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2018 Issue 4: The public health issue

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Making sure the kids are alright

Making sure the kids are alright

[illustration of teens in a variety of activities]
(c) Katy Dockrill/i2iart.com

Katy Dockrill illustrates some of the healthy and  unhealthy behaviours tracked by the HBSC.

As of October 17, 2018, Canadians live in a society in which cannabis products are, within certain parameters, perfectly legal. One of the central reasons Prime Minister Justin Trudeau cited for pushing ahead with legalization was that too many young people were being exposed to cannabis and that the old system of prohibition was clearly not working. On the campaign trail, at rallies, and during media interviews, he repeated the same fact time and again: young people in Canada consume more cannabis than their peers in other developed countries. For the Canadians who helped elect his Liberal party, Mr. Trudeau’s policy points made sense: if the current framework couldn’t protect young people from the dangers of marijuana, why not adopt a system of legalization with strict restrictions for minors, similar to what is already in place for tobacco products?

It’s too soon to know how successful this new policy will be. But because of the Health Behaviour in School-Aged Children survey, we’ll know if it leads to a decrease in cannabis use among adolescents in Canada. Every four years, researchers at Queen’s gather this data, along with information on a myriad of factors affecting Canadian youth. They are part of a massive 30-year, multinational effort to uncover the health risks facing children and adolescents around the world.

The Health Behaviour in School-Aged Children study is a survey given to nearly 30,000 Canadian students – and their peers in nearly 50 other countries – to try and understand virtually everything about their lives and what affects their health, from the types of relationships they have with their parents and friends, to whether they have ever bullied anyone, to their experiences with sex, alcohol, drugs, and tobacco.

The 2010 survey showed that Canadian youth ranked first in cannabis use among the 43 countries and regions surveyed. About one-third of Canadian kids in grades 9 and 10 reported having used cannabis in the previous year.

The findings, which corroborated other research, sparked a cascade of events, including a flurry of newspaper headlines and calls for action from substance abuse experts. As the years went by, more studies were done about the potential harms posed by cannabis use in youth. Health experts began pushing for legalization as a way to protect young people from harm. Finally, in 2015, the federal Liberal party campaigned on a promise to make Canada one of the first jurisdictions in the world to fully legalize cannabis.

The HBSC is one of the most powerful surveys in existence in terms of the scale and scope of information it can provide about young people and the potential health challenges they face. Researchers from around the world use the data to look for trends, identify emerging health challenges, and investigate how public policy and health promotion can be used to help address health issues.

The HBSC survey began in 1983 as an effort among just three countries: England, Finland, and Norway. Researchers were interested in studying the habits and behaviours of young people at critical developmental phases of their lives and determining what, if anything, they could learn from the results.

Canada joined the survey more than 25 years ago and today is one of four dozen countries in Europe and North America that uses it to identify challenges and develop policies to address them. From the beginning, the Canadian HBSC team has been led by Queen’s University. The Social Program Evaluation Group, supported by the Public Health Agency of Canada, coordinates the Canada survey from its headquarters at Duncan McArthur Hall.

“It provides evidence in support of a lot of decisions in health and education across the country,” said William Pickett, professor in the Department of Public Health Sciences at Queen’s and co-leader of the HBSC study in Canada.

Adolescence is a critical age group to study and understand, as it’s a time when risk-taking behaviours can begin and certain patterns and habits that can have lifelong health impacts emerge. Many of the questions are exactly the same in each of the countries involved, allowing researchers to make direct comparisons and see which countries are doing well – and which need to do better.

“It gives us a picture of adolescence in Canada,” said Wendy Craig, professor and head of the Department of Psychology and co-leader of the HBSC survey at Queen’s.

There are numerous examples of how the HBSC study has led to real-world policy changes making a substantive difference in the lives of young people. In the early 2000s in Germany, the study was instrumental in identifying a worrying trend of young people binge drinking on flavoured alcoholic beverages. The findings led to a major tax on the drinks and a prohibition on marketing to young people, which helped lower rates of youth alcohol consumption. In 2004, results showing high consumption of sugary beverages and treats prompted Latvian lawmakers to become one of the first countries to ban them in schools. And in Sweden, the survey found that from 1986 to 2004, symptoms like sleeping problems, irritability, and depression had doubled among young people, leading to a nationwide study to identify the causes and a huge investment from the federal government to fund mental health programs.

But according to Dr. Craig, there’s an opportunity to do even more with the HBSC study. Over the course of the next few months, she and Dr. Pickett, along with their other Canadian partners on the study (at UBC, McGill, University of Waterloo, and Public Health Agency of Canada) on the study will be busy gathering the final 2017-2018 results and turning them into a massive report that can be used by health groups, researchers, and policy-makers across the country.

The Canadian team will be doing a major push to ensure governments across the country are aware of the survey and the potential opportunities it offers for creating important evidence-based public policy that can help young people throughout Canada.

“Our dream, actually, is for policy-makers to be analyzing these results more often to inform their health policy or check their health policy,” said Dr. Craig. “I think [the HBSC study] is Canada’s under-utilized jewel.”

The Public Health Agency of Canada funds the study and collaborates with the researchers. The partnership has helped shape and inform government policy on issues such as youth mental health, physical activity, and use of electronic cigarettes, said Matthew Enticknap, manager of youth policy and partnerships at the agency. “The HBSC directly informs our policy and program advice,” Mr. Enticknap said, adding that the survey has become a valued resource that different levels of government across the country can use to make evidence-based policy decisions.


One of Canada’s biggest contributions to the HBSC study is on issues relating to bullying. Dr. Craig is one of the country’s foremost experts on bullying and knows that those affected by it can carry lifelong scars as a result. In recent years, stories about young people dying by suicide related to online or in-person harassment have emerged, leading to growing questions from parents, educators, and politicians about what can be done to stop bullying.

But where to start? That’s where Dr. Craig and her expertise comes in. As part of her work as principal investigator on the Canadian HBSC study, Dr. Craig has been instrumental in ensuring questions about bullying behaviours are included in the survey, giving researchers and policy-makers a rich data set to draw on as they look for solutions to this complex problem.

Since 1998, the survey has been asking respondents about their experiences with bullying – whether they have instigated bullying or have experienced victimization themselves. This means researchers like Dr. Craig can actually study how trends are shifting with time and how various anti-bullying policies may be working, both here and abroad.

[illustrations of three teens on a bench]

While headlines about bullying often paint a grim picture, the evidence emerging from the HBSC study shows there may be hope on the horizon. The most recent published survey, conducted in 2013-2014, showed that while the prevalence ofbullying has risen since 2006, the number of people who report engaging in bullying behaviours has actually gone down.

It’s an important change, one that coincides with increased awareness of the prevalence of bullying in Canada and the adoption of policies by some schools across the country to address the problem.

According to Dr. Craig, the HBSC survey has provided invaluable insights into the complex nuances of bullying, such as who is more likely to be a target for online aggressors or the types of characteristics that makes individuals more likely to bully others.

The international component of the survey also allows Canadian researchers to see how other countries are addressing the problem of bullying, Dr. Craig said. For instance, Scandinavian countries typically have some of the lowest reported incidents of bullying of all the countries in the survey. Those countries have also adopted national policies against bullying, which means that everyone from politicians to school teachers are made aware of the importance of anti-bullying initiatives and protecting children from the effects of this troubling behaviour.

“It allows us to monitor and have surveillance on key issues,” Dr. Craig said. “It allows us to do international comparisons. It tells us how well Canada is doing, but it also informs us about what we can learn from other countries doing better.”

Globally, the HBSC survey data is an important part of UNICEF's annual report on the well-being of children in industrialized countries, the Innocenti Report Card, a much-respected and well-used resource worldwide.


Ian Janssen, a professor and the Canada Research Chair in Physical Activity and Obesity in the School of Kinesiology and Health Studies, as well as the Department of Public Health Sciences, is one of Canada’s leading experts on obesity and how rising rates of inactivity are affecting the health of young people nationwide.

As one of the Canadian team members of the HBSC study, Dr. Janssen has spent much of his career combing through survey results to glean important insights about the complex relationship between the environment and activity levels. What he’s found is surprising – and a good example of why the long-term investment in a survey of this magnitude is paying off.

One of the biggest puzzles for obesity researchers is how they can get people to incorporate more physical activity in their lives. With the demands of daily life and the availability of smartphones and other screens, it’s becoming more of a challenge than ever. But what studies of adults have shown is that living in a walkable neighbourhood helps people to get moving. If you live close to work, or live in an area in close proximity to grocery stores, restaurants, public parks, and other amenities, it encourages you to ditch the car and get out of the house.

Dr. Janssen and his colleagues wanted to see if those same aspects of walkability could be translated to a younger market – teens and children. If they lived in more walkable neighbourhoods, would they get more physical activity by walking to and from school or heading to a friend’s house? Those sorts of questions were incorporated into a recent HBSC survey. But the results were not what Dr. Janssen expected. For adolescents, the walkability of their home environment didn’t have a positive impact on their activity levels.

[illustration of teen looking out of his window]What did matter, in a big way, was whether adolescents felt safe in their neighbourhoods. The survey revealed that young people who felt secure and safe in the streets around their home were more likely to walk to places and play outside in their neighbourhoods. Surprisingly, researchers found that young people who lived in low-crime, safe areas – such as a typical Canadian subdivision – were quite likely to report feeling afraid by the threat of strangers, traffic, and other dangers, which would keep them inside. Thus, there is a big disconnect between the actual dangers of being outdoors and what young people perceive as being unsafe.

The survey results are merely a starting point from which researchers like Dr. Janssen can explore the potential implications and develop ways to solve the problem. Dr. Janssen said some of the work in this area is now focusing on safety perception and risk and how to understand the disconnect that convinces parents and young people who live in safe areas that their neighbourhoods aren’t safe for outdoor play and active travel.

“The main purpose of doing a lot of the work I do is to help inform these interventions,” Dr. Janssen said.


HBSC researchers from around the world gather a few times a year to set research priorities and discuss results, said Dr. Pickett, who described the meetings as “like a little United Nations.”

Dr. Pickett, who has been involved with the HBSC survey for more than 20 years, said one of the biggest changes in recent years is that researchers now look to the study subjects themselves to determine their research priorities.

“It’s really important if you are studying children that they have a voice in your research,” he said.

Canada is a signatory to the U.N. Convention of the Rights of the Child. The right of children toparticipate and be heard is an important principle in this agreement.

In the context of the HBSC study, that means asking young people what issues really matter to their lives as well as getting their feedback on the survey findings. The results can be illuminating and can help the researchers understand their study subjects in a new light.

With a survey that has been active for 30 years, there needs to be room to explore new and emerging areas of health. During the most recent survey, which went out to schools across Canada earlier this year, one of the new areas of focus was the use of electronic media. That’s hardly surprising, considering that smartphones, tablets, and other screens are now a ubiquitous part of everyday life. But there are many unanswered questions about what impact this is having on adolescent brain development, physical activity levels, relationships with peers and family members, and many other aspects of life.

[illustration of two kids looking at their phones]

Dr. Craig said it’s no longer a debate over whether screen time is good or bad. The technology is here to stay. What we need to figure out now, she said, is how screen time can be used – and what it’s replacing in the lives of young people. The next report will look at sleep and health and how even small amounts of sleep deprivation can have significant impacts on the health of young people. In partner countries in Europe, the new HBSC survey will also address the issue of migration and health and what effects forced migration and displacement have on the young people who are involved. The Canadian team will begin to look at the health experiences of children of military personnel and veterans.

Organizing an international survey of this size and scope every four years is such a massive undertaking that it’s impressive that researchers in dozens of countries that on two continents manage to pull it off. But the countries that have invested in the HBSC study know how valuable it can be, which is why this international network of researchers puts in the hard work to get it done.

Matthew King, the national project co-ordinator with the HBSC survey in Canada who is responsible for data collection, says it can be “incredibly challenging” to develop questions everyone agrees on and receive permission from school boards across the country to administer the survey, which takes about one hour to complete. Mr. King, who has been involved with the survey since Canada started participating in 1990, said the Queen’s-based group has developed important alliances with provincial and territorial governments that helps them ensure the results are truly national.

[illustration of a smiling teenager]For Dr. Craig, it’s a necessary investment in the future. “The strength of it for me is that not only are we learning new things, but we have an opportunity to inform and change policy to support the healthy development of young people in Canada,” she said.


Carly Weeks,Artsci'03, is a health reporter at The Globe and Mail.

Illustrations (c) Katy Dockrill/i2iart.com

[illustration for 'the public health' issue of the Queen's Alumni Review]