Multidimensional Poverty Among Adolescents in 38 Countries: Evidence from the Health Behaviour in School-aged Children (HBSC) 2013/14 Study

Depósito de Investigación de la Universidad de Sevilla https://idus.us.es/ This version of the article has been accepted for publication, after peer review and is subject to Springer Nature’s AM terms of use, but is not the Version of Record and does not reflect post-acceptance improvements, or any corrections. The Version of Record is available online at: https://doi.org/10.1007/s12187-017-9489-0 Child Indicators Research Multidimensional deprivation among adolescents in 39 countries: evidence from the Health Behaviour in School-Aged Children (HBSC) 2013/14 study --Manuscript Draft-- Manuscript Number: ISCI-D-16-00082 Full Title: Multidimensional deprivation among adolescents in 39 countries: evidence from the Health Behaviour in School-Aged Children (HBSC) 2013/14 study Article Type: Original research Keywords: multidimensional deprivation; adolescent well-being; Health Behaviour in School-aged Children Study; Sustainable Development Goals Corresponding Author: Zlata Bruckauf UNICEF Office of Research-Innocenti ITALY Corresponding Author Secondary Information: Corresponding Author's Institution: UNICEF Office of Research-Innocenti Corresponding Author's Secondary Institution: First Author: Yekaterina Chzhen First Author Secondary Information: Order of Authors: Yekaterina Chzhen Zlata Bruckauf Emilia Toczydlowska Frank Elgar Concepción Moreno-Maldonado Gonneke Stevens Dagmar Sigmundová Geneviève Gariépy Order of Authors Secondary Information: Funding Information: Agencia de Innovación y Desarrollo de Andalucía (SEJ 08007) MSc Concepción Moreno-Maldonado Abstract: This study investigated the application of UNICEF's Multiple Overlapping Deprivation Analysis (MODA) framework to 40 European regions and Canada using data on adolescents aged 11, 13 and 15 from the 2013/14 Health Behaviour in School-aged Children survey. It is the first application of MODA that is based entirely on data collected from adolescents themselves rather than from household reference persons on their behalf. Unlike other MODA studies, the present analysis mostly focuses on non-material, relational aspects of child deprivation. Although there is substantial cross-country variation in the prevalence of adolescent deprivations regarding nutrition, perceived health, school environment, protection from peer violence, family environment and information access, our findings underline that these more subjective single dimensions of deprivation hardly vary with national wealth and income inequality However, when focusing on deprivation on at least three dimensions (i.e., multidimensional deprivation), results showed that with increasing national level income inequality, shares of adolescents deprived in three or more out of six dimensions also increased. In the majority of countries. girls were at a higher risk of multidimensional deprivation than boys. In addition, adolescents not living with both parents in the household and those reporting lower levels of family wealth were Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation consistently more deprived than other adolescents, both regarding single and multidimensional deprivation. The results of this study show the interconnectedness of social (family, school support) and psychological (health and violence) deprivations for adolescents throughout Europe, e.g. children deprived in the domain of family and school environment are likely to be also deprived in the perceived health and protection from peer violence. Powered by Editorial Manager® and ProduXion Manager® from Aries Systems Corporation Multidimensional deprivation among adolescents in 39 countries: evidence from the Health Behaviour in School-Aged Children (HBSC) 2013/14 study Chzhen, Y1., Bruckauf, Z.1, Toczydlowska, E.1, Elgar, F.2, Moreno-Maldonado, C.3, Stevens, GW.J.M..4, Sigmundová, D.5 and Gariépy, G.6 1 UNICEF Office of Research-Innocenti, Piazza SS Annunziata, 12, 50122 Florence, Italy 2 Institute for Health and Social Policy and Douglas Institute, McGill University, 1130 Pine Avenue West, Montreal, QC H3A 1A3, Canada 3 Department of Developmental and Educational Psychology, University of Seville, C/ Camilo José Cela, s/n, 41018 Seville, Spain 4 Utrecht Centre for Child and Adolescent Studies, Utrecht University, P.O. Box 80140, 3508 TC Utrecht, The Netherlands 5Faculty of Physical Culture, Palacký University Olomouc, Tř. Míru 117, 77111 Olomouc, Czech Republic 6 Institute for Health and Social Policy | McGill University, 1130 Pine Ave West, Montreal, QC, H3A 1A3 Corresponding Author: Zlata Bruckauf. E-mail address: [email protected]. Tel: (+39) 055 20 330 Fax: (+39) 055 2033 220 Acknowledgements: The Health Behaviour in School-aged Children (HBSC) study is a World Health Organization collaborative study and is supported by each member country of the HBSC network (www.hbsc.org). The HBSC study is coordinated internationally by Dr Joanna Inchley, University of St. Andrews, Scotland, with international data coordination performed by Dr Oddrun Samdal, University of Bergen, Norway. Title Page 1 Multidimensional deprivation among adolescents in 39 countries: evidence from the Health Behaviour in School-Aged Children (HBSC) 2013/14 study Abstract This study investigated the application of UNICEF’s Multiple Overlapping Deprivation Analysis (MODA) framework to 40 European regions and Canada using data on adolescents aged 11, 13 and 15 from the 2013/14 Health Behaviour in School-aged Children survey. It is the first application of MODA that is based entirely on data collected from adolescents themselves rather than from household reference persons on their behalf. Unlike other MODA studies, the present analysis mostly focuses on non-material, relational aspects of child deprivation. Although there is substantial cross-country variation in the prevalence of adolescent deprivations regarding nutrition, perceived health, school environment, protection from peer violence, family environment and information access, our findings underline that these more subjective single dimensions of deprivation hardly vary with national wealth and income inequality. However, when focusing on deprivation on at least three dimensions (i.e., multidimensional deprivation), results showed that with increasing national level income inequality, shares of adolescents deprived in three or more out of six dimensions also increased. In the majority of countries, girls were at a higher risk of multidimensional deprivation than boys. In addition, adolescents not living with both parents in the household and those reporting lower levels of family wealth were consistently more deprived than other adolescents, both regarding single and multidimensional deprivation. The results of this study show the interconnectedness of social (family, school support) and psychological (health and violence) deprivations for adolescents throughout Europe. Children deprived in the domain of family and school environment are also likely to be deprived in the perceived health and protection from peer violence. Key words: multidimensional deprivation; adolescent well-being; Health Behaviour in School- Aged Children Study; Sustainable Development Goals. Blinded Manuscript Click here to view linked References 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 2 1. Introduction It has been widely acknowledged that children have basic human rights, such as a sufficient supply of healthy foods, access to health care, access to education, and freedom to grow up in a safe environment. These rights are fundamental to child wellbeing and enshrined in the United Nations’ 1989 Convention on the Rights of the Child (CRC). UNICEF has developed the Multiple Overlapping Deprivation Analysis (MODA) to facilitate research and surveillance of children and adolescents who are deprived of these rights. Like UNICEF’s Global Study on Child Poverty and Disparities (Gordon et al. 2003; UNICEF 2007), MODA uses child-relevant indicators to measure deprivations in dimensions rooted in the CRC but with a greater emphasis on overlapping dimensions and age-appropriate constructs for children and youth (see de Neubourg et al. 2012). The aim of this study was to apply the MODA toolkit to put forward a new measure of multidimensional deprivation among adolescents in high- and middle-income countries in Europe and Canada using data from the WHO Health Behaviour in School-aged Children (HBSC) study 2013/14. This study sought to contribute to the literature on multidimensional child deprivation and to illustrate how data that were collected directly from adolescents could be used to assess progress towards the new universal Sustainable Development Goals.1 It is the first study of multidimensional child deprivation that is based entirely on data collected from children themselves rather than from household reference persons on behalf of children (e.g. Chzhen et al. 2016a; Chzhen and Ferrone 2016; de Milliano and Handa 2014; de Milliano and Plavgo 2014). Unlike previous MODA studies, the present analysis mostly focused on nonmaterial, relational aspects of child deprivation. Research questions and hypotheses Child poverty is conventionally measured in monetary terms, as a share of children living in households with income or consumption below a certain poverty line. However, this approach assumes that children receive a fair portion of household resources and can control their share of family resources, including social, educational, and cultural capital (Chzhen and Ferrone 2016). Direct measures of child deprivation have been found to complement household-based monetary indicators of deprivation (de Neubourg et al. 2014; Guio et al. 2012; Main and Bradshaw 2012). While certain household-level deprivations (e.g. housing conditions) affect 1 SDG Target 1.2 calls for “reducing at least by half the proportion of men, women and children of all ages living in poverty in all its dimensions according to national definitions” by 2030. See https://sustainabledevelopment.un.org/sdg1. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 3 children and youth (Chzhen et al. 2016a; Guio et al. 2012), it is useful to collect at least some information from children themselves. Self-reports are especially useful to measuring children’s exposure to violence outside the home, school experiences, and access to information. Until now, the consequences of deprivation for adolescents are discussed less than for other age groups (Viner et al. 2012). This may be an important omission in the literature, as adolescence is a formative life stage in which disadvantages have lasting impacts on the life course (Alemán-Díaz et al. 2016; Brener et al. 2013; Hanson and Chen 2007; Woodward et al. 2003; Dmitrieva 2013). Although high-income Western European welfare states have achieved an unprecedented level of material wealth, studying adolescent deprivation in these contexts is still crucial (Mackenbach 2012). Social and economic changes in these states have increased the risk of poor health – not just for economically disadvantaged families but for more middleclass families and families with young children as well (Li et al. 2008). In studying adolescent deprivation, the use of multidimensional domains may be of vital importance as different experiences tend to co-exist (Evans and Kim 2010). For instance, a recent study of adolescents based on HBSC data found that a cluster of risk behaviors (smoking, drinking, fighting, physical injuries, and bullying others) related to psychosomatic symptoms and consumption of sugary drinks and sweets (Walsh et al. 2016). The HBSC study collects health information from adolescents aged 11, 13 and 15 years across more than 40 countries in Europe and North America.2 The HBSC does not collect information on household income and although it collects some socio-economic information such as parental occupation or education, these data are often subject to inaccurate or missing responses (Ridolfo and Maitland 2011; Richter et al. 2012). However, in addition to information on common material assets in the home (e.g. cars, computers), the HBSC survey collects a wealth of information on non-material aspects of child well-being, such as health, risk behaviours, peer and family relationships, and peer violence (Currie et al. 2014). Leveraging these rich data in a cross-country comparative context, the specific objectives of this study were to: (1) examine cross-national differences in the proportion of multidimensional adolescent deprivation in 39 countries (and 41 regions) that participated in the 2013/14 HBSC study,3 including associations between deprivation rates, region wealth and income inequality; (2) analyze differences in multiple deprivation owing to individual characteristics such as age, 2 See www.hbsc.org. 3 We excluded Greenland from the analysis. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 4 gender, family structure and perceived family wealth; and (3) identify groups of children in multiple dimensions of deprivation and constellations of multiple deprivations that tend to cooccur. Previous cross-national studies have found that the most robust structural determinants of adolescent health and wellbeing are national wealth (i.e. national GDP per capita) and income inequality (Viner et al. 2012; Elgar et al. 2015a; Elgar et al. 2015b). Based on this evidence and other findings from MODA analyses in low and middle income countries (de Milliano and Plavgo 2014), we expected to find that low country wealth and high inequality both relate to more deprivation in adolescents in single and in multiple dimensions. Based on known social inequalities in adolescent health between gender groups and levels of socioeconomic position (Inchley et al. 2016), we expected to find more deprivation in females than in males and in lower socioeconomic groups (particularly in the health dimension). Furthermore, given the robust contribution of family and peer support on adolescent health and wellbeing (Inchley et al. 2016), we expected to find the highest degrees of deprivation overlap among the dimensions rooted in health and family and peer relationships. 2. Data and methods The 2013/14 HBSC study recruited nearly 220,000 adolescents aged 11, 13 and 15 years across 39 countries (42 regional units). We had sub-national information for two countries: Belgium (Flanders and Wallonia) and Great Britain (England, Scotland and Wales). We refer to all countries and sub-national units as regions in the remainder of this paper. Stratified samples of schools that represent the regional, economic, and public-private distribution of schools in each regional unit were recruited using a common protocol (Inchley et al. 2016). Schools were sampled with replacement as needed within each stratum to ensure consistent sample composition between countries. The HBSC protocol stipulated a standard questionnaire format, item order, and testing conditions. Teachers or trained interviewers distributed the questionnaires in classroom settings. Each member country obtained ethics clearance to conduct the survey from a university-based review board or equivalent regulatory body. Youth in private and special needs schools and street and incarcerated youth were excluded. 2.1.Indicators and dimensions The HBSC questionnaire focuses on health outcomes, well-being, health-related behaviours and social environments (Inchley et al. 2016). The data are suited to the study of adolescent multidimensional deprivation using UNICEF’s MODA framework because they cover many 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 5 of the child rights dimensions embedded in the CRC (United Nations 1989) “that are essential to any child’s development irrespective of their country of residence, socio-economic status, or culture” (de Neubourg et al. 2012, pp.14-15). The CRC has been ratified by all countries except the United States. We identified six dimensions in the HBSC data: nutrition, perceived health, school environment, protection from peer violence, family environment, and access to information. Table 1 classifies HBSC variables into indicators and dimensions of child deprivation. Each of the six dimensions is represented by two indicators. The role of these indicators is to operationalize the rights-based dimensions using the best data available (Chzhen et al. 2016a). For instance, giving all adolescents computers would not necessarily eradicate the underlying deprivation in information access, but not having a computer at home suggests lower access to information. Indicators are aggregated into dimensions using the union approach: if a child is deprived on just one indicator out of the two, they are counted as deprived in the respective dimension. Although this results in a higher deprivation headcount than if deprivation in both indicators were required (i.e., the intersection approach), the union approach is more consistent with the child rights framework: the absence of deprivation in one indicator does not make up for deprivation in another. Table 1 Child deprivation indicators, dimensions and thresholds Dimension Indicator Indicator threshold: de p rived if Nutrition Breakfast on weekda y s Never eats breakfast on weekda y s. Consumption of fruits and ve g etables Consumes fruits or vegetables less than once a week. Perceived health Self-rated health Fair or p oor self-rated health. Health complaints Reports two or more out of eight health s y m p toms ever y da y . School environment Student support No classmate support. Disagrees or strongly disagrees with at least one of the following statements: “the students in my class enjoy being together”, “most of the students in my class are kind and helpful” and “other students acce p t me as I am”. Teacher support No teacher support. Disagrees or strongly disagrees with at least one of the following statements: “I feel that my teachers accept me as I am”, “I feel that my teachers care about me as a person” and “I feel a lot of trust in m y teachers”. Protection from peer violence Bullied Being bullied at school at least once in the past couple of months. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 12 widespread or consistent as in health deprivation. Girls were more likely to be deprived in classmate or teacher support in seven regions out of 41, with the largest differences of 6 and 7 points in Lithuania and Estonia, respectively. In contrast, boys were at a greater risk in Germany (4 points), Israel (3 points) and Slovenia (3 points). Figure 4 ranks regions by the rate of deprivation in protection from peer violence, ranging from a low of 15% in Armenia to a high of 61% in Lithuania. Just over half of adolescents (51%) were deprived in this dimension in Wallonia (Belgium), Russia, Latvia and Lithuania. Again, prevalence rates did not vary significantly with macro-economic factors. Across the two indicators, the rates of deprivation were higher for bullying than for cyberbullying. Boys were more likely to report the former, while girls were more likely to report the latter. Boys were more likely to be deprived in the overall violence dimension in 13 regions out of 41, with the largest difference of 16 points in Israel, while girls were at a greater risk in nine regions, with the largest gaps of 7-10 points found in Canada, Wales, England, Scotland and Ireland. Incidence of deprivation in family environment ranged from 16-17% in Sweden, Finland, Norway and Denmark to 41-45% in Russia and Bulgaria (Figure 5), but there were no significant associations with macro-economic indicators. At the lower end of the deprivation ranking, poorer regions like Lithuania and Ukraine had one in five adolescents deprived in this dimension, compared with at least one in three in richer regions like Ireland, Iceland and France at the higher end of the ranking. Gender differences within regions were mixed: girls were more likely to be deprived in nine regions (with the largest gap of 7 points in Flanders) and boys in another eight (with the largest gap of 6 points in Moldova). Figure 6 demonstrates that deprivation proportion in information access was generally lower than in other dimensions, ranging from one in twenty adolescents in the Netherlands, Wales, Scotland and Finland to around one in five (21-23%) in Armenia and Moldova and over one in three (35%) in Albania. In contrast to the other dimensions, deprivation in information access varied significantly with economic development (GDP per capita; r=-0.46; p<0.01) and income inequality (Gini coefficient; r=0.41; p<0.05).9 Across the two indicators, proportions of adolescents with no computer at home were below 10% (except in Albania, Armenia and Moldova), which was consistently lower than the share of adolescents who did not use computers on weekdays. Boys and girls were as likely to have a computer at home (except in 9 The effect of income inequality appears to be spurious because when the information deprivation rate is regressed on both GDP per capita (PPP) and the Gini coefficient, the effect of the latter is no longer significant. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 13 Albania where girls were more deprived on this indicator), but boys were more likely to not use computers on weekdays (except in Albania and Armenia). This produced significantly higher deprivation rates in information access among boys in 18 regions, with the largest gender gap of 5 points in Bulgaria. Meanwhile, the deprivation rate was 3 points and 11 points higher for girls in Armenia and Albania, respectively. Across all six dimensions, adolescents not living with both parents in the household and those reporting lower levels of family wealth were consistently more deprived. Older adolescents were more likely to be deprived in each dimension except violence10 and information access. Net gender effects in deprivation rates remained even when adjusted for age, family structure and family wealth, since these characteristics were distributed equally across boys and girls. In the two countries for which we had sub-national information, differences between regions were sometimes stark. Adolescents in Wallonia were substantially more likely to be deprived than their Flemish counterparts in every dimension except family environment and information access. Deprivation rates were lower in England than in Scotland and Wales in nutrition, health and school environment. 3.2.Multidimensional deprivation The six dimensions of deprivation tended to overlap in this study so that even in regions with lower deprivation rates in single dimensions, at least one in two adolescents were deprived in one or more dimensions. This proportion ranged from the low of 54% in Sweden to the high of 87% in Russia and Wallonia. Drawing the cut-off at two or more dimensions out of six produced deprivation rates ranging from 24% in Sweden to 61% in Bulgaria and Wallonia. In the remainder of these analyses, we used the cut-off of three dimensions because it produced less extreme headcount rates than the cut-off of two or more, while still maintaining a high degree of variation across regions. Higher cut-offs (i.e. four or more; five or more) produced substantially lower deprivation rates, with little variation across regions, suggesting that most differences lied in the shares of adolescents deprived in two or three dimensions simultaneously. The choice of one cut-off for illustrative purposes is somewhat arbitrary, but due to space limitations we could not show the results for all possible cut-offs. Our robustness 10 Older adolescents were consistently less likely to be bullied, but in several countries they were at a higher risk of cyberbullying by pictures or messages. Since the rates of cyberbullying tend to be lower, older adolescents appeared to be less likely to be deprived in the protection from violence dimension (estimates available on request). 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 14 checks show similar results when using two or three out of six dimensions as the cut-off (estimates available on request). Figure 7 ranks regions by the share of adolescents deprived in at least three out of six dimensions. Rates ranged from one in ten (9-10%) in Norway and Sweden to about one in three in Bulgaria, Latvia, Russia and Wallonia (32-34%). Wealthier nations tended to have lower rates of multidimensional deprivation (r=-0.31; p<0.10), but this relationship appears to have been driven by income inequality. More income unequal countries had higher shares of adolescents deprived in three or more dimensions (Figure 8), while richer regions tended to be more equal. If the multidimensional deprivation rate was regressed on both region wealth and income inequality then the association of region wealth was no longer significant, while the effect of income inequality held. Girls were more likely to be deprived in three or more dimensions than boys in 25 of 41 regions, with the largest difference of 8 points in England. Boys were more likely to be deprived than girls in Israel (5 points). Older children were more likely to be deprived in three or more dimensions in 21 regions, but less likely to be deprived in another two (Estonia and Ukraine). Children living with one or no parent and those reporting low family wealth were consistently more likely to be deprived in the majority of countries. The largest differences by family structure were found in Canada (14 points) and Ireland (16 points), while Estonia showed the greatest net effect of perceived family wealth (35 points). 3.3.Overlap between dimensions To investigate which dimensions mainly drove multidimensional deprivation among the HBSC regions, we calculated the proportion of adolescents deprived in three dimensions at a time for each of the 20 unique combinations of six dimensions. The three most frequent combinations of three simultaneous deprivations were: health, school environment, and family environment; health, school environment, and protection from peer violence; and school environment, family environment, and protection from peer violence. Each combination comprised around 6% of adolescents in the overall sample. It is notable that the same four dimensions were involved in the top three combinations. In fact, 3% of adolescents on average across regions were deprived in all four simultaneously. Figure 9 shows the share of adolescents deprived in health, school environment, family environment and protection from peer violence at once, separately by region. Rates ranged from 1% in Albania, Sweden, Albania and Norway to 6% in Latvia, Russia, Wallonia and Wales. Girls were more likely to be deprived in all four dimensions at once in the majority of 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 15 the regions (29 of 41), with the largest difference of six points in Wales. Boys were more likely to be deprived in all four dimensions in Israel (by 1.5 points). Controlling for gender, family structure and perceived family wealth, older adolescents were more likely to be deprived in these four dimensions in just under one-half of the regions (16 of 41). In 26 of 41 regions, adolescents from non-two-parent families were significantly more likely to be deprived in all four dimensions. Adolescents who reported that their family was not very/not at all well off were more likely to be deprived in these four dimensions simultaneously in all but two regions (Albania and Armenia), with the largest difference of 15 points found in Estonia and Latvia. 4. Discussion and conclusion This study demonstrated the application of the MODA framework to 40 European regions and Canada using data on adolescents aged 11, 13 and 15 from the HBSC study. It is the first application of MODA that is based entirely on data collected from adolescents themselves rather than from household reference persons on behalf of adolescents (e.g. de Milliano and Handa 2014; de Milliano and Plavgo 2014; Chzhen et al. 2016a; Chzhen and Ferrone 2016). Unlike other MODA studies, the present analysis mostly focuses on non-material, relational aspects of child deprivation, corresponding closely to universal children’s rights embedded in the CRC. As such, these aspects could be used to develop nationally tailored measures of multidimensional adolescent deprivation to monitor progress towards reaching sustainable development goals (“SDGs”), goal 1, target 1.2 for this age group. All countries of the world signed up to reduce “at least by half the proportion of men, women and children of all ages living in poverty in all its dimensions according to national definitions.” Most countries are yet to agree on the national definitions of multidimensional poverty, so the present study illustrates the potential for developing an adolescent-specific multidimensional measure. The study highlights substantial cross-region variation in the prevalence of adolescent deprivations. Nordic countries had the lowest levels of multidimensional deprivations among adolescents. Sweden, Norway, Denmark, Finland and Iceland all had 15% or less of adolescents deprived in three or more dimensions out of six. Only the Netherlands had comparably low levels of multiple deprivations. Traditionally, these are countries with consistently better outcomes in many indicators of child well-being (Kamerman et al. 2003; Bradshaw and Richardson 2009). Although Sweden recently ranked below average on inequality of child outcomes across 41 OECD and EU countries (UNICEF 2016), in our study it had the lowest proportion of adolescents deprived from a poor school environment, poor family environment as well as multiple deprivations (three plus). The difference between our 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 16 results and those from UNICEF could be explained by the methodological differences in measures (outcomes vs. social relationships). Francophone regions (Wallonia and France) show a relatively high concentration of deprivation among adolescents (both countries are in the top 5 of regions with the highest percentages of deprivation in three or more dimensions), comparable only to Bulgaria, Latvia and Russia, countries with lower levels of economic development. This is somewhat in line with findings of the recent UNICEF (2016) report, which ranked France and Belgium in 28th and 29th place out of 41 countries on inequality in all dimensions (income, education, health and life-satisfaction). Although there were limits to cross-regional comparability of the results due to cultural differences and norms related to family and peer relationships, our findings underline that the more subjective single aspects of child deprivation do not vary with national wealth and income inequality. However, more income unequal countries tended to have higher shares of adolescents deprived in three or more dimensions. This is an important finding in the light of post-2015 SDG agenda of reducing inequality within and among countries.11 Only for both indicators of perceived health, consistent gender differences were found in all countries, with girls being more deprived than boys. For the other dimensions, results revealed gender differences in only some of the countries (and often in opposing directions). These findings are consistent with earlier studies showing that girls have a poorer perception of their health (Cavallo et al. 2006; Inchley et al. 2016; Chzhen et al. 2016b). Remarkably, multidimensional deprivation (three or more domains) was more common for girls than for boys in 60 percent of the countries, showing that girls are more vulnerable to multiple deprivations than boys. The risk of deprivation was not only larger for girls but also for adolescents that perceived their family affluence as relatively low and those from non-two-parent families. These links were not only found for all single dimensions of deprivation but also for the likelihood of facing at least three types of deprivation. Differences according to perceived family wealth were larger than age and family structure across all regions. Although the associations between family background and adolescent health behavior and outcomes are well established in the literature (Currie et al. 2008; Elgar et al. 2015b), this is the first HBSC-based study to show that vulnerabilities of adolescents from lower perceived socio-economic status families go beyond individual aspects of adolescents’ life to also explaining the multidimensionality of these experiences. 11 https://sustainabledevelopment.un.org/sdg10. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 17 The results of this study show the interconnectedness of specific psychological and social deprivations. More specifically, a lack of perceived support in school and family coincided most often with experiences of being bullied and poor health, while nutrition and information access are less likely to be interconnected with these dimensions of deprivation. It might be that adolescents who lack good communication and support at school and family are likely to become victims of bullying and suffer from poor health. There is no claim of causality or direction of these associations, but from policy perspective they draw attention to a group of adolescents who are marginalised or excluded within the school environment as these adolescents and young people are vulnerable in all their social ties and connections during their adolescent lives. References Alemán-Díaz, A. Y., Toczydlowska, E., Mazur, J., Frasquilho, D., Melkumova, M., & Holmqvist, G. (2016). Why income inequalities matter for young people’s health: A look at the evidence. Innocenti Working Paper 2016-06. 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