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13 Children's health
James Nazroo, Harriet Becher, Yvonne Kelly and Anne McMunn
This chapter reports on the Health Survey findings for children from minority ethnic groups, together with a comparison general population group. Although children aged 2-15 have been covered by the Health Survey since 1995, with a boosted sample of children in the 1997 Health Survey, previous samples have not been large enough to allow detailed analysis of minority ethnic children. Other studies have had similar problems with small sample sizes, so the data reported in this chapter provide the only detailed coverage of health and health behaviours for minority ethnic children in England. In the boosted minority ethnic sample for the 1999 Health Survey, up to three children in selected households were surveyed, rather than up to two children as in previous Health Surveys, to maximise the sample size of minority ethnic children. In households with three or less children, all were included. In households with more than three children, three were randomly selected for inclusion. For the 1999 general population survey the procedure was the same as in preceding years, with up to two children being included from each selected household. The topics covered for children by the Health Survey and reported on in the remaining sections of this chapter are as follows: 13.2 Longstanding illness, acute sickness, self-assessed general health (ages 2-15) 13.3 Psychological health (GHQ ages 13-15, SDQ ages 4-15) 13.4 Respiratory symptoms (ages 2-15) and lung function (ages 7-15) 13.5 Tobacco use (ages 8-15) and cotinine (ages 4-15) 13.6 Alcohol consumption (ages 8-15) 13.7 Anthropometric measures (ages 2-15) 13.8 Blood pressure (ages 5-15) 13.9 Physical activity (ages 8-15 for housework/gardening, ages 2-15 for others) 13.10 Non-fatal accidents (ages 2-15) 13.11 Use of health services, dental visits and use of prescribed medicines (ages 2-15) In general, for children aged 2-12 a parent answered questions on behalf of the child, while children aged 13-15 years answered questions directly. Because of children's need for privacy in respect of their responses for some topics, some information was collected using self-completion questionnaires. In these cases, children responded directly even if they were younger than 12: for example, questions on smoking and drinking alcohol were answered by children themselves down to the minimum age (8) for this topic. In the special case of the Strengths and Difficulties Questionnaire (SDQ), parents completed a self-completion questionnaire about their children for the full age range of 4-15. Throughout the report results for the minority ethnic groups are compared with those for the general population. For this chapter, the 1997 Health Survey sample is usually used for this comparison, because this was a year when the child sample was substantially increased in size. In some cases the relevant topic was not covered in the 1997 Health Survey (use of health services, dental visits and use of prescribed medicines), or the questions were not asked in exactly the same way (alcohol consumption and physical activity). In these cases the general population figures are drawn from the most recent Health Survey year that covered the topic (usually 1999, but for prescribed medication and physical activity it is the 1998 Health Survey, because these topics were not covered for the general population in 1999). In the chapters in this report dealing with adults age standardisation has usually been used, because of the marked differences in the age profiles of the various adult populations. In the case of children, the age profiles were considered sufficiently similar for age standardisation not to be routinely needed. As in the adult chapters, though, tables present key comparisons with the general population in the form of ratios. For some topics in this chapter standardisation is used when making these comparisons. For height and weight the data are age standardised, for lung function and blood pressure the data are both age and height standardised (both lung function and blood pressure are strongly related to height). For these topics, standardisation has been carried out by entering age (and height where it has been included) into linear regression models. The resulting regression coefficients are equivalent to age (and height where it has been included) standardised absolute differences in the mean value for the outcome for the minority ethnic group compared with the general population. 13.2.1 Longstanding and limiting longstanding illness Informants were asked whether they had any longstanding illness, disability or infirmity that had troubled them over a period of time, or was likely to trouble them over a period of time. Those who said that they had such an illness were asked about the nature of the complaint. Illnesses were coded into broad categories that were aggregated into groups which correspond as far as possible to the chapter headings of the Ninth Revision of the International Classification of Diseases (ICD)1 (see Chapter 2, Section 2.2.3.). Informants were also asked whether the condition limited their activities in any way For boys, the prevalence of any longstanding illness ranged from 17% in the Bangladeshi group to 29% in the general population. For girls, the prevalence of any longstanding illness ranged from 11% in the Pakistani and Bangladeshi groups to 27% in the Irish group. The prevalence of limiting longstanding illness among boys ranged from 6% in the Irish group to 11% in the general population, while for girls limiting longstanding illness ranged from 4% in the Chinese group to 9% in the Black Caribbean, Irish and general population groups. Overall, for both boys and girls, Indian, Pakistani, Bangladeshi and
Chinese children were significantly less likely to report any longstanding
illness than children in the general population. For limiting longstanding
illness this remained the case only for Bangladeshi boys and Chinese
girls. Irish boys were also significantly less likely to report a limiting
longstanding illness than boys in the general population. Chapter
2, Section 2.2.1, showed that among adults, too, differences between
minority ethnic groups and the general population were smaller for limiting
longstanding illness than for any longstanding illness. As discussed
in Chapter 2, it is possible that the 'threshold'
at which people in some minority ethnic groups report a longstanding
illness is higher than in the population as a whole, a difference that
might be smaller when the more qualified category of limiting
longstanding illness is used. 13.2.2 Types of longstanding illnesses Respiratory system problems and skin complaints were the most common types of longstanding illness reported. For both boys and girls the highest rates of respiratory system illnesses were reported in the Black Caribbean group (167/1000 for boys, 132/1000 for girls) and Irish group (160/1000 for boys, 113/1000 for girls) and in the general population (164/1000 for boys, 130/1000 for girls). The prevalence of longstanding illnesses involving blood and related organs was most common in Black Caribbean boys (25/1000), but was also relatively high among Pakistani boys (8/1000), Black Caribbean girls (13/1000), Indian girls (20/1000) and Irish girls (9/1000). In boys the prevalence of mental disorders ranged from 24/1000 in
the Black Caribbean group to 1/1000 in the Indian group, with relatively
low rates also reported among Bangladeshi boys (5/1000). In contrast,
for girls the highest rate of mental disorders were reported among the
Bangladeshi group (11/1000), but rates were low overall for girls compared
with boys in all groups. 13.2.3 Acute sickness Acute sickness was defined as having to cut down, in the two weeks preceding the interview, on anything usually done about the house, at school, or in free time, because of illness or injury. Informants reporting an acute sickness were asked for how many days their activities had been limited in this way, as a measure of the severity of the sickness. The prevalence of acute sickness ranged from 5% for Bangladeshi boys
and Chinese girls to 14% for Irish girls and for both boys and girls
in the general population. Black Caribbean, Indian, Pakistani, Bangladeshi
and Chinese boys were less likely to have acute sickness than boys in
the general population. This pattern of reduced risk was found also
for girls, with Black Caribbean, Indian, Pakistani, Bangladeshi and
Chinese girls being significantly less likely to have acute sickness
than girls in the general population. 13.2.4 Self-assessed general health Informants (or their parents, for those aged 12 or less) were asked to rate their general health on a five point scale, from 'very good' to 'very bad'. For boys, the prevalence of 'good'/'very good' health ranged from
84% in the Bangladeshi group to 94% in the Irish group. Both Pakistani
and Bangladeshi boys were significantly less likely to have 'good'/'very
good' health than boys in the general population. The prevalence of
'good'/'very good' health in girls ranged from 87% in the Indian group
to 92% in the Pakistani group and the general population. Differences
among the girls were not statistically significant.
13.3.1 General Health Questionnaire (GHQ12) The General Health Questionnaire (GHQ12) was designed to detect possible psychiatric morbidity in the general population2 and is described in more detail in Chapter 2. The GHQ12 is not recommended for use with children, but has been used successfully with adolescents from age 13,3,4,5 and in the present survey was administered to those aged 13-15. The GHQ12 was designed for English-speaking informants, but it has been translated into more than 30 languages.1,6 Several studies have conducted cross-cultural factor analysis of the GHQ12 and found it to be reliable and to have factor structures consistent with those found in the original studies,7,8,9 but only one of these was conducted in an adolescent sample.10 Nevertheless, as discussed in Chapter 2, Section 2.5.1 there remain doubts about the validity of the GHQ12 for conducting cross-cultural comparisons. This potential problem may be aggravated by the use of translations, as obtaining exact equivalences in several languages of the concepts covered by the questions is difficult to achieve. As in previous Health Survey reports, a threshold score of four or more on the GHQ12 is used to identify possible psychiatric disorder. There was no significant ethnic variation in the likelihood of scoring
high on the GHQ12. For all minority ethnic groups and in the general
population, girls were more likely than boys to have a score above the
threshold of four or more. It should be noted that, because the GHQ12
was only administered to adolescents aged 13-15, the sample sizes are
small, particularly for Chinese children, but also for Irish children,
Black Caribbean boys and Indian girls. 13.3.2 Strengths and Difficulties Questionnaire (SDQ) The Strengths and Difficulties Questionnaire (SDQ) is designed to detect behavioural, emotional or relationship difficulties in children aged 4-15.10 The questionnaire is based on 25 items divided into 5 scales of 5 items each: hyperactivity, emotional symptoms, conduct problems, peer problems and prosocial behaviour. A 'Total Deviance' score, or Total Score, is derived from the sum of scores from the first four of these scales. The SDQ correlates highly with other measures of behavioural and emotional problems in childhood, such as the Rutter questionnaire and the Child Behaviour Checklist.11 The SDQ is shorter than these screening instruments and is the first to include a scale focusing on positive behaviour: the Prosocial Behaviour Scale. The SDQ is currently available in over 40 languages. However, as with the GHQ12, its validity for cross-cultural comparisons remains uncertain and may be aggravated by the use of translations. The SDQ was administered to children aged 4-15 using a self-completion booklet given to their parents. Threshold scores used for the SDQ are those recommended by its author. The scoring system is described in a note at the end of this chapter.12 Threshold scores for each of the scales are described in full in the report of the 1997 Health Survey.13 The prevalence of behavioural and emotional problems as measured by
the SDQ Total Score ranged from 8% (for Irish boys and Chinese girls)
to 22% for Pakistani boys. Pakistani boys and girls and Indian and Irish
girls were significantly more likely to have scored high on the SDQ
Total Score than children in the general population. Other differences
in the SDQ Total Score were not significant.
For the subscales of the SDQ, Pakistani boys were also more likely to score high on the Emotional and Peer Problems scales, but significantly less likely to be Hyperactive, than boys in the general population. Irish boys were significantly less likely to have Emotional Symptoms, Peer Problems and a low Prosocial Score. Bangladeshi boys were significantly more likely to have Peer Problems and a low Prosocial Score. Indian boys were also more likely to have Peer Problems than boys in the general population. Black Caribbean boys were significantly less likely to have a low Prosocial Behaviour Score than boys in the general population. As with Pakistani boys, Pakistani girls were around twice as likely as girls in the general population to have a high Emotional Symptoms Score, and a high score on the Peer Problems scale. Irish girls were more likely to have a high Conduct Problems score than girls in the general population. Similar to the pattern for Bangladeshi boys, Bangladeshi girls were almost two-and-a-half times more likely to have Peer Problems and more than five times more likely to have a low Prosocial Score than girls in the general population. They were also more likely to have a high Emotional Symptoms score, as were Indian girls. Boys were more likely than girls to have behavioural and emotional problems in the Pakistani and Chinese groups and in the general population, although this difference was only statistically significant in the general population. Among Irish children, girls were more likely to have a high SDQ total score than boys, although not significantly. The prevalence of behavioural and emotional problems was fairly equal between boys and girls in the other groups. 13.4 Respiratory symptoms and lung function 13.4.1 Respiratory symptoms and doctor-diagnosed asthma In Britain asthma is the most common chronic childhood disease. The prevalence of asthma has increased in recent decades, peaking around 1993 and 1994, and rates in Britain are amongst the highest in the world.14,15 The causes of asthma and reasons for rises in its prevalence are unclear, but a number of potential explanatory factors have been investigated, including changes in exposure to outdoor16 and indoor17,18 pollution and allergens, smoking, and changes in dietary factors.19 The questions used to determine the prevalence of respiratory symptoms in the Health Survey were asked of all children aged 2-15. They are the same as those used in the International Study of Asthma and Allergies in Childhood (ISAAC),20 and have been validated and extensively used nationally and internationally. For both boys and girls respiratory symptoms were more common in the Black Caribbean and Irish groups and in the general population than in the Indian, Pakistani, Bangladeshi and Chinese groups. With the exception of boys in the general population, the same was true of reported doctor-diagnosed asthma. For boys the prevalence of ever having wheezed ranged from 18% in the Bangladeshi group to 41% in the Black Caribbean group. Ever having wheezed was significantly more common for Black Caribbean boys, and significantly less likely for Indian, Pakistani and Bangladeshi boys, compared with the general population sample. The prevalence of wheezing in the last 12 months, wheezing without a cold and breathlessness when wheezing followed a similar pattern, with reported symptoms always being most common for Black Caribbean boys, slightly lower for Irish boys, with much lower rates for Indian, Pakistani and, particularly, Bangladeshi boys. The prevalence of doctor-diagnosed asthma followed a similar pattern to that of reported symptoms, being highest for Black Caribbean boys (30%) and lowest for Indian (17%), Pakistani (18%), and Bangladeshi (17%) boys. Table 13.7, Figure 13B In girls the prevalence of ever having wheezed was highest in the
Irish group (34%), and lowest in the Bangladeshi group (11%). Wheezing
in the last 12 months and wheezing without having a cold followed a
similar pattern. Breathlessness when wheezing was most common for Black
Caribbean girls (20%) and least common for Pakistani and Bangladeshi
girls (both 5%). The prevalence of wheezing and breathlessness were
significantly lower for Indian, Pakistani, Bangladeshi and Chinese girls
than in the general population. The prevalence of doctor-diagnosed asthma
was significantly higher for Black Caribbean girls (24%), and significantly
lower for Indian (13%), Pakistani (10%), and Bangladeshi (8%) girls
than in the general population. 13.4.2 Severity of respiratory symptoms and impact on daily life The severity of respiratory symptoms was assessed by asking questions
about the frequency of wheezing attacks and whether wheezing interfered
with sleep, speech or daily activities. For frequency of wheezing attacks,
sleep disturbance due to wheezing, and the occurrence of speech limiting
attacks of wheezing, there were no significant ethnic differences for
either boys or girls, although rates for all of these outcomes were
lowest for Pakistani and Bangladeshi girls. In boys there were only
small differences in the prevalence of wheezing which interfered with
daily activities, whereas in girls prevalence ranged from 3% in the
Bangladeshi group to 13% in the Irish group. 13.4.3 Lung function Lung function was assessed in those aged 7-15 by measuring forced expiratory volume in one second (FEV1), forced vital capacity (FVC), and peak expiratory flow (PEF). Measurement of lung function in children younger than seven is known to be more difficult and less reliable. As in previous Health Surveys, the Vitalograph 'Escort Spirometer' was used to measure lung function. For this instrument the manufacturer reports the accuracy of volume measurement as +/-3% or +/- 0.05 litres, which is greater, and of flow measurement as +/- 5%. The measurement technique involves a maximum inspiration followed by a forced expiration (for as long as possible) into the instrument. After a demonstration by the nurse, informants were asked to carry out the test up to five times, to allow for practice and technically unsatisfactory attempts. The data presented here are based on the highest values for each of the three parameters (FEV1, FVC, PEF) from any of the technically satisfactory tests, so the values used for a particular informant may not all come from the same test. Full details of the methods used can be found in report of the 1997 Health Survey.21 As lung function is strongly related to height, in addition to showing mean values within groups, age and height standardised regression coefficients (which indicate absolute difference in mean value for the minority ethnic group compared with the general population) are also shown. For boys mean FEV1 was 2.38 litres in the general population, while
among the minority ethnic groups it ranged from 2.08 litres in the Bangladeshi
group to 2.31 litres in the Irish group. Regression coefficients adjusted
for age and height showed that for Bangladeshi, Indian and Black Caribbean
boys mean FEV1 was significantly lower (by 260, 240 and 140
ml respectively) than for boys in the general population. In girls mean
FEV1 was 2.25 litres in the general population, and for the
minority ethnic groups it ranged from 1.91 litres in Bangladeshi girls
to 2.39 litres in the Irish group. Regression coefficients adjusted
for age and height show that mean FEV1 was again significantly lower
in Bangladeshi (by 310 ml), Indian (by 240 ml) and Black Caribbean (by
110 ml) groups, and also significantly lower for Pakistani (by 270ml)
and Chinese (by 220 ml) girls (although findings for Chinese girls are
based on a small sample), than in the general population. In boys mean FVC was 2.78 litres for the general population and for
the minority ethnic groups FVC ranged from 2.38 litres in Bangladeshi
boys to 2.73 litres in the Irish group. Regression coefficients adjusted
for age and height show that mean FVC was significantly lower in Bangladeshi
boys (by 360 ml) and Indian boys (by 300 ml) compared with boys in the
general population. For girls in the general population mean FVC was
2.55 litres with, in the minority ethnic groups, a range from 2.22 litres
for Bangladeshi girls to 2.69 litres for Irish girls. Age and height
adjusted regression coefficients show that FVC was significantly lower
in Chinese girls (by 330 ml), Bangladeshi girls (by 320 ml), Pakistani
girls (by 300 ml), and Indian girls (by 230 ml) compared with girls
in the general population (although findings for Chinese girls are based
on a small sample). In boys mean PEF for the general population was 316 l/min, while in
the minority ethnic groups it ranged from 288 l/min in Bangladeshi boys
to 327 l/min in the Indian group. After adjustment for age and height,
the regression coefficients show that the Bangladeshi boys' mean PEF
was significantly lower (by 23.5 l/min) than those in the general population.
In girls the general population mean PEF was 306 l/min, and for minority
ethnic groups it ranged from 253 l/min in the Bangladeshi group to 317
l/min in the Irish group. After adjusting for age and height, the regression
coefficient shows that the mean PEF was significantly lower in Bangladeshi
girls (by 50.26 l/min), Pakistani girls (by 32.27 l/min), and Chinese
girls (by 17.34 l/min) compared with girls in the general population
(although findings for Chinese girls are based on a small sample). 13.5.1 Self-reported cigarette smoking among those aged 8-15 Information on tobacco use and exposure to tobacco smoke in children was collected by means of both self-reported behaviour (among those aged 8-15) and measurements of the cotinine levels in informants' saliva (among those aged 4-15). This section deals with self-report: cotinine is dealt with in the next section (Section 13.5.2). The Health Survey series has collected information about cigarette smoking among children since 1995. As in previous surveys, information from those aged 8-15 was collected by means of self-completion questionnaires filled in while the interviewer was at the house. Separate self-completion questionnaires were designed for those aged 8-12 and for those aged 13-15. All informants were asked whether they had ever tried smoking a cigarette and how often (if at all) they currently smoked cigarettes. Answers to these questions were used to provide measures of whether children had ever smoked and their current smoking frequency. The use of self-completion methods is intended to allow children to reply without any other household member knowing their responses, which should reduce under-reporting. However, the annual in-school surveys of Smoking, Drinking and Drug Use among Secondary School Children have consistently shown higher reported levels of cigarette smoking than the Health Survey.22 While it is possible that there could be over-reporting in the Schools Survey, the most likely explanation is that the proximity of parents and other household members when the questionnaire is being completed inhibits children's reporting of smoking behaviour in the Health Survey. This interpretation has been supported by the fact that the Schools survey findings are more consistent with the Health Survey's findings on cotinine saliva levels than its findings on self-reported smoking behaviour.23 The implication is that the data on self-reported smoking may underestimate the prevalence of smoking among children. With this reservation, self-report data from the Health Survey nevertheless allows useful comparisons of tobacco use between groups. The proportion of children aged 8-15 reporting having ever smoked
a cigarette ranged among boys from 6% in the Chinese group to 25% in
the Irish group, and among girls from 1% in the Bangladeshi group to
30% in the Irish group. Equivalent figures for the general population
were 19% of boys and 21% of girls. Among Black Caribbean children and
Irish boys the percentage who reported ever having smoked was not significantly
different from that observed in the general population. Irish girls
were significantly more likely, and Indian, Pakistani, Chinese and Bangladeshi
children were significantly less likely, to report having tried smoking
than children in the general population. Differences were particularly
marked for the girls in these groups.
Among both boys and girls in the general population, about 4% reported
that they currently smoked cigarettes, with 2% of boys and 3% of girls
reporting that they smoked once a week or more. Pakistani and Bangladeshi
boys were less likely than other boys to report any current smoking,
while boys in other minority ethnic groups reported levels of current
smoking frequency similar to those in the general population. Indian,
Pakistani, Bangladeshi and Chinese girls were very unlikely to report
that they currently smoked. Black Caribbean and Irish girls reported
similar levels of current smoking frequency to girls in the general
population. Age differences in smoking behaviour Among boys, cigarette smoking prevalence increased with age. In the general
population, 7% of boys aged 8-10 and 27% of boys aged 11-15 reported
having ever tried smoking. This pattern was consistent across all minority
ethnic groups, although it was most marked for Black Caribbean and Irish
boys. For girls in the general population a similar, although slightly more
marked, pattern existed; 4% of girls aged 8-10 and 33% of girls aged
11-15 reported having tried smoking. This finding was replicated among
Black Caribbean and Irish girls (among the latter group it was particularly
noticeable, with 2% of those aged 8-10 and 46% of those aged 11-15 reporting
having tried smoking). The association was also present among Indian,
Pakistani, Bangladeshi and Chinese girls, although for these groups
the proportion smoking in the older age group remained relatively small. Current frequency of smoking was also associated with age; almost
no boys or girls aged 8-10 in the general population reported that they
currently smoked, compared with 6% of 11-15 year old boys and 7% of
11-15 year old girls. Reported smoking frequency among those aged 8-10
in the minority ethnic groups was very similar to that in the general
population. For those aged 11-15 the differences between ethnic groups
reported in the previous section emerged; Pakistani and Bangladeshi
boys aged 11-15 were less likely to report regular or occasional current
smoking, as were Indian, Pakistani and Bangladeshi girls aged 11-15.
However, the small percentages and small base sizes mean that these
differences should be interpreted with caution. Particularly small base
sizes for Chinese children mean that reliable estimates cannot be provided
for Chinese children in this age group. Measurements of cotinine levels were obtained from saliva samples taken from those aged 4-15 . Cotinine is a metabolite of nicotine and is therefore a useful indicator of exposure to tobacco. A cotinine level of 15 ng/ml or more is taken as a fairly accurate criterion of recent tobacco use or exposure. For a discussion of the measurement of cotinine levels in the Health Survey see Chapter 4. The measurement of cotinine levels in the Health Survey provides an objective cross-check on self-reported smoking behaviour, independent of the inaccuracies of recall and of considerations of social acceptability that might affect responses to questions. Saliva cotinine levels can also be useful in detecting exposure to other people's smoking (passive smoking), or to other forms of tobacco use, such as chewing. For boys in the general population, the mean saliva cotinine level was 7 ng/ml.
Levels for Black Caribbean, Indian and Bangladeshi boys were broadly
similar to those in the general population, while levels were significantly
lower for Pakistani, Chinese and Irish boys. The mean saliva cotinine
level for girls was 9 ng/ml in the general population. As with the boys,
levels were similar for Black Caribbean and Bangladeshi girls, and were
significantly lower for Pakistani and Chinese girls. However, in contrast
to the findings for boys, Indian girls' mean cotinine levels were significantly
lower than the general population, while Irish girls showed cotinine
levels that were similar to those in the general population.
Among the general population, 5% of boys had cotinine levels of 15 ng/ml or more. Percentages were significantly lower among Pakistani and Chinese boys, but similar among the other groups. The proportion of girls in the general population with cotinine levels of 15 ng/ml or more was 6%. Percentages were significantly lower among Black Caribbean, Indian, Pakistani and Chinese girls but similar for the Bangladeshi and Irish groups. Cotinine levels and self-reported cigarette smoking Reports of regular cigarette smoking can be compared with the proportion who
have cotinine levels of 15 ng/ml for children aged 8-15 (younger children
were not asked about smoking behaviour). With the exception of Black
Caribbean, Indian, and Pakistani girls, and Chinese boys and girls,
the rate of exposure to tobacco as detected by cotinine levels was much
higher than that detected by self-reports of smoking, with the differences
most marked in the Bangladeshi group. The difference may be a consequence
of under-reporting, passive smoking, or exposure to other forms of tobacco
(such as chewing products). For example, Chapter
4, Sections 4.2.2 and 4.4.2 show that among adults the rate of cigarette
smoking is high for Bangladeshi men relative both to the general population
and to other minority ethnic groups, while the prevalence of tobacco
chewing is high for Bangladeshi men and women.
Cotinine levels by age As with self-reported cigarette smoking, both mean cotinine level and proportions with cotinine levels of 15 ng/ml or more increased with age. This pattern was clear in the general population, for both boys and girls. It was also true for all minority ethnic groups, with the exception of Pakistani boys and girls, and Indian girls, whose overall levels remained low across age groups. Base sizes for Chinese children were too small to allow any comparisons. Questions about drinking alcohol were asked of those aged 8-15. All informants were asked whether they had ever drunk a whole alcoholic drink (not just tasting one) and how often they drank. As children may wish to conceal their drinking behaviour from their parents, all information was provided as part of a self-completion questionnaire in order to increase the confidentiality of their responses. However, there remains a risk with a home interview survey that children will under-report behaviours such as alcohol consumption, because of concerns that a parent will see their answers. As Section 13.5.2 showed, analysis of saliva cotinine levels suggested significant under-reporting of smoking behaviour in this age group despite the use of a self-completion questionnaire, and it is possible that this will have also occurred for self-reported alcohol use. Although the Health Survey does not collect any evidence to support this hypothesis, comparisons with surveys of children's drinking behaviour carried out in schools suggest that a home-based interview under-reports alcohol use as well as smoking.22 Among those aged 8 to 15 in the general population, 40% of boys and 32% of
girls reported ever having drunk alcohol. Numbers were lower than this
(between 8% and 18%) among Indian and Chinese groups, and even lower
among Pakistani and Bangladeshi children, where only 1%-2% reported
having drunk alcohol. Observed percentages for Black Caribbean and Irish
children were similar to those in the general population. Among both boys and girls in the general population, experience of
drinking increased with age; 17% of boys and 10% of girls aged 8-10
reported ever having drunk alcohol, compared with 54% of boys and 47%
of girls aged 11-15. A similar pattern was evident among Black Caribbean,
Indian, Chinese and Irish children. Levels of reporting drinking alcohol
in the Pakistani and Bangladeshi groups remained very low (1%-2%) across
age groups and for both boys and girls. The heights and weights of children were measured and BMI was derived in the standard way: weight (kg) divided by the square of height (m2). For a description of the methods used to measure height and weight see Chapter 6. Both height and weight are, of course, strongly related to age, so, in addition to showing mean values within groups, age-standardised regression coefficients (which indicate absolute difference in mean value for the minority ethnic group compared with the general population) are also shown. 13.7.1 Height In boys mean height ranged from 127.5 cm in the Pakistani group to 137.1 cm
in the Black Caribbean group. Age-standardised regression coefficients
show that on average Black Caribbean boys were significantly taller
(by 2.27 cm) than boys in the general population, while Bangladeshi
and Chinese boys were on average significantly shorter than those in
the general population (by 2.15 cm and 2.18 cm respectively). For girls
mean height ranged from 129.4 cm in the Bangladeshi group to 132.6 cm
in the Black Caribbean group. Age-standardised regression coefficients
show that on average Black Caribbean girls were significantly taller
(by 2.65 cm) than girls in the general population. Girls in three minority
ethnic groups were on average significantly shorter than girls in the
general population: Indian (by 1.57 cm), Bangladeshi (by 3.00 cm), and
Chinese (by 3.99 cm). 13.7.2 Weight
Boys' mean weight ranged from 30.6 kg in the Bangladeshi group to 36.2 kg in the Indian and Black Caribbean groups. After adjustment for age the regression coefficients show that Bangladeshi boys were on average significantly lighter (by 2.20 kg) than boys in the general population. The weight range in girls ranged from 30.9 kg in the Bangladeshi group to 13.7.3 BMI In boys mean BMI ranged from 17.1 kg/m2 in the Bangladeshi
group to 18.4 kg/m2 in the Indian group. Compared with the
general population, mean BMI was high among Black Caribbean and Indian
boys, while for Bangladeshi boys mean BMI was lower than for boys in
the general population. In girls BMI ranged from 17.7 kg/m2
in the Chinese group to 13.8.1 Measuring children's blood pressure Measurement of blood pressure in children aged 5-15 was introduced to the Health Survey in 1995 and has been repeated in each subsequent survey. See Chapter 7 for a discussion of the methods used to collect blood pressure for the Health Survey. Blood pressure is known to have a stronger relationship with age, height and weight in children than in adults.24,25,26 This is reflected in the most recent guidelines on high blood pressure in children, which take account of both specific age-year and height percentile.27 Consequently, as well as reporting observed values, blood pressure values in this chapter have also been adjusted for age and height using linear regression (the regression coefficients indicate absolute difference in mean value compared with the general population). Currently, the guidelines which are most widely used for blood pressure in children are those published in 1996 by the National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents in the US.7 Because body size is the most important determinant of blood pressure in childhood and adolescence, the Working Group created age-, sex- and height-specific blood pressure curves based on ten mixed-ethnicity samples of American children. These 1996 guidelines define high blood pressure as values above the 95th percentile of a child's age-, sex- and height-specific curve. High normal rates fall between the 90th and 95th percentiles. In the light of these guidelines, the 90th and 95th percentiles are included in the blood pressure tables for this chapter. 13.8.2 Systolic blood pressure (SBP) Among boys, observed mean SBP ranged from 109.3 mmHg in the Irish group to
113.5 mmHg in the Indian group. After controlling for age and height
using linear regression, Pakistani boys had significantly higher mean
SBP, almost 3 mmHg higher, than boys in the general population. Irish
boys' mean SBP was nearly 2 mmHg lower than mean SBP for boys in the
general population, although this was of only borderline significance. For girls, observed mean SBP ranged from 108.7 mmHg among Chinese
girls to 111.6 mmHg among Pakistani girls. After controlling for age
and height using linear regression, mean SBP among Black Caribbean girls
was nearly 2 mmHg lower than the SBP of girls in the general population.
There were no significant differences in SBP for any of the other groups
of girls. 13.8.3 Diastolic blood pressure (DBP) As with SBP, Irish boys had the lowest observed mean DBP at 55.8 mmHg. Pakistani
boys had the highest observed mean DBP at 60.9 mmHg. After controlling
for age and height using linear regression, mean DBP was about 4 mmHg
higher among Pakistani boys and about 3mmHg higher among Indian and
Chinese boys than the mean DBP of boys in the general population. For girls, observed mean DBP ranged from 57.7 mmHg among Irish girls
to 60.5 mmHg among Bangladeshi girls. After controlling for age and
height using linear regression, mean DBP was 1.52 mmHg higher for Pakistani
girls and about 3 mmHg higher for Bangladeshi and Chinese girls than
for girls in the general population. 13.9.1 Coverage and methods The health benefits of regular physical activity for people of all ages are long established. The Health Survey has asked children questions about their participation in physical activity since 1997. The original set of questions were modified for the 1998 and 1999 Health Surveys, so that information was gathered about all periods of physical activity, not just those lasting 15 minutes or more. This change means that the 1999 data is not directly comparable with that collected in 1997. Also, the physical activity questions were not asked of the general population in 1999. Consequently, the 1998 general population sample is used as the reference group here. Children's physical activity is more diverse than adults' and therefore more difficult to quantify (for a fuller discussion of methodology see Chapter 8 of the 1997 report).21 Details were collected about the activity of children aged 2-15 for the following categories: sports and exercise, active play and walking. For each of these activity types children (or, for children under 13, their parents) were asked if they had done the activity in the past week, for how many days, and for how long on each day. In addition, children aged 8-15 were asked if they had done any housework or gardening lasting at least 15 minutes a time in the past week. For each type of activity, the proportion of children participating, the mean number of days in the past week and the mean number of hours in the past week are shown. 13.9.2 Participation by children in different physical activities in the past week Walking was the most frequently reported form of physical activity, with 91%
of boys and 92% of girls in the 1998 general population having done
at least one walk of 5 minutes or more in the past week. Other groups
reported similarly high levels of walking in the past week, although
rates were slightly lower for Indian, Pakistani and Chinese children
and Bangladeshi girls. 92% of boys in the general population had participated in active play
for at least 5 minutes over the past week. Slightly fewer Indian, Pakistani
and Bangladeshi boys (87% in each group) reported participating in active
play. The equivalent reported figures for girls were lower across all
groups, ranging from 86% of girls in the general population to 81% of
Indian, Pakistani, Bangladeshi and Chinese girls. Among boys in the general population, 63% reported participating in
sport and exercise for 5 minutes or more over the past week. Similar
figures were observed for Black Caribbean and Irish boys, while figures
were lower for the other minority ethnic groups, ranging from 46% of
Pakistani boys to 59% of Indian boys. As with active play, levels were
lower for girls than boys across all groups, with 56% of girls in the
general population having participated in sport and exercise for more
than 5 minutes in the past week. As with the boys, fewer girls in the
Indian, Pakistani and Bangladeshi groups reported participating in sport
and exercise compared with the general population. Numbers of those aged 8-15 participating in housework or gardening
over the past week were relatively low, with 32% of boys and 36% of
girls in the general population reporting having participated for at
least 15 minutes. Among boys, similar levels were reported across all
groups. However, among girls, Black Caribbean, Indian and Pakistani
girls were more likely, and Chinese girls less likely to report having
participated in housework and gardening than girls in the general population.
13.10.1 Coverage and methods This section covers major and minor non-fatal accidents occurring to children aged 2-15. Major accidents include all those about which a doctor was consulted or a hospital was visited. Minor accidents include all other accidents that caused pain or discomfort for over 24 hours. For major accidents informants were asked to recall how many such accidents they had had in the six months prior to interview. For the most recent major accident informants were asked to give details about how and where the accident occurred. For minor accidents the recall period covered was four weeks, but the analysis presented is based on the number of accidents reported for the last two weeks. The chosen length of the recall period for major and minor accidents is intended to cover periods sufficiently long to generate details of enough accidents to provide robust estimates, but at the same time to be sufficiently short for informants to recall numbers and details of accidents accurately. Nevertheless, there remains a possibility of recall bias, discussed at more length in Chapter 12 and in previous Health Survey reports.21 As informants may have had more than one accident in the period covered by questioning, comparisons are based on the mean number of accidents occurring within a particular population group. These have been calculated as the mean number of accidents occurring per year per 100 children (that is the annual accident rate per 100 children). 13.10.2 Annual accident rates Among boys major accident rates in the Black Caribbean and Irish groups were
similar to those in the general population (32 per 100, 29 per 100 and
31 per 100 respectively). Indian (18 per 100), Pakistani (14 per 100),
Bangladeshi (11 per 100) and Chinese (10 per 100) boys all had rates
that were significantly lower than those for the general population.
For girls the annual major accident rate ranged from 8 per 100 children
in the Pakistani and Bangladeshi groups to 24 per 100 children in the
Black Caribbean group. As in the case of boys, girls in the Black Caribbean
group had rates of major accident that were similar to those for the
general population (22 per 100) and Pakistani (8 per 100), Bangladeshi
(8 per 100) and Chinese (10 per 100) girls had significantly lower rates
of major accidents. However, in contrast to findings for boys, Irish
girls had low rates (12 per 100) and Indian girls had relatively high
rates (20 per 100). Rates of minor accidents varied greatly between minority ethnic groups. For boys the annual rate ranged from 20 per 100 children in the Bangladeshi group to 221 per 100 children in the general population group. For girls the annual rate ranged from 5 per 100 children in the Bangladeshi group to 252 per 100 children in the Irish group. As in the case of major accidents, Black Caribbean children had rates of minor accidents that were not significantly different from those in the general population. Chinese children also had rates that were not significantly different to those for the general population, while boys and girls in the other minority groups (except for Irish girls) had rates that were significantly lower. Given the very large differences between minority ethnic groups in annual minor accident rates, which are partly mirrored for major accident rates, there is a strong possibility that, for some groups at least, there is considerable under-reporting of accidents. 13.10.3 Types of major accident The general patterns reported for all major accidents in the previous section also applied to specific types of accidents, with rates being consistently high in the general population and for Black Caribbean children, and in some instances being high for Indian and Irish boys. For both boys and girls and across all of the groups the commonest types of major accident were those that involved major falls (excluding those occurring while playing sports or exercising) and those occurring during sport or while at play. Indian boys, and boys in the general population, also had relatively high rates of accidents caused by a tool or other implement and Irish boys had a relatively high rate of accidents involving a bicycle. 13.11 Use of health services and prescribed medication 13.11.1 GP consultations Using questions based on the General Household Survey (GHS),28
informants were asked whether they had talked to a doctor in the past
two weeks, other than during a visit to a hospital, on whose behalf
the consultation had been made, whether it was on the NHS or paid for
privately, and whether the doctor consulted was a GP. For both boys
and girls and across all of the groups, most of those who had consulted
a NHS GP within the past two weeks had had only one consultation. Among
boys the proportion consulting a GP in the general population was 11%.
Among the minority ethnic groups it ranged from 5% among Irish boys
to 16% among Pakistani boys. For girls, consultation rates covered a
similar range. In the general population it was 9% and among the minority
ethnic groups it ranged from a rate of 9% in the Bangladeshi group to
16% in the Indian group. Overall, the rate of consultation appeared
to be highest in the Indian and Pakistani groups, though only Indian
girls and Pakistani boys reported consultation rates that were significantly
greater than those for the general population. The only group with significantly
lower consultation rates than those for the general population were
Irish boys.
These findings contrast with those for adults, where consultation rates were higher compared with the general population for both men and women in the Indian, Pakistani and Bangladeshi groups, and for Black Caribbean men (see Chapter 11, Section 11.2.2). The rate of GP consultation was related to age for all groups. Among
boys in each group there was a marked decrease with age in consultation
rates between those aged 2-5 and those aged 6-15. This pattern was also
present for girls, though less marked for the Bangladeshi group and
for the general population. 13.11.2 Visits to the dentist Informants were asked whether they had ever visited a dentist, including
private and NHS dentists, but excluding school dentists. Informants
were also asked the reason for their last visit to the dentist. To provide
an indication of dental health, informants were also asked whether they
had had toothache in the last four weeks. For both boys and girls there
were large variations in the proportion who had ever visited a dentist.
The lowest rates were found among Bangladeshi children (46% for boys
and 45% for girls) and the highest rates were found in the general population
(89% for boys and 88% girls). For both boys and girls all of the minority
ethnic groups had lower consultation rates than the general population.
Differences were not large for Black Caribbean, Indian, Chinese (for
Chinese girls they were not significant) and Irish (for Irish boys they
were not significant) children. But for Pakistani children the rate
of having ever visited a dentist was around 70% of the general population
rate and for Bangladeshi children it was around half of the general
population rate. Responses to the question asking for the reason for the last visit
to a dentist showed a pattern consistent with the rates of ever having
visited a dentist. The last visit for more than 80% of children in the
general population was for a regular check-up. In contrast, less than
half of the last visits for Bangladeshi children had been for a regular
check-up: in this group visits for trouble with teeth were just as common
as those for a check-up. For the other minority ethnic groups the proportion
of last visits that were for a regular check up was on the whole lower,
and often significantly lower, than that for the general population,
but the difference was not large. In the general population the rate of toothache reported for the past
four weeks was similar for boys (5%) and girls (6%). Among the minority
ethnic groups the lowest rate of reported toothache, and a rate similar
to that for the general population, was found among Indian boys and
Bangladeshi girls (at 5%). Indian girls (at 12%) and Irish boys (at
10%) had rates that were significantly higher than those for the general
population. Given the very low rates of visits to the dentist among
Bangladeshi children, it is worth noting that they reported rates of
toothache that were very similar to those reported by children in the
general population.
13.11.3 Hospital attendance Questions derived from the GHS were used to cover hospital attendance.28
Informants were asked whether they had attended an outpatient or casualty
department, or had been admitted to hospital as a day patient or as
an inpatient (overnight or longer), during the last year. Among boys,
the proportion who had been to a hospital outpatient clinic in the past
year ranged from 15% in the Bangladeshi group to 31% in the Irish group.
In comparison with the general population, the proportion was between
a third and a quarter lower in the Indian, Pakistani and Chinese groups,
while for the Bangladeshi group it was almost half that for the general
population. Rates of day patient and inpatient treatment did not vary
greatly among boys. For the girls, the lowest rate of having been to a hospital outpatient
clinic in the past year was found among the Chinese group (11%), although
rates were similarly low among the Pakistani (12%) and Bangladeshi (13%)
groups. Rates among the general population and the Irish and Black Caribbean
groups were more than twice as high as those for the Chinese and Pakistani
groups, and close to twice as high as those for the Bangladeshi group.
The proportion of Indian girls who had been to an outpatient clinic
in the last year was also significantly lower than that for the general
population.
13.11.4 Prescribed medication In addition to information on consultation rates, at the nurse visit
details of the medication taken by informants was recorded. For all
of the groups, among those children taking a prescribed medication very
few reported taking more than two types of medication, and the split
between those taking one type of medication and those taking more than
one type was roughly even. The proportion taking one or more types of
prescribed medication varied from 13%-15% for Pakistani and Indian boys
and girls to 27% for Black Caribbean boys. In comparison with the general
population rates of 21% for boys and 20% for girls, the only significant
differences for taking one or more prescribed medicines were the lower
rates among Indian and Pakistani children.
The types of drugs most frequently taken for both boys and girls and in all
of the groups were those for respiratory symptoms, followed by those
for the skin. Other more commonly prescribed medicines were those for
infections and for eye, ear, nose and throat (combined into one category).
(Data not shown.) References and notes 1 The International Classification of Diseases and Related Health Problems (Ninth Revision),WHO, Geneva 1977. 2 Goldberg D. The Detection of Psychiatric Illness by Questionnaire. Maudsley Monograph No. 21. Oxford: Oxford University Press. 3 Mann AH, Wakeling A, Wood K, Monck E, Dobbs R, Szmukler G. Screening for abnormal eating attitudes and psychiatric morbidity in an unselected population of 15-year-old schoolgirls. Psychological Medicine 1983; 13:573-580. 4 Weyerer S, Elton M, Diallina M, Fichter MM. The principal component structure of the General Health Questionnaire among Greek and Turkish adolescents. Eur Arch Psychiatr Neurol Sci 1986; 236:75-82. 5 D'arcy C, Siddique CM. Psychological distress among Canadian adolescents. Psychological Medicine 1984; 14:615-628. 6 Various studies have demonstrated that average sensitivity (77.6%) and specificity (77.3%) in non-English speaking countries which is slightly lower than in English speaking countries (sensitivity: 82.1%; specificity: 84.3%). 7 Kilic C, Rezaki M, Rezaki B, Kaplan I, Ozgen G, Sagduyu A, Ozturk MO. General Health Questionnaire (GHQ12 & GHQ28):psychometric properties and factor structure of the scales in a Turkish primary care sample. Soc Psychiatry Psychiatr Epidemiol 1997; 32:327-331. 8 Politit PL, Piccinelli M, Wilkinson G. Reliability, validity and factor structure of the 12-item General Health Questionnaire among young males in Italy. Acta Psychiatr Scand 1994; 90:432-437. 9 Gureje O. Reliability and the factor structure of the Yoruba version of the 12-item General Health Questionnaire. Acta Psychiatr Scand 1991; 84: 125-129. 10 Goodman R. The Strengths and Difficulties Questionnaire: A Research Note. Journal of Child Psychology and Psychiatry 1997; 38:581-586. 11 Goodman R, Scott S. Comparing the Strengths and Difficulties Questionnaire and the Child Behaviour Checklist: Is small beautiful? Journal of Abnormal Child Psychology 1999; in press. 12 The SDQ measures 25 attributes, 10 strengths, 14 difficulties and 1 neutral item. The 25 SDQ items are divided into 5 scales (Hyperactivity, Emotional Symptoms, Conduct Problems, Peer Problems and Prosocial Behaviour) made up of 5 items each. Each SDQ item has three possible answers, each of which are assigned a value 0, 1 or 2. The score for each scale is generated by adding up the scores on the 5 items within that scale, producing scale scores ranging from 0 to 10. The Total Deviance score is derived by adding the scores of each of the scales, except the Prosocial Behaviour scale, producing a total score ranging from 0 to 40. See Goodman (1997) for a full discussion of the SDQ. 13 McMunn A, Bost L, Nazroo J, Primatesta P. Psychological Health (Chapter 10) in Prescott-Clarke P and Primatesta P. (eds) Health Survey for England: The health of young people '95-97, The Stationery Office, London, 1998. 14 Central Health Monitoring Unit. Asthma - An epidemiological overview. HMSO, London, 1995. 15 Anderson HR, Butland BK, Strachan DP. Trends in the prevalence and severity of childhood asthma. BMJ 1994; 308:1600-04 16 Andre S, Axelson O, Bjorksten B, Fredriksson M, Kjellman NI. Symptoms of bronchial hyperreactivity and asthma in relation to environmental factors. Arch Dis Child 1998; 63:473-78 17 Infante-Rivard C. Childhood asthma and indoor environmental risk factors. Am J Epidemiol 1993; 137:834-44 18 Warner JA. Environmental allergen exposure in homes and schools. Clin Exp Allergy 1992; 22:1044-45. 19 Seaton A, Goddon DJ, Brown. Increase in asthma: a more toxic environment or a more susceptible population? Thorax 1994; 49:171-174. 20 Jenkins MA, Clarke JR, Carlin JB Robertson CF, Hopper JL, Dalton MF. Validation of questionnaire and bronchial hyperresponsiveness against respiratory physician assessment in the diagnosis of asthma. Int J Epidemiol 1996; 25:597-602 21 Prescott-Clarke P, Primatesta P. (eds.) Health Survey for England: The Health of Young People '95-97. The Stationery Office, London 1998. 22 See for example Jarvis L, Smoking among secondary school children in 1996. The Stationery Office, London, 1997. 23 Hedges B, Jarvis M. Cigarette smoking (Chapter 6) in Prescott-Clarke P and Primatesta P. (eds) Health Survey for England: The health of young people '95-97, The Stationery Office, London, 1998. 24 Chen Y, Rennie DC, Reeder BA. Age-related associations between body mass index and blood pressure: The Humboldt Study. Int J Obesity 1995; 19:825-831. 25 Clarke WR, Woolson RF, Lauer RM. Changes in ponderosity and blood pressure in childhood: the Muscatine Study. Am J Epidemiol 1986; 124:195-206. 26 Kaas Ibsen K. Factors influencing blood pressure in children and adolescents. Acta Paediatr Scand 1985; 74:416-422. 27 National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents. Update on the 1987 Task Force Report on High Blood Pressure in Children and Adolescents: A Working Group Report from the National High Blood Pressure Education Program. Pediatrics 1996; 98:649-658. 28 Living in Britain: results from the 1996 General Household Survey. The Stationery Office, London, 1997. 13.1 Prevalence of longstanding illness and limiting longstanding illness, by minority ethnic group 13.2 Rate per thousand reporting longstanding illness conditions, by minority ethnic group 13.3 Acute sickness, by minority ethnic group 13.4 Self-assessed general health, by minority ethnic group 13.5 GHQ12 score, by minority ethnic group 13.6 SDQ score, by minority ethnic group 13.7 Respiratory symptoms and doctor-diagnosed asthma, by minority ethnic group 13.8 Severity of respiratory symptoms and impact on everyday life, by minority ethnic group 13.9 FEV1, by minority ethnic group 13.10 FVC, by minority ethnic group 13.11 PEF, by minority ethnic group 13.12 Ever smoked cigarettes, by minority ethnic group 13.13 Current frequency of cigarette smoking, by minority ethnic group 13.14 Ever smoked cigarettes, by age within minority ethnic group 13.15 Current frequency of cigarette smoking, by age within minority ethnic group 13.16 Saliva cotinine levels, by minority ethnic group 13.17 Saliva cotinine levels, by age within minority ethnic group 13.18 Reported experience of drinking alcohol, by minority ethnic group 13.19 Reported experience of drinking alcohol, by age within minority ethnic group 13.20 Height, by minority ethnic group 13.21 Weight, by minority ethnic group 13.22 BMI, by minority ethnic group 13.23 Systolic blood pressure (SBP), by minority ethnic group 13.24 Diastolic blood pressure (DBP), by minority ethnic group 13.25 Summary of participation in different activities, by minority ethnic group 13.26 Annual accident rates per 100 children, by minority ethnic group 13.27 Annual major accident rates per 100 children for types of accident, by minority ethnic group 13.28 (NHS) GP consultations in the two weeks before interview, by minority ethnic group 13.29 (NHS) GP consultations in the two weeks before interview, by age within minority ethnic group 13.30 Ever visited dentist, by minority ethnic group 13.31 Reason for last visit to dentist, by minority ethnic group 13.32 Toothache in the last four weeks, by minority ethnic group 13.33 Hospital attendance in the past year, by minority ethnic group 13.34 Number of prescribed medicines taken, by minority ethnic group
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