Preteen children’s health related quality of life in Sweden: changes over time and disparities between different sociodemographic groups

There is a growing interest in health-related quality of life (HRQoL) measures as a tool to evaluate health related functioning and wellbeing in a population. This measure has been proved valuable when exploring healthcare needs, evaluating health system performance and as a basis for resource allocation [1, 2]. More recently, HRQoL has been used to evaluate inequities between different groups in the society [3‐6].

Health inequity refers to systematically exposing disadvantaged social groups to further disadvantages with regards to their health. On the other hand, health inequality is a normative free concept that refers to differences in health that are neither systematic nor unfair. However, when measuring differences in health between various social group, health inequalities may indirectly reflect inequities as it shows health advantages to already socially advantaged groups [7, 8]. To identify, monitor and act upon health inequities, the PROGRESS framework suggests that various factors should be taken into consideration. PROGRESS stands for; Place of residence, Race/ethnicity/culture/language, Occupation, Gender/sex, Religion, Education, Socioeconomic status and Social capital [9]. This framework has been adapted for evaluation of health related inequities by for instance the PRISMA-Equity Bellagio group [10].

Few studies have addressed changes over time in health and HRQoL among younger school-aged children in Sweden, and even fewer have captured the view of the child [11]. Given the low to moderate parent-child agreement in reports of health-related issues in general populations, self-reported measures are advised [12, 13]. The available literature on parent and child reported aspect of HRQoL e.g. psychosomatic and depressive symptoms, are conflicting. Some studies show no changes over time of such symptoms among 11-year-olds while others show increasing HRQoL problems in the preteen children [14, 15]. Thus, there is a need to further investigate changes over time in self-reported HRQoL among preteen children.

Assessing sociodemographic disparities in child HRQoL is important, as such disparities is unjust and might affect health later in life [16]. Previous studies have reported associations between subjective health outcomes and some sociodemographic characteristics [17‐23]. Age and sex appear to play a role in HRQoL disparities in Sweden with better HRQoL among younger than older children and among boys compared to girls [17, 18]. Family structure may also play a role for children’s HRQoL. A Swedish study has shown that children who live with two parents, or in a joint custody, reported better HRQoL than those living mainly with one parent [19]. Regarding migration status, results are contradictory; some Swedish studies suggest that adolescents with a migrant background experience more health complaints and worse HRQoL than native Swedish adolescents [20, 21], while others have shown that migrant adolescents experience less or as much ill-health as Swedish adolescents [22]. The role of parents’ education and occupation are not well studied in Sweden and the international literature is conflicting. Some studies indicate that higher education may have a positive impact on preteens’ HRQoL [23]. Others find no overall variation in relation to parents’ education but indicate differences between countries [3, 5]. The major part of the literature on social disparities in child HRQoL and related health outcomes targets adolescents only [21], or a wide age group with no possibility to obtain specific information about disparities among younger children [3, 5, 22]. However, sociodemographic disparities in health and HRQoL could differ between preteen children and teenagers [19, 23]. Thus, there is a need to further investigate the social distribution of child health related outcomes in different cultures, and a particular need of studies targeting sociodemographic disparities among preteen children.

The aim of our study was to explore HRQoL among 12-year-olds in Sweden with respect to differences between the years 2005 and 2009, and disparities related to sociodemographic characteristics.

Characteristics of the study population and prevalence of reported HRQoL problems are presented in Table 1. About half of the participants were girls, and around 80 % had a Swedish origin. Skilled non-manual workers were the most common parents’ occupation and nearly 50% had at least one parent with a high education level. Over half of the parents who were registered as students were from countries considered as low-income countries. The most commonly reported problems were pain followed by mood problems, while the prevalence of problems related to self-care were very low and therefore results from this dimension were not further analyzed.

Analyses of children’s questionnaires with missing parents’ responses showed somewhat higher prevalence of pain (21.9%) and mood problems (15.5%).

In this study, we have shown that HRQoL problems related to pain and mood problems were higher in 2009 compared to 2005 among 12-year-olds in Sweden. Our study revealed few sociodemographic disparities in HRQoL in 12-year-olds and these disparities were mainly among girls. In general, girls reported more pain and mood problems than boys, however, there were no differences based on parents’ occupation. Of the five HRQoL dimensions, only one, mood problems, differed by parents’ education level where a higher parents’ education was unfavorable. Municipality size and family structure were associated with different levels of pain and abilities to perform usual activities among girls. In addition, children living with two parents had less mood problems than children living in other family constellations.

This study shows an increased prevalence of children reporting pain and mood problems in the more recent cohort of preteen children. Previous literature is conflicting. One study reported similar results between 2003 and 2011 among 12-year-olds in Northern Sweden when using parent-proxy EQ-5D measures [14]. However, based on the same type of data, another study found no upward time trend for pain or mood problems between 2003 and 2011 in a sample of preteen children representing the whole of Sweden [33]. Studies that used a scale of four or five levels of self-rated health, also reported no changes in self-perceived health over time [14, 33]. The possible reasons behind the health differences between 2005 and 2009 that we found in this study were not investigated. However, based on the results of other studies we speculate in the following explanations: the worsening of body image especially among adolescent girls [15], the increased feeling of pressure in schools [15], and the 2008 economic recession which had negative impact on child’s health in several high income countries [34]. Reasons behind these health differences between 2005 and 2009 should be further studied and future trends in self-rated HRQoL among preteen children should also continue to be reported.

This study reveals a negative relation between living in small municipalities and preteens’ HRQoL especially among girls. Girls living in small municipalities perceived more problems performing usual activities and pain. The literature about this relation between rurality and child’s health problems is conflicting. In one study, self-reported subjective health complaints, including pain and nervousity, were not related to residential area in children aged 11, 13 and 15 years [35]. While another study shows more problems related to pain and performing usual activities in preteen children living in rural area [36]. Together these findings indicate that the association between municipality size and health problems may vary depending on the age of the child. The better HRQoL in children living in a large size municipality may be partly explained by an expected greater access to neighborhood services in larger municipalities (sidewalks, parks, or playing areas), and increased feeling of safety and satisfaction [36]. Another explanation could be that preteen children who live in small municipalities feel more isolated and restricted and they perceive lower social capital due to daily environmental and social constraints [37]. Even though a stronger societal cohesion in these areas promotes wellbeing, it might promote exclusion and social control as well [37].

This study shows more mood problems among preteens of one foreign parent. Contrary, girls with foreign origin showed less pain. The few studies that have looked into this before, have shown inconsistent results; one study reported more subjective health complaints among girls of foreign origin. Another study showed that children from EU/OECD background experienced less psychosomatic symptoms than those of Swedish background while other migrants experienced same level of symptoms [22]. These inconsistent results might be due to different age group studied or to the heterogeneity of migrants and their migration motives in Sweden. More studies are needed to get a better understanding of HRQoL in children of foreign-born parent(s).

We did not find an association between parents’ occupation and preteens’ HRQoL except for children of student parents who reported more HRQoL problems. More than half the parents in this group held a low-income nationality, which gives the impression that this disadvantaged group consists mostly of migrant parents most probably attending Swedish language schools. Another Swedish study showed no association between mental problems and parents’ occupation among preteens as well [38].

Our results of more mood problems experienced among children of parents’ with a high education level is not in line with other European studies which suggest better health status among children of parents’ with a high education level [3, 23, 36], or a Swedish study among 12-year-olds which shows that those with lower parents’ education level generally have poorer HRQoL using parent-proxy EQ-5D [33]. The reason behind these health disparities is a topic of further research.

The association between family structure and HRQoL, reported in our study is in line with a previous study which shows better HRQoL among children living with two parents or in joint custody [19]. Our study highlights a greater susceptibility for girls who have more disparities in HRQoL related to family structure than boys.

This study provides a valuable comparison of HRQoL status among twelve-year-olds in Sweden between 2005 and 2009. Our study indicates that HRQoL has worsened over this time period and that children of highly educated parents and those living in small municipalities have poorer health-related outcomes than others.

To study future trend, health outcomes among children in Sweden should continue to be reported periodically preferably with a self-rated HRQoL instrument. More efforts should be invested to increase the awareness of health disparities highlighted in this study especially regarding girls living in small municipalities and children of highly educated parents. Follow-up studies should be conducted to explain the reasons behind such disparities.