Abstracts

INTRODUCTION

Self-rated health (SRH) is one of the most commonly used health indicators in surveys, because it is an expression of social, psychological, and biological dimensions¹1 Larson JS. The World Health Organization's definition of health: Social versus spiritual health. Soc Indic Res 1996; 38(2): 181-92.. It is considered an easily assessed and understood, robust, valid and reliable measure of physical health status in adults²2 Boardman JD. Self-rated health among U.S. adolescents. J Adolesc Health 2006; 38(4): 401-8. ^{, 3}3 Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38(1): 21-37..

Although most widely used as a proxy of health status among adults, SRH deserves more research attention as a health indicator among adolescents. Studies comparing SRH between adults and adolescents have shown that, while SRH in adults may reflect chronic and acute conditions, in adolescents, it may extend beyond the physical health status, reflecting personal, environmental and socio-behavioral factors²2 Boardman JD. Self-rated health among U.S. adolescents. J Adolesc Health 2006; 38(4): 401-8. ^{, 4}4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97. ^{, 5}5 Page RM, Suwanteerangkul J. Self-rated health, psychosocial functioning, and health-related behavior among Thai adolescents. Pediatr Int 2009; 51(1): 120-5..

Studies on the determinants of adolescent SRH are limited. One of the ancillary studies on this subject in this age group was led by Mechanic and Hansell in 1987, who analyzed longitudinal data from 1,057 adolescents in 19 public schools in the United States. They showed that SRH was related to school achievement, physical activity and psychological well-being. They postulated that SRH among adolescents was defined in a broad and global way, and represented the overall sense of functioning of life⁶6 Mechanic D, Hansell S. Adolescent competence, psychological well-being, and self-assessed physical health. J Health Soc Behav 1987; 28(4): 364-74..

Afterwards, in 1998, Vingilis et al. found that socio-demographic variables, the structural environment, physical health, social factors, lifestyle behaviors and psychological distress were predictors of SRH among adolescents. They considered that some of these variables directly affect self-rated health (e.g. adolescent self-esteem and school performance), while others are indirect (e.g. family structure, which is mediated by the family's financial situation)⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97..

Therefore, the studies in developed countries have shown that SRH in adolescents can extend beyond the symptoms and be an expression of life distress, indicating that this age group defines health broadly and globally⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97.

5 Page RM, Suwanteerangkul J. Self-rated health, psychosocial functioning, and health-related behavior among Thai adolescents. Pediatr Int 2009; 51(1): 120-5.

6 Mechanic D, Hansell S. Adolescent competence, psychological well-being, and self-assessed physical health. J Health Soc Behav 1987; 28(4): 364-74.

7 Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health 2008; 36(1): 12-20.

8 Karademas EC, Peppa N, Fotiou A, Kokkevi A. Family, school and health in children and adolescents: findings from the 2006 HBSC study in Greece. J Health Psychol 2008; 13(8): 1012-20.

9 Vilhjalmsson R. Effects of Social Support on Self-Assessed Health in Adolescence. J Youth Adolesc 1994; 23(4):437-52.

10 Heard HE, Gorman BK, Kapinus CA. Family structure and self-rated health in adolescence and young adulthood. Popul Res Policy Rev 2008; 27(6): 773-97. ^{- 11}11 Call KT, Nonnemaker J. Socioeconomic disparities in adolescent health: contributing factors. Ann N.Y. Acad Sci 1999; 896: 352-5.. Considering that the social environment influences SRH in adolescents, it is necessary to understand how the social environment may influence the health of this age group. Then, the objective of this exploratory study was to understand which individual and socio-environmental characteristics can influence self-rated health among Brazilian adolescents in a large urban center.

METHODS

BEAGÁ HEALTH STUDY

The Beagá Health Study (Estudo Saúde em Beagá) is a population-based household survey conducted by the Observatory for Urban Health of Belo Horizonte City (OSUBH), in 2008-2009. The sample size (4,500 households) was defined based on estimates from previous research. The number of households selected was the one that produced a maximum relative error of 15% at a confidence level of 95% to the estimated proportion of variables selected (prevalence estimated between 17 and 22%). The survey focused on two of the nine administrative districts of Belo Horizonte city (Barreiro and West), with a population of about 250,000 people each and a total geographic area of 33.16 km². The sample was selected using stratified three-stage cluster sampling, including census tracts as the first level, households as the second and residents as the third level.

The sample strata were defined according to the Health Vulnerability Index (HVI)¹²12 Braga LS, Macinko J, Proietti FA, César CC, Lima-Costa MF. Diferenciais intra-urbanos de vulnerabilidade da população idosa. Cad Saúde Pública 2010; 26(12): 2307-15., an index created by combining social, demographic, economic and health indicators from each census tract. Census tracts are defined by the Brazilian Census Bureau and include an average of 1,000 residents each. In the first stage, 150 census tracts were selected from a total of 588 census tracts in the sampling frame. In the second stage, 6,493 households were initially eligible, using a sampling frame from the municipality. After deleting vacant lots, institutional and commercial buildings and eligible participants who were not found after three visits to their homes, 5,436 households remained eligible. The refusal rate was about 25.0%, resulting in a study sample of 4,051 households. In the third stage, one adolescent aged 11 - 17 years and one adult aged 18 years or older were randomly selected to participate within each sampled household¹³13 Friche AA, Diez-Roux AV, César CC, Xavier CC, Proietti FA, Caiaffa WT. Assessing the psychometric and ecometric properties of neighborhood scales in developing countries: Saúde em Beagá Study, Belo Horizonte, Brazil, 2008-2009. J Urban Health 2013; 90(2): 246-61.. A probabilistic sample of 1,042 adolescents at the age range of 11 - 17 years old was studied.

Two self-completed questionnaires were developed according to age. They were based on the UNICEF framework¹⁴14 United Nations Children's Fund. Child poverty in perspective: An overview of child well-being in rich countries. Florence: UNICEF Innocenti Research Centre; 2007. (Report Card nº 7) , on the "Birth Cohorts Follow-up of the Center for Epidemiological Research/Universidade Federal de Pelotas" (CPE/UFPel)¹⁵ 15 Universidade Federal de Pelotas (CPE/UFPel). Centro de Pesquisas Epidemiológicas. Estudo da Coorte de nascimentos de 1993 em Pelotas/RS. Pelotas: Faculdade de Medicina/Universidade Federal de Pelotas; 1993. Available from: http://www.epidemio-ufpel.org.br/site/content/coorte_1993/index.php (Cited Mar 09, 2012).
http://www.epidemio-ufpel.org.br/site/co... and on the "National Survey of School Health" (PeNSE)¹⁶16 Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE-2009). Rio de Janeiro: IBGE; 2009.. The self-reported questionnaire developed for 11 - 13 year olds focused on aspects of well-being, covering factors such as educational well-being, family structure, physical activity, dietary habits and subjective well-being. For adolescents aged 14 - 17 years old, the instrument included, besides the aforementioned factors, questions related to violence, peer relationships, sexual behaviors, as well as tobacco, alcohol and illicit drug use. Also, the adolescents' weight, height and waist circumference were assessed by trained interviewers using standardized procedures¹⁷17 World Health Organization. Physical status: the use and Interpretation of Anthropometry. Geneva: WHO; 1995. (Technical Report Series No. 854) .

VARIABLES

Despite the paucity of research on predictors of SRH among adolescents, the literature review identified several factors that may affect the subjective evaluation of health in this age group. We propose a framework for self-rated health in an urban environment, according to the personal, behavioral and socio-environmental factors that interact and define the subjective health of this age group. This framework is presented in Figure 1.

Dependent variables

The outcome measure, SRH, was assessed by the following question: "In general, do you consider your health: very good, good, reasonable, poor or very poor?" SRH was dichotomized into very poor, poor and reasonable (now called POOR), and very good or good (now called GOOD).

Independent variables

The independent variables according to the theoretical model were organized in the following blocks: sociodemographic, social support, lifestyles, psychological indicators and health indicator.

1. Sociodemographic characteristics

The following characteristics were evaluated: gender, age (11- to 13-years-old and 14- to 17-years-old), and a proxy of socioeconomic status, assessed by minimum wage obtained from the adult questionnaire and categorized into less than five and five or more times the Brazilian minimum wage.

Report of ownership of educational items at home was used as a proxy of socioeconomic status and assessed by the question¹⁴14 United Nations Children's Fund. Child poverty in perspective: An overview of child well-being in rich countries. Florence: UNICEF Innocenti Research Centre; 2007. (Report Card nº 7) : "Which one of the following objects do you have in your home? Dictionary? Calculator? Textbook for school? Desk or table to study? Computer to do school work? Internet? Educational software? A calm or quiet place to study?" The variable was created by adding all items whose score ranged from 0 to 8 and it was categorized as either low socioeconomic status (i.e. scores ranging from 0 to 5) or high socioeconomic status (i.e. 6 to 8).

2. Social support from family and school

Social support from family was comprised by the following variables: family structure (nuclear, single-parent families or stepfamilies); frequency of quarrels in the family (none, few, or many); frequency of meals with parents (less than once a week or twice or more times a week); frequency of conversations with parents (never/rarely, sometimes, or always); family members' interest in the adolescent's school life (no one, parents, or other family member) and relationship with parents. The latter variable was scored from 0 to 6 and categorized as either bad, from 0 to 4, or good, from 5 or 6. The questions used were "My parents are always there for me when I need them"; "They make me feel loved and cared for"; "I can talk to them about any problems I might have"; "We have a lot of arguments"; "They give me the attention that I need"; and "They make me feel bad about myself".

Regarding social support from school, the following variables were examined: satisfaction with school life (likes or does not like school); school type (public or private) and a positive relationship with peers (considers them nice and helpful).

3. Lifestyle

This block included questions about fruit consumption five days a week (at least once, less or more, five days or more per week), frequency of breakfast (every day or never/rarely/sometimes), time spent watching TV (less than 1 hour/day, 2 hours/day; or 3 hours/day or more), time spent per day playing videogames or on the computer (less than 1 hour, 2 hours; or 3 hours or more), and physical activity over the last seven days (active: 300 minutes or more or inactive/insufficiently active: up to 299 minutes). Physical activity was based on the instrument of the National Health Survey of School (PeNSE)¹⁶16 Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE-2009). Rio de Janeiro: IBGE; 2009.. We calculated the time of physical activity accumulated in the last seven days using a combination of the following activities: commuting to school on foot or by bicycle, physical education classes at school and other extracurricular physical activities.

4. Psychological indicators

This block was evaluated using two visual scales: life satisfaction and psychological well-being. The "Satisfaction with Life Scale"¹⁸18 McDowell I, Newell C. Measuring health: A guide to rating scales and questionnaires. New York: Oxford University Press; 1996. uses an ascending scale from 1 to 10 on the day of interview, where the lowest value represents low life satisfaction and the highest value represents high life satisfaction. Subsequently, these responses were categorized as either positive (6 to 10) or negative (1 to 5). The "Faces Scale"¹⁸18 McDowell I, Newell C. Measuring health: A guide to rating scales and questionnaires. New York: Oxford University Press; 1996. was used for psychological well-being. This schematic instrument is composed of seven faces that refer to the prevailing mood over the two weeks prior to the interview. Psychological well-being answers were categorized as very high (face 1), high (face 2), or moderate to low (faces 3 to 7) based on a previous study¹⁹19 Silva RA, Horta BL, Pontes LM, Faria AD, Souza LDM, Cruzeiro ALS, et al. Bem-estar psicológico e adolescência: fatores associados. Cad Saúde Pública 2007; 23(5): 1113-8..

5. Health indicator

Anthropometry was evaluated using body mass index (BMI), which was calculated and classified as percentiles by age group according to the World Health Organization (2007). According to this classification, a BMI below the 3^rd percentile was considered low; between the 3^rd and 85^th percentiles, it was considered adequate or normal; between the 85^th and 97^th percentiles, it was considered as overweight; and above the 97^th percentile, it was considered as obesity. Age (in months) was used as a reference (years * 12 + 6 months)²⁰20 de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bull World Health Organ 2007; 85(9): 660-7..

DATA ANALYSIS

The descriptive and univariate analysis of the SRH were carried out. Variables associated at the level of p ≤ 0.20 were included in the multivariate analysis. All variables of each domain were entered simultaneously in the model.

The analyses were carried out using multiple logistic regressions to obtain odds ratios (OR) and 95% confidence intervals (95%CI). The final analysis included all variables that remained statistically associated with SRH at the level of p ≤ 0.05. To assess the model, we used the Hosmer and Lemeshow Test.

Weights were used to correct differences in the selection probabilities of each individual. All analyses were weighted for the sample design effect through the command SVY of the STATA 10.0 software.

All participants and their parents gave their written consent to participate in the study. The study was approved by the Institutional Review Board of Universidade Federal de Minas Gerais, under case no. ETIC 253/06.

RESULTS

Regarding SRH, 11.2% (n = 120) out of 1,042 adolescents considered their health from very poor to reasonable and 88.8% (n = 915) from good to very good.

Table 1 shows the univariate analysis according to all blocks. In the sociodemographic domain, age and low socioeconomic status (SES) were significantly associated with poor SRH. With respect to the social support sub-blocks, in the family subdomain, single-parent households and stepfamilies, reports of family quarrels, rarely or never engaging in conversation with the parents and bad relationship with parents were all associated with poor health perception. In the school subdomain, dislike of school life was associated with poor health ratings (p ≤ 0,05). In the social involvement subdomain, no factors were associated with SRH. In the lifestyles domain, low consumption of fruits, not eating breakfast and physical inactivity were associated with poor SRH (p ≤ 0.05). Regarding the psychological indicators, all variables were significantly associated with poor SRH. For the physical health domain, only overweight was associated with a poor evaluation.

Table 2 presents results of the multivariate analyses. Given the existence of a significant multicollinearity between "low consumption of fruits" and "not eating breakfast", only "low consumption of fruits" was kept into the multivariate model. The variables were: age 14 - 17 years, low SES, report of quarrels in the family, report of unkind and unhelpful peers, consumption of fruits < 5 times/week, physical inactivity, overweight and low level of life satisfaction. The model showed a very good fit by the Hosmer and Lemeshow Test (p = 0.7654).

Figure 2 presents results of bivariate analysis of reports of quarrels and the relationship of adolescents with their parents. It was noted that adolescents who reported quarrels in the family also reported worse relationships with parents.

DISCUSSION

Our results show that the self-rated health in the population studied can be influenced by individual and family characteristics in a large urban center. SRH among Brazilian adolescents seemed to be a multidimensional indicator associated with five of the six blocks investigated: sociodemographic, social support, lifestyle, psychological and physical health. Brazilian adolescents living in large cities seemed to have similar factors associated with SRH when compared to those living in developed countries, suggesting that, beyond physical health, other factors may influence the SRH.

Regarding sociodemographic factors, older age and socioeconomic status have been described as risk factors for poor self-rated health in Brazilian adolescents, as well as in international studies⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97. ^{, 5}5 Page RM, Suwanteerangkul J. Self-rated health, psychosocial functioning, and health-related behavior among Thai adolescents. Pediatr Int 2009; 51(1): 120-5. ^{, 7}7 Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health 2008; 36(1): 12-20.. In this study, the prevalence of poor SRH increases with age, suggesting that adolescents may become increasingly preoccupied with their health as they age, with similar health perception patterns as adults.

According to UNICEF (2007), the lack of educational and cultural resources should rank alongside lack of income, and that the educational resources of the household, in particular, play a critical role in children's educational achievements¹⁴14 United Nations Children's Fund. Child poverty in perspective: An overview of child well-being in rich countries. Florence: UNICEF Innocenti Research Centre; 2007. (Report Card nº 7) . Therefore, in the present study, the lack of educational items was associated with poor SRH. Previous studies support this association, and showed that the possession of household assets contribute to the perception of satisfactory health²¹21 Martikainen P, Adda J, Ferrie JE, Smith GD, Marmot M. Effects of income and health on GHQ depression and poor self rated health in white collar females and males in the Whitehall II study. J Epidemiol Community Health 2003; 57(9): 718-23. ^{, 22}22 Szwarcwald CL, Souza-Júnior PRB, Esteves MAP, Damacena GN, Viacava F. Socio-demographic determinants of self-rated health in Brazil. Cad Saúde Pública 2005; 21: S54-64..

Karademas et al.⁸8 Karademas EC, Peppa N, Fotiou A, Kokkevi A. Family, school and health in children and adolescents: findings from the 2006 HBSC study in Greece. J Health Psychol 2008; 13(8): 1012-20. say that the major determinant of children's and adolescents' health and psychological indicators is the social environment in which they grow up and live, such as family and school. They showed the strong relationship of family-related factors with children and adolescents' health.

In our study, regarding family context, only one variable remained in the final model: report of quarrels, with a remarkable dose-response with poor SRH. The highest magnitude of association was with many quarrels (OR = 4.53), despite large 95% confidence intervals, due to a relatively small sample (n = 99). These findings corroborate previous studies reporting the importance of the family environment on the self-rated health of adolescents⁸8 Karademas EC, Peppa N, Fotiou A, Kokkevi A. Family, school and health in children and adolescents: findings from the 2006 HBSC study in Greece. J Health Psychol 2008; 13(8): 1012-20. ^{, 10}10 Heard HE, Gorman BK, Kapinus CA. Family structure and self-rated health in adolescence and young adulthood. Popul Res Policy Rev 2008; 27(6): 773-97.. Looking at the univariate association and trying to understand the above finding, we performed a bivariate analysis of reports of quarrels and the relationship of the adolescents with parents. It was noted that adolescents who reported quarrels in the family also reported worse relationships with parents (Figure 2), suggesting that quarrels that occurred in the family might be related to the adolescents and their parents, possibly explaining why the model could not include both variables.

The existence of family conflicts seems to be more important for the self-rated health of adolescents than the other variables in the family domain of the framework proposed (Figure 1). Mechanic and Hansell⁶6 Mechanic D, Hansell S. Adolescent competence, psychological well-being, and self-assessed physical health. J Health Soc Behav 1987; 28(4): 364-74. found that family structure is not associated with physical and psychological symptoms, unlike the existence of family conflicts. Other studies show that adolescents who live in single-parent families have worse health assessments, but they argued that this is not a direct effect, and is probably mediated by family SES and the quality of family interactions¹⁰10 Heard HE, Gorman BK, Kapinus CA. Family structure and self-rated health in adolescence and young adulthood. Popul Res Policy Rev 2008; 27(6): 773-97.. A previous study⁹ 9 Vilhjalmsson R. Effects of Social Support on Self-Assessed Health in Adolescence. J Youth Adolesc 1994; 23(4):437-52.suggested that parental support may be more important than support from peers or other adults to promote a better self-rated health in adolescents.

Adolescents who consider their colleagues as unkind and unhelpful had poorer SRH as compared to their counterparts. This variable is part of the social subdomain of the conceptual model proposed, and can inform about the relationships with colleagues/peers. Some authors show that peer support also influences adolescent health. In particular, relationships with colleagues are one of the most important parts of an adolescent's social life; being supported by friends is associated with better self-rated health⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97. ^{, 9}9 Vilhjalmsson R. Effects of Social Support on Self-Assessed Health in Adolescence. J Youth Adolesc 1994; 23(4):437-52. ^{, 10}10 Heard HE, Gorman BK, Kapinus CA. Family structure and self-rated health in adolescence and young adulthood. Popul Res Policy Rev 2008; 27(6): 773-97..

In the lifestyle domain, unhealthy behaviors, represented by the low consumption of fruit and physical inactivity, were associated with poor SRH. Previous studies³3 Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38(1): 21-37. ^{, 23}23 Peres MA, Masiero AV, Longo GZ, Rocha GC, Matos IB, Najnie K, et al. Auto-avaliação da saúde em adultos no Sul do Brasil. Rev Saúde Pública 2010;44(5): 901-11.

24 Tsai J, Ford ES, Li C, Zhao G, Pearson WS, Balluz LS. Multiple healthy behaviors and optimal self-rated health: findings from the 2007 Behavioral Risk Factor Surveillance System Survey. Prev Med 2010; 51(3-4): 268-74. ^{- 25}25 Harrington J, Perry IJ, Lutomski J, Fitzgerald AP, Shiely F, McGee H, et al. Living longer and feeling better: healthy lifestyle, self-rated health, obesity and depression in Ireland. Eur J Public Health 2009; 20(1): 91-5. with adults have found persistent relationships between dietary habits, physical activity and SRH. In the study based on the Nord-Trøndelag Health Study (HUNT), which included 2,741 adolescents aged 13 - 19 years old, the absence of exercise was associated with poor self-rated health⁷7 Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health 2008; 36(1): 12-20..

In the literature⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97. ^{, 26}26 Barros MBA, Zanchetta LM, Moura EC, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saúde Pública 2009; 43(S2): 27-37., we also found that physical health status is a relevant predictor of SRH among adolescents, despite the influence of personal, socio-environmental, behavioral and psychological factors. Considering BMI as an objective physical health indicator, being overweight remained associated with health perception in the final model. According to the literature, a high BMI may influence the subjective health of individuals⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97..

As expected, adolescents who have lower satisfaction with their life reported worse SRH. The importance of psychological well-being for SRH among adolescents has been demonstrated by most studies dealing with a subjective evaluation of health. These studies highlight the association of low self-esteem⁶6 Mechanic D, Hansell S. Adolescent competence, psychological well-being, and self-assessed physical health. J Health Soc Behav 1987; 28(4): 364-74. and low level of life satisfaction⁸8 Karademas EC, Peppa N, Fotiou A, Kokkevi A. Family, school and health in children and adolescents: findings from the 2006 HBSC study in Greece. J Health Psychol 2008; 13(8): 1012-20. with worse SRH. So, we can add to the body of the literature the same finding for adolescents living in an urban area in a developing country.

The Beagá Health Study seems to have external validity when compared with some estimates provided by the School-based Health Survey (PeNSE, 2009). This school survey interviewed 60,973 adolescents in the 9^th grade of elementary school (13 to 15 years old) in all Brazilian capitals and the Federal District in 2009¹⁶16 Brasil. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar (PeNSE-2009). Rio de Janeiro: IBGE; 2009.. The citywide PeNSE showed that in Belo Horizonte 36.8% of school children reported fruit consumption in five or more days per week, similar to that found herein (35.0%). Likewise, regarding violence in Belo Horizonte, the proportion of adolescents involved in fights (12.9%) was very similar to that found in this study (14.6%). PeNSE, like other studies involving adolescents in Brazil, did not evaluate SRH, which precludes comparison with the results of our study.

Possible limitations include the cross-sectional nature of this study, which does not allow causal or temporal inferences about the associations found²⁶26 Barros MBA, Zanchetta LM, Moura EC, Malta DC. Auto-avaliação da saúde e fatores associados, Brasil, 2006. Rev Saúde Pública 2009; 43(S2): 27-37.. Also, researching SRH poses difficulties because of the need for extensive information that enables researchers to control for potential confounders²⁷27 Franks P, Gold MR, Fiscella K. Sociodemographics, self-rated health, and mortality in the US. Soc Sci Med 2003; 56(12): 2505-14.. Although the present study included information regarding different aspects of adolescent health and its determinants, it did not investigate reported morbidity, but only objectively measured the weights and heights of participants. Thus, a more in-depth analysis regarding the physical health dimensions of SRH was limited.

Importantly, the Odds Ratio can overestimate or underestimate the strength of an association. But the choice of Binary Logistic Regression, which provides the Odds Ratio, was made on the basis of this method being suitable for outcomes considered "rare", as is the case in the present study that the prevalence of poor SRH was equal to 11.2% in the total sample, and 7.63% among teens aged 11 - 13 years old, and 13.71% between adolescents aged 14 - 17 years old.

Moreover, other factors not investigated here may also be associated with subjective health and may interact with the blocks studied, such as relationship with teachers, presence of siblings, reports of co-morbidity, child labor, and/or domestic violence.

CONCLUSIONS

Self-rated health and its determinants, as reported in this study, have been only incipiently evaluated in the literature, despite its importance and contemporaneity. In our study population, SRH was associated with individual and socio-environmental factors, including family, peers, school and neighborhood. This composition reassembles the theoretical framework of child well-being proposed by UNICEF¹⁴14 United Nations Children's Fund. Child poverty in perspective: An overview of child well-being in rich countries. Florence: UNICEF Innocenti Research Centre; 2007. (Report Card nº 7) , which was considered a strong indicator of social inequities²⁸28 Pickett KE, Wilkinson RG. Child wellbeing and income inequality in rich societies: ecological cross sectional study. BMJ 2007; 335: 1080-5..

The findings have important implications for public health and for epidemiological surveys involving adolescents. Self-rated health seems to be a good measure to assess the subjective health of adolescents, reinforcing the findings of the international literature, which demonstrates the importance of this single-item measure used in the assessment of adolescent health⁴4 Vingilis ER, Wade TJ, Adlaf E. What factors predict student self-rated physical health? J Adolesc 1998; 21(1): 83-97.

5 Page RM, Suwanteerangkul J. Self-rated health, psychosocial functioning, and health-related behavior among Thai adolescents. Pediatr Int 2009; 51(1): 120-5.

6 Mechanic D, Hansell S. Adolescent competence, psychological well-being, and self-assessed physical health. J Health Soc Behav 1987; 28(4): 364-74.

7 Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health 2008; 36(1): 12-20.

8 Karademas EC, Peppa N, Fotiou A, Kokkevi A. Family, school and health in children and adolescents: findings from the 2006 HBSC study in Greece. J Health Psychol 2008; 13(8): 1012-20.

9 Vilhjalmsson R. Effects of Social Support on Self-Assessed Health in Adolescence. J Youth Adolesc 1994; 23(4):437-52. ^{- 10}10 Heard HE, Gorman BK, Kapinus CA. Family structure and self-rated health in adolescence and young adulthood. Popul Res Policy Rev 2008; 27(6): 773-97..

REFERENCES

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