Age and gender differences in health-related quality of life of adolescents from Latin American countries
Age and gender differences in health-related quality of life of adolescents from Latin American countries
ABSTRACT
The purpose of this study was to examine gender and age differences in health-related quality of life (HRQoL) in a large international sample of adolescents from Latin American countries. The KIDSCREEN-52 questionnaire was completed by 1357 youths aged 12 to 17 years (48.6% male) in three countries (Argentina, Brazil, and Chile). The study used a cross-sectional design, and different approaches for sample selection were used across countries in order to obtain random samples. With the use of ANOVA the influence of age and gender on aspects of HRQoL was reported. The results indicate that generally there was significant variation between countries in the HRQoL dimensions.
Female adolescents demonstrated a poorer HRQoL score than their male counterparts, and the majority of the HRQoL dimensions showed lower scores with increasing age. In conclusion, it is clear that meaningful gender and age differences exist in the field of HRQoL of adolescents, and that these differences have relevance for the research and practice of public health. It is also clear that interventions in prevention and health promotion must be age- and gender-specific, and must be designed to reach target groups by emphasizing what is important to them.
INTRODUCTION
Health-related quality of life (HRQoL) as a general health outcome is of growing interest in public health. The use of such a health-oriented outcome is especially suitable for the evaluation of young people, considering the low mortality and morbidity in these population groups. In particular, HRQoL measures are considered as relevant alternative to traditional existing indicators when assessing treatments, public health programs, or health care systems (Valderas et al., 2008). Still, in a primarily health population, HRQOL can discriminate among different levels of physical, psychological and social well-being (Ravens-Sieberer et al, 2001). Furthermore, knowing more about the HRQOL of adolescents is of special relevance because quality of life in this age is the basis for quality of life and health in adulthood (Fryback et al., 2007). For these reasons, HRQOL measures have received increasing attention in pediatrics and adolescent care for a few years.
However, research specifically assessing young populations’ HRQoL is rare. Besides, age and gender differences in HRQoL are not completely clarified in the literature. In some individual aspects, values seen in children are often higher than seen in adolescents (Michel et al, 2009; Ravens-Sieberer et al, 2005). With regard to gender differences the findings are unclear, but several studies tend to indicate higher values in adolescent male than in adolescents females (Bisegger et al, 2005; Michel et al, 2009).
The diverse results regarding differences in age and gender stem partly from the fact that the studies were based on different instruments with in some cases very different concepts and operationalizations of HRQoL. This highlights the importance of addressing the various aspects as comprehensively as possible for the life domains of the target group when investigating HRQoL, and of incorporating a broadly accepted definition of HRQoL in the sense of subjective health encompassing well-being and functioning in physical, psychological, social and everyday domains as perceived and expressed by the respondent (Evans, 1994).
Self-reported questionnaires are regarded as the primary method for assessing HRQoL. Most of the currently available HRQoL questionnaires for young people have been generated within one country and have subsequently been translated into other languages (Pane et al., 2006). An exception is the KIDSCREEN-52 questionnaire which is the first questionnaire that was developed simultaneously in several different Europe countries and tested in a large representative sample of children and adolescents (Ravens-Sieberer et al, 2003), thereby helping to provide a broad perspective on the understanding and interpretation of HRQoL across different countries.
With this questionnaire it is possible to investigate specific aspects of the quality of life of young people, such as physical and psychological well-being, moods and emotions, self perception, relationship to parents and peers, school environment, or social acceptance. The KIDSCREEN questionnaire comprises identical questions for males and female of 8- to 17-year-old. Thus, various aspects of the HRQoL can be compared directly for different age groups and for both genders.
The purpose of this study was to examine gender and age differences in HRQoL dimensions in a large international sample of adolescents from three Latin American countries using data collected with internationally recognized and validated questionnaire (KIDSCREEN-52).
METHODS
Participants and sampling
The sample consisted of 1357 adolescents aged 12 to 17 years in three countries Latin American (Argentina, Brazil and Chile). The data were analyzed in three age groups: 12-13 years, 14-15 years, and 16-17 years – table 1. The study used a cross-sectional design. Different approaches for sample selection were used across countries in order to obtain random samples. Fieldwork was carried out between May and September 2008.
Table 1. Number of adolescents involved in the study (n = 1357).
Table 1. Age and gender differences in health-related quality of life of adolescents from Latin American countries
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The adolescents were told that the purpose of the study was to attain knowledge about the quality of life and health, in general, among teenagers. They were further informed that their responses would be treated anonymously and that there was no right or wrong answer. The scale instructions were given in written form, and the test was performed during school hours and lasted 30 to 40 min. The rights of all participants were safeguarded through informed consent and confidentiality. The adolescents filled in the questionnaire at school and the inclusion criteria were to be between 12 and 17 years old, to be able to read and complete the questionnaire themselves, and to consent to be involved in the study.
Measures
HRQoL was measured using the KIDSCREEN-52 questionnaire, a self-report measure applicable to healthy and chronically ill children and adolescents 8-18 years old. Various psychometric aspects of the KIDSCREEN-52 had been studied in European (Ravens-Sieberer et al., 2005; Robitail et al, 2006) and Latin American countries (Berra et al, 2009; Guedes & Guedes, 2010).
The KIDSCREEN-52 questionnaire measures HRQoL in ten dimensions: Physical Well-being (PHY, five items); Psychological Well-being (PWB, six items); Moods and Emotions (MOOD, seven items), Self Perceptions (SELF, five items), Autonomy (AUTO, five items), Parents Relations and Home Life (PAR, six items), Social Support and Peers (SOC, six items), School Environment (SCHO, six items), Social Acceptance (BULL, three items), Financial Resources (PFIN, three items). In table 2 all dimensions are characterized more in details.
Table 2. Overview of the KIDSCREEN-52 dimensions
Table 2. Age and gender differences in health-related quality of life of adolescents from Latin American countries
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The KIDSCREEN-52 item uses five-point Likert-type scales to assess either the frequency (never, seldom, sometimes, often, always) or intensity (not at all, slightly, moderately, very, extremely) and the recall period is one week. The score of each dimension was then transformed linearly to a 0-100 point scale, with 100 indicating the best quality of life and 0 the worst (Ravens-Sieberer et al., 2003).
Statistical analyses
The statistical analyses were performed using SPSS for Windows (Version 17.0; SPSS, Chicago, IL, USA). The results regarding HRQoL scores were first compared to a normal distribution by the Kolmogorov-Smirnov distance test. Since the data showed a normal distribution, parametric tests were used and the mean and standard deviation were calculated. ANOVA were used with each of the KIDSCREEN-52 dimension as dependent variable and gender (two levels) and age groups (three levels) as independent factors. The Scheffe post-hoc multiple comparisons test was used o identify specific differences in the HRQoL dimensions. A p ≤ 0.05 was considered as indicating statistical significance.
RESULTS
The results indicate that there was significant variation between countries in the HRQoL dimensions. Generally the Brazilian adolescents of both genders had higher mean scores, while the Chilean adolescents had the lowest scores in the Parents Relations and Home Life, Social Support and Peers, and School Environment dimensions. The Argentine adolescents showed significantly lower mean scores in the Physical Well-being, Moods and Emotions, Self Perceptions, Social Acceptance/Bullying and Financial Resources dimensions. The mean scores equivalent to “Psychological Well-being and Autonomy dimensions were similar among the adolescents from three countries – table 3.
Table 3. Differences in KIDSCREEN-52 dimensions scores of adolescents from Latin American countries
Table 3. Age and gender differences in health-related quality of life of adolescents from Latin American countries
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Abbreviations – PHY: Physical Well-being; PWB: Psychological Well-being; MOOD: Moods and Emotions; SELF: Self Perceptions; AUTO: Autonomy; PAR: Parents Relations and Home Life; SOC: Social Support and Peers; SCHO: School Environment; BULL: Social Acceptance/Bullying; PFIN: Financial Resources.
Considering the selected samples of adolescents from three Latin American countries, female adolescents demonstrated a poorer HRQoL dimensions than their male peers, and the majority of the HRQoL dimensions showed lower scores with increasing age. Girls and boys aged 12-13 had similar mean scores in all HRQoL dimensions. With the exception of the Social Acceptance/Bullying dimension, the mean scores were decreasing continually for adolescents of older age. In this case, while the mean scores were decreasing with every age group in both genders, it was decreasing more in girls than boys.
At age 16-17, mean scores for boys were significantly higher than girls for the Physical Well-being, Psychological Well-being, Moods and Emotions, Self Perceptions, Autonomy, Parents Relations and Home Life, and School Environment dimensions. The mean scores of the Social Support and Peers, Social Acceptance/Bullying and Financial Resources dimensions were similar in both genders. Regarding Social Acceptance/Bullying dimension, the mean scores increased significantly with age for both genders – table 4.
Table 4. Differences in KIDSCREEN-52 dimensions scores by gender and age group
of adolescents from Latin American countries
Table 4. Age and gender differences in health-related quality of life of adolescents from Latin American countries
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Abbreviations – PHY: Physical Well-being; PWB: Psychological Well-being; MOOD: Moods and Emotions; SELF: Self Perceptions; AUTO: Autonomy; PAR: Parents Relations and Home Life; SOC: Social Support and Peers; SCHO: School Environment; BULL: Social Acceptance/Bullying; PFIN: Financial Resources.
DISCUSSION
The present study showed gender and age differences in HRQoL dimensions scores of adolescents from three Latin American countries. The strength of the study is mainly that the different aspects of HRQoL could be analyzed separated by a multi-dimensional instrument (KIDSCREEN-52 questionnaire). Consistent with prior studies including European countries (Bisegger et al., 2005; Michel et al., 2009), the typical pattern of the majority of dimensions was a significant decreasing HRQoL score across age groups, which was generally more pronounced in girls compared to boys. Compared with their younger peers, adolescents aged 16-17 showed only mean scores significantly higher in the Social Acceptance/Bullying HRQOL dimension.
Based on a developmental psychology perspective many aspects of the decrease in HRQoL during adolescence can be explained. When adolescents find themselves in puberty, they often encounter problems in coping with their environment (Hampel, 2007). In growing up, they are confronted with a physical and social transition in life and need to adapt to their changing bodies and gender identities (Eccles, 1999). Physiological processes may get out of line through hormonal changes (Patton & Viner, 2007). All this may lead to an impaired HRQoL.
Gender differences in HRQoL for adolescents have been little studied so far, although a diversion is reported after the age of 12 years (Bisegger et al., 2005). This finding is supported by the present study showing a stronger gender difference with increasing age. From age 12, girls are in a worse position than boys regarding subjective health and HRQoL. This falls together with the menarche and an imbalance of the hormonal status, the prevalence of stressful life events, and specific coping mechanisms, which may all lead to worse psychological well-being (Gadin & Hammarstrom, 2005; Patton & Viner, 2007).
Moreover, studies indicate that girls and boys during adolescence are generally more worried, more concerned with their well-being, and more sensitive making them more vulnerable to psychosomatic disorders and mental complaints (Steinberg & Morris, 2001). Studies also suggest that bullying is generally more frequent in childhood than in adolescence (Newman et al., 2005), a finding that corresponds with the improved Social Acceptance/Bullying HRQoL scores with the age for both genders.
HRQoL of adolescents differs across Latin American countries, assuming an innate influence of countries’ cultural and socio-economic factors on young people’s subjective health and well-being. Previous studies on child and adolescent well-being also showed significant variation between European countries pointing to the importance of the national context for children’s and adolescents’ HRQOL (UNICEF, 2007). However, future studies are needed in order to explore age and gender differences in HRQOL between different Latin American countries in more detail.
CONCLUSION
For the first time adolescents’ HRQoL across Latin American were assessed using a large representative sample and a comprehensive and standardized instrument. In conclusion, it is clear that meaningful gender and age differences exist in the field of HRQOL of adolescents, and that these differences have relevance for the research and practice of public health. It is also clear that interventions in prevention and health promotion must be age- and gender-specific, and must be designed to reach target groups by emphasizing what is important to them.
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