Using Quantitative & Qualitative Research in Surveillance Systems for Adolescents Health Behaviour and Lifestyles R

1. Using Quantitative & Qualitative Research in Surveillance Systems for Adolescents Health Behaviour and Lifestyles R. Forero, PhD and K.C. Tang, PhD The Health Promotion Forum in the Americas Wednesday 23 October 2002, Santiago, Chile

2. Acknowledgements to other members of the team • Prof. Adrian Bauman, Research Director, ACHP • Dr Yodi Olatunbosun-Alakija, UNICEF, South Pacific • Dr PH Phongsanvan, Former UNICEF, South Pacific • Dr Gauden Galea, WHO • Ben Smith, Acting Director, International Health,ACHP • Dr Jack Chen, Biostatistician, ACHP • Dr Chris Rissel, Director Health Promotion Unit, ACHP • Marilyn Wise, Executive Director ACHP • Margaret Thomas, NSW Health and ACHP RU

3. Introduction The purpose of this presentation is to • Briefly examine practical and technical applications of qualitative and quantitative approaches for developing surveys among adolescents. • Develop regional surveys culture specific. • Identify regional needs and strategies.

4. Why ? • Regional representatives of WHO Health Promoting Schools in Western Pacific Region in 1994-1995 recognised the urgent need for obtaining good quality data. • They wanted to implement and evaluate a “life skills program” but most health services and health promotion initiatives were based on anecdotal information. • These representatives focused their initiatives regionally, through Australian Centre for Health Promotion (WHO collaborating centre, Western Pacific). • Three countries participated during 2000-2001: Vanuatu, Tonga and Federated States of Micronesia (FSM). • Minimal funding WHO / UNICEF for regional training and capacity building in each country was available.

5. Region:South West Pacific: many small island nations

8. The issues: • What is the nature and extent of health related behaviours of young people, their psychosocial and physical health? • Should health agencies address young people’s health issues differently from adults’ leading causes of morbidity and mortality? • Is the prevalence of health problems similar across south pacific countries? • What is the effect of rapid changes in social, cultural and physical environments on young people’s lifestyle? • What are the main features of schools across South Pacific countries?

9. The strategy: • In order to answer these questions we required a wide range of both quantitative and qualitative variables. • We also needed a validated tool… • …a tool that had previously been used in the region such as HBSC surveys which were conducted in NSW, Australia (1992 and 1996).

10. Challenges for measuring health behaviours among school aged children in the Pacific • developing regional surveys • culture specific HBSC variants • maintaining links with HBSC Europe • identifying regional needs and strategies

11. More challenges…. • Some countries have high out of school populations by age 15 • Need to conduct ‘in school’ and ‘out of school’ sampling frames • To compare these youth using same measures • Need to have interview format for low literacy countries

12. Health Outcomes • behavioural outcomes • smoking, physical activity, alcohol, injuries, • psychosocial outcomes • loneliness, peer support, family support, depression, happiness • other variables measuring family environment, school environment

13. The Australian Centre for Health Promotion Research Unit is part of an international advisory group which coordinates the HBSC surveys endorsed by WHO Europe and the Research Centre for Health Promotion, University of Bergen, Norway

14. The HBSC basic features • We can compare similar information across countries. • We use single items to answer specific questions: • How healthy do you think you are? • In general how do you feel about you life at present? • Scales to measure more complex constructs: • Dietary behaviours • Psychosocial health • Bullying and violence • School perceptions

15. HBSC “Health Behaviours in Schoolchildren” surveys in Europe 1983-1998

17. HBSC aims • to monitor adolescent health overtime, to assess the achievement of health promotion targets • to help understand and explain adolescent health behaviours • to understand the school setting, and its influence upon adolescents

18. Extending HBSC to the Pacific Region • Each country funded and conducted its own studies, with analysis and reporting centrally and in each country. • Technical support provided from Sydney. • Field work coordinated by Unicef Pacific. • WHO Pacific endorsed the process. • Country specific modifications were made to the questionnaires, with a “common core” asked in all countries.

19. Phase 1Stage 1 Qualitative analysis of issues affecting young people and questionnaire development Phase 2Stage 2 Pilot testing of questionnaireStage 3 Sampling and implementationStage 4 Data entry and data cleaning Phase 3Stage 5 Quantitative analysis and scale developmentStage 6 Report writing and recommendations for implementing and evaluating life skills program

20. Questionnaire development -VanuatuPhoto Voice process20 young people working with NGOsTook photos that tell a story about the health of young peoplePhotos emphasised social and physical living conditions e.g.. pregnant women, toilets, unoccupied young people, lack of resources affecting substance choices

21. Questionnaire development - VanuatuKey-informant interviewsYouth workers and representatives of NGOs and Ministries of Health, Education and YouthUnstructured discussions about major health issues affecting young people Highlighted:substances (mushrooms, 120); deliberate injury; sexual health; prospects for work; consumption of processed foods

22. Questionnaire development -VanuatuFocus groupsYouth workers and their contactsUnstructured approach with participants responding to information arising from Photo Voice and key informant interviews Highlighted:substance use and sexual health issues

23. Questionnaire domains - VanuatuSubstance useMental healthSchool environments and peer relationships NutritionPhysical activityInjuryTrust in adults and social institutionsParticipation HygieneSexual behaviourDemographic characteristics

24. Additional items - VanuatuSubstance use - use of home brew, kava, 120, marijuana, glueMental health - happiness, loneliness, depression, job prospects, support from clergy and youth workersNutrition - consumption of taro, tinned fish and meat, fresh fish and meat, coconut juice, teaInjury - sources of deliberate injury

25. Additional items - VanuatuTrust in adults and social institutions - parents, adults, teachers, church, local and national governmentParticipation - confidence to express views to peers, community, church, parentsSexual behaviour - ever had sex, no. of partners, experience, unwanted sex when drunk, use of contraception, STD preventionDemographics - religious affiliation, location of parents’ residence

26. SummaryQualitative phase provided a context for understanding the results obtainedFundamental to increasing the relevance of the questionnaireIncreased the interest in and ownership of the process

27. Conclusions • These surveys were a major step forward in a regional effort to address health needs of adolescents. • Measurement of key information areas to guide policy was very important. • The data provided a profile for participating countries and highlighted specific issues for tailoring effective health promotion programs. • We could use qualitative and quantitative approaches for developing and using good measures for all program evaluations. • These tools are now reliable and valid for local use and for monitoring effective programs overtime.

28. Finally… • We have Completed studies in New South Wales, Australia (1992 and 1996), Vanuatu and Tonga (2000), and FSM (2001). • Other countries in Asia-Pacific region have used the instrument in collaboration with the ACHP: Malaysia (1995), Indonesia (1996) and Mongolia (2001). • We are hoping to continue this collaborative work with other countries in the South Pacific and other regions.

29. The end