International Journal of Nursing Studies 52 (2015) 920–929
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Family characteristics and health behaviour as antecedents of school nurses’ concerns about adolescents’ health and development: A path model approach Hannele Poutiainen a,*, Esko Leva¨lahti b,1, Tuovi Hakulinen-Viitanen c,2, Tiina Laatikainen d,b,e,3 a
Social and Health Affairs, City of Lahti, P.O. Box 116, 15101 Lahti, Finland National Institute for Health and Welfare, Department of Chronic Disease Prevention, P.O. Box 30, 00271 Helsinki, Finland National Institute for Health and Welfare, Department of Children, Young People and Families, P.O. Box 30, 00271 Helsinki, Finland d University of Eastern Finland, Institute of Public Health and Clinical Nutrition, P.O. Box 1627, 70211 Kuopio, Finland e Hospital District of North Karelia, Tikkama¨entie 16, 80210 Joensuu, Finland b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 November 2013 Received in revised form 22 December 2014 Accepted 4 January 2015
Background: Family socio-economic factors and parents’ health behaviours have been shown to have an impact on the health and well-being of children and adolescents. Family characteristics have also been associated with school nurses’ concerns, which arose during health examinations, about children’s and adolescents’ physical health and psychosocial development. Parental smoking has also been associated with smoking in adolescents. Objectives: The aim of this study was to determine to what extent school nurses’ concerns about adolescents’ physical health and psychosocial development related to family characteristics are mediated through parents’ and adolescents’ own health behaviours (smoking). Design: A path model approach using cross-sectional data was used. Settings: In 2008–2009, information about health and well-being of adolescents was gathered at health examinations of the Children’s Health Monitoring Study. Participants: Altogether 1006 eighth and ninth grade pupils in Finland participated in the study. Methods: The associations between family characteristics, smoking among parents and adolescents and school nurses’ concerns about adolescents’ physical health and psychosocial development were examined using a structural equation model. Results: Paternal education had a direct, and, through fathers’ and boys’ smoking, an indirect association with school nurses’ concerns about the physical health of boys. Paternal labour market status and family income were only indirectly associated with concerns about the physical health of boys by having an effect on boys’ smoking through paternal smoking, and a further indirect effect on concerns about boys’ health. In girls, only having a single mother was strongly associated with school nurses’ concerns about psychosocial development through maternal and adolescent girl smoking.
Keywords: Family characteristics Smoking School nursing Health concerns Health examination Path model
* Corresponding author. Tel.: +358 503987724. E-mail addresses: hannele.poutiainen@lahti.fi (H. Poutiainen), esko.levalahti@thl.fi (E. Leva¨lahti), tuovi.hakulinen-viitanen@thl.fi (T. Hakulinen-Viitanen), tiina.laatikainen@pkssk.fi (T. Laatikainen). 1 Tel.: +358 29 524 7807. 2 Tel.: +358 29 524 7109. 3 Tel.: +358 50 599 8031. http://dx.doi.org/10.1016/j.ijnurstu.2015.01.001 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
921
Conclusions: Socio-economic family characteristics and parental smoking influence adolescent smoking and are associated with school nurses’ concerns about adolescents’ physical health and psychosocial development. The findings underline the importance of comprehensively taking into account adolescents’ and parents’ health behaviours and the family situation in health-care contacts when providing health counselling. ß 2015 Elsevier Ltd. All rights reserved.
What is already known about the topic? Parental smoking has an effect on smoking among adolescents. Family socio-economic status and other family characteristics are associated with health behaviours. Adolescents living in nuclear families smoke less frequently than others. What does this paper add? Adolescent smoking, family characteristics and adolescents’ and parents’ health behaviours increase school nurses’ concerns about adolescents’ health and psychosocial development. The effect of the family’s socio-economic characteristics on nurses’ concerns are partly mediated through the parents’ own health behaviours. These results highlight the importance of comprehensively taking into account family characteristics in health-care contacts and targeting preventive healthcare measures to the entire family. 1. Introduction In Western countries, the health of adolescents is generally good. However, it seems that both healthpromoting and health-harming habits accumulate in certain individuals (Anda et al., 2002; Jefferis et al., 2004; Engels et al., 2005; Kemppainen et al., 2006). A significant proportion of the health and mortality gap between social classes is explained by lifestyle factors, such as alcohol use, smoking, unhealthy eating habits and a lack of exercise (e.g. Strand and Tverdal, 2004; Laaksonen et al., 2007). While health discrepancies between social classes are not as obvious in children as in adults (Chen et al., 2002), adolescents’ health behaviours, and selfperceived health in particular, are associated with socioeconomic factors (Torhsheim et al., 2004; Spencer, 2006; Richter et al., 2009). Low parental education level, poor social status and single parenthood have been observed to be linked to children’s dietary habits, such as a low consumption of fruit and vegetables (Roos et al., 2004; Riediger et al., 2007) or a lack of exercise or sports activities (Tammelin et al., 2003; Stalsberg and Pedersen, 2010). In Finland, differences in adolescents’ smoking status by education level become evident early on. Thirteen per cent of boys and 12% of girls in grade 8 (14–15 years) smoke, while 10% of students in upper secondary school (16–18 years) are smokers, compared to as many as 40% of girls and boys who have started vocational education (16– 17 years) (Luopa et al., 2009). Correspondingly, about 5% of university students and 13% of applied university students
are smokers (Kunttu, 2012). About 17% and 1% of 14–15 year-old boys and girls, respectively, have tried other tobacco products, such as snuff. Compared to the European average, Finnish adolescents smoke more, but they use drugs less often (Hibell et al., 2012). The typical age for trying out smoking and for the onset of smoking is between 12 and 17 (Ashley et al., 2008; Rainio and Rimpela¨, 2009). Several studies (e.g. Rajan et al., 2003; Avenevoli and Merikangas, 2003; Otten et al., 2007) have shown that adolescents are more likely to start smoking if their parents or older siblings smoke. Maternal smoking seems to have a greater impact on children’s smoking than paternal smoking (Milton et al., 2004). Maternal smoking has an effect on smoking in girls in particular (Kestila¨ et al., 2006; Ashley et al., 2008). Conversely, parental non-smoking (Rosendahl et al., 2003) and negative attitudes towards smoking (SimonsMorton, 2004) have been linked to adolescent nonsmoking. An association between family type and smoking in adolescents has been detected. According to previous studies (Griesbach et al., 2003; Kestila¨ et al., 2006; Otten et al., 2007), the nuclear family seems to be a protective factor against smoking compared to other family forms. Other protective factors reducing the likelihood of smoking and daily smoking among adolescents include strong family ties, communication within the family as well as parental support and participation in children’s activities (Fleming et al., 2002; Tilson et al., 2004). Adolescents’ substance use is also affected by the cultural and social environment in which they live (Kendler et al., 2008; Kulbok et al., 2008). Friends’ smoking seems to have an effect on experimenting with tobacco and the establishment of a smoking habit (Avenevoli and Merikangas, 2003). It seems that, rather than friends having a direct impact on smoking behaviour, adolescents who come from a family of smokers or who smoke themselves seek out a circle of friends who are smokers (Engels et al., 2004; Kemppainen et al., 2006). Young people often see smoking as an aid in social interactions or as a way to pass the time (Walsh and Tzelepis, 2007). On the other hand, adolescent smoking may be associated with symptoms of depression and anxiety or poor school performance (Kinnunen et al., 2010; Saban and Flisher, 2010). Although the need to smoke is often related to situations that are emotionally and mentally difficult, or smoking is used as a means to alleviate anxiety, adolescents do not commonly consider it a sign of dependence (Walsh and Tzelepis, 2007). The aim of school health care is to ensure the healthy growth and development of pupils as well as to promote prevention and the early detection of health problems.
922
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
Regular health examinations and health counselling are the core preventive functions of Finnish school health care. In addition, school health nurses provide care on small, acute occasions such as traumas. The school nurse and doctor meet the entire cohort and parents during a health examination during grade 8, which is the so-called extensive health examination. During the examinations, the adolescent’s growth and development and the entire family’s health habits and well-being are assessed by the school nurse and doctor (Government Decree 338/2011). The aim of the present study is to determine to what extent school nurses’ concerns about adolescents’ physical health and psychosocial development are mediated through parents’ and adolescents’ own health behaviours (smoking) and family characteristics. Based on earlier research (e.g. Poutiainen et al., 2013), it is known that family characteristics are associated with school nurses’ concerns about adolescents’ physical health as well as their psychosocial development. Parents’ labour market status, their income level and single parenthood were characteristics that were associated with school health nurses’ concerns about the child’s growth and development that arose during health examinations. Research on the associations between family characteristics, family and adolescent health behaviours and health-care professionals’ concerns about adolescents’ growth and development is lacking.
2. Materials and methods 2.1. Data collection The date used here are part of the Children’s Health Monitoring (LATE) Study, which was conducted in 2007– 2009 on child and school health care commissioned by the National Institute for Health and Welfare. The target population of the study was 0.5–15-year-old children in Finland, where a total of 6506 children participated the study with a response rate of 81%. The participation rate among eighth and ninth graders was 70% (n = 1006). Factors affecting participation included eighth and ninth graders’ own unwillingness to take part in the study as well as various family reasons. The analyses in this study were based on data from pupils in grades 8–9 (n = 958), which included 457 boys and 501 girls, who took part in the study. Adolescents with missing data concerning school nurses’ concerns (n = 28) or whose form containing family information was completed by someone other than their father or mother (n = 14) were excluded. In addition, only one adolescent per family was randomised for inclusion in the study (excluded n = 6). The guardians of the adolescents who took part in the study completed a survey with questions on the adolescent’s living environment, the family’s socio-demographic characteristics, the adolescent’s health and the guardians’ health habits (e.g. smoking). The adolescents’ health behaviours were evaluated with a questionnaire completed by the adolescents themselves (Ma¨ki et al., 2012). In addition, the data included a total assessment of the adolescents’ health status and the possible existence of
concern on the part of the school nurse based on the health examination (Poutiainen et al., 2013). 2.2. Conceptual model The conceptual model for this study was constructed based on earlier research on the associations between family characteristics, parents’ and children’s health behaviour and school nurses’ concerns (Poutiainen et al., 2013). Previous findings show clear relationships between smoking behaviour and socio-economic status both among adults and children (Richter et al., 2009; Laaksonen et al., 2007). In addition, parents’ smoking is associated with the onset of smoking among their children (Avenevoli and Merikangas, 2003; Otten et al., 2007). Furthermore, family characteristics—especially education, income, working status and family type—are associated with increased concerns among school nurses (Poutiainen et al., 2013). The full model used as the starting point in these analyses is described in Fig. 1. 2.3. Statistical analysis When analysing the data, adolescents’ and parents’ response alternatives to the question on smoking were categorised as a dichotomous variable: non-smokers versus daily and occasional smokers. School nurses’ concerns about adolescents’ physical health and psychosocial development were also dichotomised into no concern versus mild and clear concern. Family type, parental education and labour market status as well as parents’ views on the sufficiency of their income to cover family expenses were chosen as the variables describing the family socio-economic characteristics. Family type comprised three categories: a nuclear family (both parents and child/children), a single-parent family and other family type. Parental education was categorised into at most secondary, lower academic (approximately three years of higher education) and advanced academic degree (approximately 6 years of higher
maternal / paternal smoking
b6
b2 b3
child smoking
school nurses’ concern on physical health and psychosocial development
b1
b5 b4 family characteriscs: educaon labor market status income sufficiency family type
Fig. 1. Conceptual model.
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
923
concerns, labour market status and self-reported income sufficiency were dichotomous variables, paternal education was an ordinal variable and the family type was further categorised into a dichotomous variable (the categories of nuclear family and other family type were combined into one category). Thus, the mean and variance-weighted leastsquares estimation method was used. Subsequently, the full models were run separately for concerns on physical health and psychosocial development, maternal and paternal smoking and all of the selected family factors. Sub models were created by fixing the different paths for b1–b6 to find the best fitting model. Finally, six different sub models for boys were created which included both maternal and paternal smoking, concerns on physical health and from family factors, paternal education, paternal labour market status and self-reported income sufficiency. Among boys, the smoking status of the adolescent was not sufficiently related to concerns on psychosocial development and, thus, models including psychosocial development were not run. Among girls, parents’ smoking was not related to
education). Parents’ labour market status (separately for both parents,) and their views on the sufficiency of the family income were categorised as dichotomous variables: non-full-time employment versus full-time employment and income not sufficient versus sufficient. All analyses were performed separately for boys and girls. Participants’ background characteristics are shown in Table 1. The associations between factors were examined using the Pearson’s chi-squaretest (Tables 2 and 3). The threshold for statistical significance was set at p 0.05. Those family factors that were related to adolescents’ smoking habits, or to nurses’ concerns about physical health or psychosocial development, were selected for path analysis using structural equation modelling. These were paternal education, paternal labour market status, selfreported income sufficiency and family type. Thus, as the indicator of socio-economic position, paternal education was used in all models to describe the family’s educational status. In the structural equation modelling, the smoking status of both adolescents and parents, the existence of Table 1 The basic characteristics of study population. Smoking
Boys (n = 455)
Girls %
(n = 497)
Chi-square test %
Boys vs. girls p-Value
Child Non-smoker 415 Smoker 40 Mother Non-smoker 363 Smoker 89 Father Non-smoker 297 Smoker 137 Family type Nuclear family 321 Single-parent family 72 Other 54 Education Maternal education At most secondary education 178 Lower academic degree 194 Advanced academic 66 degree Paternal education At most secondary 245 education 113 Lower academic degree Advanced academic 62 degree Labours market status Maternal labour market status Non-full-time employment 116 Full-time employed 337 Paternal labour market status Non full-time employment 63 Full-time employed 361 Self-perceived income sufficiency Not sufficient income 101 Sufficient income 352 Public health nurses’ concern of child’s physical health No Concern 371 Concern 86 Public health nurses’ concern of child’s psychocial development No concern 394 Concern 63
91.2 8.8
450 47
90.5 9.5
0.722
80.3 19.7
389 108
78.3 21.7
0.439
68.4 31.6
320 152
67.8 32.2
0.837
71.8 16.1 12.1
333 102 59
67.4 20.6 11.9
0.195
40.6 44.3 15.1
170 232 73
35.8 48.8 15.4
0.297
58.3
269
59.8
26.9 14.8
119 62
26.4 13.8
0.886
25.6 74.4
116 381
23.3 76.7
0.417
14.9 85.1
63 404
13.5 86.5
0.558
22.3 77.7
115 381
23.2 76.8
0.744
81.2 18.8
422 79
84.2 15.8
0.212
86.2 13.8
421 80
84.0 16.0
0.344
924
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
Table 2 The impact of parental smoking and family characteristics on adlolescent smoking (b2 + b5). Boys’ smoking (n = 450)
Parental smoking Mother Non-smoker Smoker Father Non-smoker Smoker Family type Nuclear family Single-parent family Other Education Maternal education At most secondary education Lower academic degree Advanced academic degree Paternal education At most secondary education Lower academic degree Advanced academic degree Labours market status Maternal labour market status Non-full-time employed Full-time employed Paternal labour market status Non-full-time employed Full-time employed Self-perceived income sufficiency Not sufficient income Sufficient income
p-Value
Girls’ smoking (n = 493)
p-Value
Boys
Non-smoker
Smoker
Girls
Non-smoker
N
%
%
N
%
361 89
91.7 89.9
8.3 10.1
0.588
386 107
94.3 77.6
5.7 22.4
Contents lists available at ScienceDirect
International Journal of Nursing Studies journal homepage: www.elsevier.com/ijns
Family characteristics and health behaviour as antecedents of school nurses’ concerns about adolescents’ health and development: A path model approach Hannele Poutiainen a,*, Esko Leva¨lahti b,1, Tuovi Hakulinen-Viitanen c,2, Tiina Laatikainen d,b,e,3 a
Social and Health Affairs, City of Lahti, P.O. Box 116, 15101 Lahti, Finland National Institute for Health and Welfare, Department of Chronic Disease Prevention, P.O. Box 30, 00271 Helsinki, Finland National Institute for Health and Welfare, Department of Children, Young People and Families, P.O. Box 30, 00271 Helsinki, Finland d University of Eastern Finland, Institute of Public Health and Clinical Nutrition, P.O. Box 1627, 70211 Kuopio, Finland e Hospital District of North Karelia, Tikkama¨entie 16, 80210 Joensuu, Finland b c
A R T I C L E I N F O
A B S T R A C T
Article history: Received 27 November 2013 Received in revised form 22 December 2014 Accepted 4 January 2015
Background: Family socio-economic factors and parents’ health behaviours have been shown to have an impact on the health and well-being of children and adolescents. Family characteristics have also been associated with school nurses’ concerns, which arose during health examinations, about children’s and adolescents’ physical health and psychosocial development. Parental smoking has also been associated with smoking in adolescents. Objectives: The aim of this study was to determine to what extent school nurses’ concerns about adolescents’ physical health and psychosocial development related to family characteristics are mediated through parents’ and adolescents’ own health behaviours (smoking). Design: A path model approach using cross-sectional data was used. Settings: In 2008–2009, information about health and well-being of adolescents was gathered at health examinations of the Children’s Health Monitoring Study. Participants: Altogether 1006 eighth and ninth grade pupils in Finland participated in the study. Methods: The associations between family characteristics, smoking among parents and adolescents and school nurses’ concerns about adolescents’ physical health and psychosocial development were examined using a structural equation model. Results: Paternal education had a direct, and, through fathers’ and boys’ smoking, an indirect association with school nurses’ concerns about the physical health of boys. Paternal labour market status and family income were only indirectly associated with concerns about the physical health of boys by having an effect on boys’ smoking through paternal smoking, and a further indirect effect on concerns about boys’ health. In girls, only having a single mother was strongly associated with school nurses’ concerns about psychosocial development through maternal and adolescent girl smoking.
Keywords: Family characteristics Smoking School nursing Health concerns Health examination Path model
* Corresponding author. Tel.: +358 503987724. E-mail addresses: hannele.poutiainen@lahti.fi (H. Poutiainen), esko.levalahti@thl.fi (E. Leva¨lahti), tuovi.hakulinen-viitanen@thl.fi (T. Hakulinen-Viitanen), tiina.laatikainen@pkssk.fi (T. Laatikainen). 1 Tel.: +358 29 524 7807. 2 Tel.: +358 29 524 7109. 3 Tel.: +358 50 599 8031. http://dx.doi.org/10.1016/j.ijnurstu.2015.01.001 0020-7489/ß 2015 Elsevier Ltd. All rights reserved.
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
921
Conclusions: Socio-economic family characteristics and parental smoking influence adolescent smoking and are associated with school nurses’ concerns about adolescents’ physical health and psychosocial development. The findings underline the importance of comprehensively taking into account adolescents’ and parents’ health behaviours and the family situation in health-care contacts when providing health counselling. ß 2015 Elsevier Ltd. All rights reserved.
What is already known about the topic? Parental smoking has an effect on smoking among adolescents. Family socio-economic status and other family characteristics are associated with health behaviours. Adolescents living in nuclear families smoke less frequently than others. What does this paper add? Adolescent smoking, family characteristics and adolescents’ and parents’ health behaviours increase school nurses’ concerns about adolescents’ health and psychosocial development. The effect of the family’s socio-economic characteristics on nurses’ concerns are partly mediated through the parents’ own health behaviours. These results highlight the importance of comprehensively taking into account family characteristics in health-care contacts and targeting preventive healthcare measures to the entire family. 1. Introduction In Western countries, the health of adolescents is generally good. However, it seems that both healthpromoting and health-harming habits accumulate in certain individuals (Anda et al., 2002; Jefferis et al., 2004; Engels et al., 2005; Kemppainen et al., 2006). A significant proportion of the health and mortality gap between social classes is explained by lifestyle factors, such as alcohol use, smoking, unhealthy eating habits and a lack of exercise (e.g. Strand and Tverdal, 2004; Laaksonen et al., 2007). While health discrepancies between social classes are not as obvious in children as in adults (Chen et al., 2002), adolescents’ health behaviours, and selfperceived health in particular, are associated with socioeconomic factors (Torhsheim et al., 2004; Spencer, 2006; Richter et al., 2009). Low parental education level, poor social status and single parenthood have been observed to be linked to children’s dietary habits, such as a low consumption of fruit and vegetables (Roos et al., 2004; Riediger et al., 2007) or a lack of exercise or sports activities (Tammelin et al., 2003; Stalsberg and Pedersen, 2010). In Finland, differences in adolescents’ smoking status by education level become evident early on. Thirteen per cent of boys and 12% of girls in grade 8 (14–15 years) smoke, while 10% of students in upper secondary school (16–18 years) are smokers, compared to as many as 40% of girls and boys who have started vocational education (16– 17 years) (Luopa et al., 2009). Correspondingly, about 5% of university students and 13% of applied university students
are smokers (Kunttu, 2012). About 17% and 1% of 14–15 year-old boys and girls, respectively, have tried other tobacco products, such as snuff. Compared to the European average, Finnish adolescents smoke more, but they use drugs less often (Hibell et al., 2012). The typical age for trying out smoking and for the onset of smoking is between 12 and 17 (Ashley et al., 2008; Rainio and Rimpela¨, 2009). Several studies (e.g. Rajan et al., 2003; Avenevoli and Merikangas, 2003; Otten et al., 2007) have shown that adolescents are more likely to start smoking if their parents or older siblings smoke. Maternal smoking seems to have a greater impact on children’s smoking than paternal smoking (Milton et al., 2004). Maternal smoking has an effect on smoking in girls in particular (Kestila¨ et al., 2006; Ashley et al., 2008). Conversely, parental non-smoking (Rosendahl et al., 2003) and negative attitudes towards smoking (SimonsMorton, 2004) have been linked to adolescent nonsmoking. An association between family type and smoking in adolescents has been detected. According to previous studies (Griesbach et al., 2003; Kestila¨ et al., 2006; Otten et al., 2007), the nuclear family seems to be a protective factor against smoking compared to other family forms. Other protective factors reducing the likelihood of smoking and daily smoking among adolescents include strong family ties, communication within the family as well as parental support and participation in children’s activities (Fleming et al., 2002; Tilson et al., 2004). Adolescents’ substance use is also affected by the cultural and social environment in which they live (Kendler et al., 2008; Kulbok et al., 2008). Friends’ smoking seems to have an effect on experimenting with tobacco and the establishment of a smoking habit (Avenevoli and Merikangas, 2003). It seems that, rather than friends having a direct impact on smoking behaviour, adolescents who come from a family of smokers or who smoke themselves seek out a circle of friends who are smokers (Engels et al., 2004; Kemppainen et al., 2006). Young people often see smoking as an aid in social interactions or as a way to pass the time (Walsh and Tzelepis, 2007). On the other hand, adolescent smoking may be associated with symptoms of depression and anxiety or poor school performance (Kinnunen et al., 2010; Saban and Flisher, 2010). Although the need to smoke is often related to situations that are emotionally and mentally difficult, or smoking is used as a means to alleviate anxiety, adolescents do not commonly consider it a sign of dependence (Walsh and Tzelepis, 2007). The aim of school health care is to ensure the healthy growth and development of pupils as well as to promote prevention and the early detection of health problems.
922
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
Regular health examinations and health counselling are the core preventive functions of Finnish school health care. In addition, school health nurses provide care on small, acute occasions such as traumas. The school nurse and doctor meet the entire cohort and parents during a health examination during grade 8, which is the so-called extensive health examination. During the examinations, the adolescent’s growth and development and the entire family’s health habits and well-being are assessed by the school nurse and doctor (Government Decree 338/2011). The aim of the present study is to determine to what extent school nurses’ concerns about adolescents’ physical health and psychosocial development are mediated through parents’ and adolescents’ own health behaviours (smoking) and family characteristics. Based on earlier research (e.g. Poutiainen et al., 2013), it is known that family characteristics are associated with school nurses’ concerns about adolescents’ physical health as well as their psychosocial development. Parents’ labour market status, their income level and single parenthood were characteristics that were associated with school health nurses’ concerns about the child’s growth and development that arose during health examinations. Research on the associations between family characteristics, family and adolescent health behaviours and health-care professionals’ concerns about adolescents’ growth and development is lacking.
2. Materials and methods 2.1. Data collection The date used here are part of the Children’s Health Monitoring (LATE) Study, which was conducted in 2007– 2009 on child and school health care commissioned by the National Institute for Health and Welfare. The target population of the study was 0.5–15-year-old children in Finland, where a total of 6506 children participated the study with a response rate of 81%. The participation rate among eighth and ninth graders was 70% (n = 1006). Factors affecting participation included eighth and ninth graders’ own unwillingness to take part in the study as well as various family reasons. The analyses in this study were based on data from pupils in grades 8–9 (n = 958), which included 457 boys and 501 girls, who took part in the study. Adolescents with missing data concerning school nurses’ concerns (n = 28) or whose form containing family information was completed by someone other than their father or mother (n = 14) were excluded. In addition, only one adolescent per family was randomised for inclusion in the study (excluded n = 6). The guardians of the adolescents who took part in the study completed a survey with questions on the adolescent’s living environment, the family’s socio-demographic characteristics, the adolescent’s health and the guardians’ health habits (e.g. smoking). The adolescents’ health behaviours were evaluated with a questionnaire completed by the adolescents themselves (Ma¨ki et al., 2012). In addition, the data included a total assessment of the adolescents’ health status and the possible existence of
concern on the part of the school nurse based on the health examination (Poutiainen et al., 2013). 2.2. Conceptual model The conceptual model for this study was constructed based on earlier research on the associations between family characteristics, parents’ and children’s health behaviour and school nurses’ concerns (Poutiainen et al., 2013). Previous findings show clear relationships between smoking behaviour and socio-economic status both among adults and children (Richter et al., 2009; Laaksonen et al., 2007). In addition, parents’ smoking is associated with the onset of smoking among their children (Avenevoli and Merikangas, 2003; Otten et al., 2007). Furthermore, family characteristics—especially education, income, working status and family type—are associated with increased concerns among school nurses (Poutiainen et al., 2013). The full model used as the starting point in these analyses is described in Fig. 1. 2.3. Statistical analysis When analysing the data, adolescents’ and parents’ response alternatives to the question on smoking were categorised as a dichotomous variable: non-smokers versus daily and occasional smokers. School nurses’ concerns about adolescents’ physical health and psychosocial development were also dichotomised into no concern versus mild and clear concern. Family type, parental education and labour market status as well as parents’ views on the sufficiency of their income to cover family expenses were chosen as the variables describing the family socio-economic characteristics. Family type comprised three categories: a nuclear family (both parents and child/children), a single-parent family and other family type. Parental education was categorised into at most secondary, lower academic (approximately three years of higher education) and advanced academic degree (approximately 6 years of higher
maternal / paternal smoking
b6
b2 b3
child smoking
school nurses’ concern on physical health and psychosocial development
b1
b5 b4 family characteriscs: educaon labor market status income sufficiency family type
Fig. 1. Conceptual model.
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
923
concerns, labour market status and self-reported income sufficiency were dichotomous variables, paternal education was an ordinal variable and the family type was further categorised into a dichotomous variable (the categories of nuclear family and other family type were combined into one category). Thus, the mean and variance-weighted leastsquares estimation method was used. Subsequently, the full models were run separately for concerns on physical health and psychosocial development, maternal and paternal smoking and all of the selected family factors. Sub models were created by fixing the different paths for b1–b6 to find the best fitting model. Finally, six different sub models for boys were created which included both maternal and paternal smoking, concerns on physical health and from family factors, paternal education, paternal labour market status and self-reported income sufficiency. Among boys, the smoking status of the adolescent was not sufficiently related to concerns on psychosocial development and, thus, models including psychosocial development were not run. Among girls, parents’ smoking was not related to
education). Parents’ labour market status (separately for both parents,) and their views on the sufficiency of the family income were categorised as dichotomous variables: non-full-time employment versus full-time employment and income not sufficient versus sufficient. All analyses were performed separately for boys and girls. Participants’ background characteristics are shown in Table 1. The associations between factors were examined using the Pearson’s chi-squaretest (Tables 2 and 3). The threshold for statistical significance was set at p 0.05. Those family factors that were related to adolescents’ smoking habits, or to nurses’ concerns about physical health or psychosocial development, were selected for path analysis using structural equation modelling. These were paternal education, paternal labour market status, selfreported income sufficiency and family type. Thus, as the indicator of socio-economic position, paternal education was used in all models to describe the family’s educational status. In the structural equation modelling, the smoking status of both adolescents and parents, the existence of Table 1 The basic characteristics of study population. Smoking
Boys (n = 455)
Girls %
(n = 497)
Chi-square test %
Boys vs. girls p-Value
Child Non-smoker 415 Smoker 40 Mother Non-smoker 363 Smoker 89 Father Non-smoker 297 Smoker 137 Family type Nuclear family 321 Single-parent family 72 Other 54 Education Maternal education At most secondary education 178 Lower academic degree 194 Advanced academic 66 degree Paternal education At most secondary 245 education 113 Lower academic degree Advanced academic 62 degree Labours market status Maternal labour market status Non-full-time employment 116 Full-time employed 337 Paternal labour market status Non full-time employment 63 Full-time employed 361 Self-perceived income sufficiency Not sufficient income 101 Sufficient income 352 Public health nurses’ concern of child’s physical health No Concern 371 Concern 86 Public health nurses’ concern of child’s psychocial development No concern 394 Concern 63
91.2 8.8
450 47
90.5 9.5
0.722
80.3 19.7
389 108
78.3 21.7
0.439
68.4 31.6
320 152
67.8 32.2
0.837
71.8 16.1 12.1
333 102 59
67.4 20.6 11.9
0.195
40.6 44.3 15.1
170 232 73
35.8 48.8 15.4
0.297
58.3
269
59.8
26.9 14.8
119 62
26.4 13.8
0.886
25.6 74.4
116 381
23.3 76.7
0.417
14.9 85.1
63 404
13.5 86.5
0.558
22.3 77.7
115 381
23.2 76.8
0.744
81.2 18.8
422 79
84.2 15.8
0.212
86.2 13.8
421 80
84.0 16.0
0.344
924
H. Poutiainen et al. / International Journal of Nursing Studies 52 (2015) 920–929
Table 2 The impact of parental smoking and family characteristics on adlolescent smoking (b2 + b5). Boys’ smoking (n = 450)
Parental smoking Mother Non-smoker Smoker Father Non-smoker Smoker Family type Nuclear family Single-parent family Other Education Maternal education At most secondary education Lower academic degree Advanced academic degree Paternal education At most secondary education Lower academic degree Advanced academic degree Labours market status Maternal labour market status Non-full-time employed Full-time employed Paternal labour market status Non-full-time employed Full-time employed Self-perceived income sufficiency Not sufficient income Sufficient income
p-Value
Girls’ smoking (n = 493)
p-Value
Boys
Non-smoker
Smoker
Girls
Non-smoker
N
%
%
N
%
361 89
91.7 89.9
8.3 10.1
0.588
386 107
94.3 77.6
5.7 22.4
