
2014 |
HBSC |
2018 |
The percentage has declined from 75% in 2002 |
* Gender no gender difference * Age The percentage reduced with age, from 72% at 13 to 64% at 15 |
Scotland only question |
9.3 Key points
- Almost a quarter of children lived in relative poverty after housing costs. Child poverty rates fell substantially between the late 1990s and 2011/12 - 2013/14 (21%), but have since started to increase.
- Almost two thirds of households in poverty had at least one working adult.
- Only 57% of 11, 13 and 15 year olds reported a high level of peer support. Among 15 year olds, this was lower than the international average.
- 62% of 11, 13 and 15 year olds agreed that their classmates are kind and helpful. This was lower than the international average for all ages and genders.
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