A study among schoolchildren 11, 13 and 15 years old

This study was part of Denmark's participation in Health Behaviour in School-Aged Children: A WHO Cross-National Study. A total of 4046 pupils in grades 5, 7 and 9 from 45 randomly selected schools from all of Denmark responded to an anonymous questionnaire on self-assessed health, health behaviour, social factors and contact with the school health nurse. The purpose of this study was to use the assessment of the pupils to analyse whether the quality of health dialogue differed according to the sex of the pupils and according to how the school health nurse organized the dialogue.

The results showed that most pupils had experienced health dialogue of high quality. Both boys and girls were mostly positive, but the boys were more positive, and more girls than boys had experienced poor-quality health dialogue. More girls than boys considered the quality of the dialogue to be fair or poor, both when they determined the topic and when the school health nurse did so. It was more important for the boys' than the girls' assessment of quality that they had been able to decide to visit the school health nurse spontaneously. Uncertainty about how the dialogue was organized was the factor most strongly associated with pupils not considering the dialogue to be of high quality. Qualitative interviews with the pupils could investigate these issues in greater detail.

Introduction

Legislation on health promotion schemes for children and adolescents in Denmark (1) requires that pupils be offered a medical examination upon starting school (about 7 years old) and leaving school (about 16 years old) and regular contact and health dialogue with a school health nurse in the intervening years. Such health dialogue can be individual or in groups and can cover topics and problems brought up by pupils, parents, teachers or school health nurses. Borup (2,3,4) has focused on the pupils' assessment of the content of the dialogue, who learns from the dialogue, the benefits to the pupils and the factors that influence whether pupils benefit. Most pupils engage in such health dialogue. Girls, younger pupils and pupils of lower social class discussed more topics (2,3) and learned more from the health dialogue compared with boys, older pupils and pupils of higher social class. The content differed according to sex: more girls than boys discussed being sad and more boys than girls discussed the areas in which they excel. Other researchers (5,6,7) have also found sex differences in pupils' health behaviour. More girls than boys smoke tobacco among 15-year-olds in Denmark (7). More boys than girls assess their health as being good in Denmark (5). Girls have more complaints than do boys (6). Borup (3) showed that being young, being a girl, having frequent headaches and the desire to end schooling after grade 9 are critical factors associated with pupils approaching the school health nurse spontaneously. Borup (3) found that what pupils learn in health dialogue is associated with how satisfied they are with school.

Pupils consider that health dialogue is really positive when they can contribute to deciding the topic of the dialogue, are satisfied about attending school, feel positive about the school environment, are keeping up academically and are healthy (4).

Evaluation of health dialogue is a new research area, and knowledge about other types of activities

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to promote health is therefore relevant. Jensen (8) has investigated pupils' attitudes towards health and health education in Denmark and indicates that, if children are to develop the skills and knowledge that allow them to take action, they have to participate in creating objectives for changing their behaviour. Nevertheless, Jensen says that skills and knowledge are not sufficient. Children will not adopt health promotion objectives until they develop attitudes that these objectives are important for them and have experience showing that adopting the objectives produces results. Jensen's point is in accordance with the principles of Kalnins et al. (9) on empowerment for children.

Empowerment is a multifaceted concept; Kalnins et al. define empowerment as feeling that one has control over one's own health and the prerequisites that determine health. This requires that health promotion activities focus on the key everyday problems in pupils' lives. This should influence the perception of pupils as active participants in health dialogue and not as mere recipients of health information.

Kalnins et al. present three principles for the empowerment of children:

• Children must participate in defining the problems they consider to be important.
• Children and experts must work together to solve the health problems children present as well as make decisions that promote children's health.
• Healthy public policy should support the viewpoints of children.

These three principles can assist in guiding how school health nurses organize health dialogue with children.

Borup (2,3,4) found that pupils said that the quality of health dialogue is optimal when they are able to participate in determining the content. Cooperation and dialogue includes the school health nurses meeting the pupils as full partners and not as the passive recipients of health information and supporting them in making healthy choices. Supportive environments make it easier to carry out healthy decisions in practice.

Borup (10) presented a model for quality inspired by Donabedian (11) in which the results of health dialogue are viewed as a process objective in a model comprising background factors and structure, process and effects. The health dialogue includes processes related to experience, learning and benefits. The effects are the subsequent benefits of the dialogue in the form of reflection, changes in orientation, increased knowledge, active experimentation or changes in health behaviour and thereby improved health. Donabedian says that structure, process and benefit are part of the effect objectives.

Thus, the purpose of this study was to use pupils' opinions to analyse whether the pupils' sex and how school health nurses organized the health dialogue influenced the quality.

Material and methods

The Health Behaviour in School-Aged Children Study was started in 1982 as a cross-national European survey of pupils' health, lifestyles and health behaviour coordinated by WHO (12,13,14). The Study has the following objectives:

• to improve understanding of and to monitor the health and health behaviour of children and adolescents;
• to obtain insight into the influence of school, the family and other social factors on the lifestyles of children and adolescents;
• to influence the development of programmes and policies that promote the health of children and adolescents; and
• to promote interdisciplinary research into the health and lifestyles of children and adolescents through an international network of health researchers.

Denmark participated in the Study surveys in 1985, 1988, 1991, 1994 and 1998 (14).

Twenty-three countries from the European Region of WHO plus Canada participated in the 1993/1994 survey (12). All participating countries used the same questions (translated into national languages) and the same procedure for collecting data to ensure comparability. The 1994 survey was the fourth time that Denmark participated in the Study. The international coordinator of the Study is Candace Currie of the University of Edinburgh. The coordinators for Denmark are Pernille Due and Bjørn Holstein from the University of Copenhagen. Denmark's survey included 4046 pupils from 234 classes in grades 5, 7 and 9 (11, 13 and 15 years old) in 45 randomly selected schools. The data were collected in February and March 1994 using a standardized questionnaire completed anonymously during school. The response rate was 99 pct. of the pupils attending school that day and 91 pct. of all pupils in the 234 classes. Since the survey was anonymous, the nonrespondents cannot be analysed in detail. A stratified representative cluster of schools was selected. Denmark was divided into five regions: 1) the City of Copenhagen, 2) suburbs of Copenhagen, 3) three cities with more than 100 000 inhabitants (Aarhus, Odense and Aalborg), 4) other towns with more than 5000 inhabitants and 5) rural areas including villages. Schools were randomly chosen from each area

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using a list of primary and lower secondary schools, both public and private. Fifty schools were asked to participate and 45 consented. The school board, principal and pupils' council gave their consent before the survey was conducted, and the school health nurse was informed.

Questionnaire

The pupils completed a standardized questionnaire. The responses are the pupils' self-reported assessment of health dialogue and contact with the school health nurse. The pupils followed standardized instructions from their teacher. In addition to the completed surveys, the teacher provided information on the number of pupils in the class, the number present when the survey was conducted and the number of questionnaires submitted. The questionnaire in Denmark had three parts:

• the core questions used in all participating countries every time the survey is conducted (translated into Danish) focusing on health, health behaviour and social factors;
• additional common questions on specific topics;
• the optional questions chosen by Denmark.

The optional questions in Denmark in 1991, 1994 and 1998 focused on pupils' contact with the school health nurse. The common questions for 1993/1994 covered psychosocial adjustment, injuries, the school experience and social inequality. The questions related to the school health nurse were only in Denmark's questionnaire. These questions contained 18 variables on the pupils' opinions of the health dialogue and contact with a school health nurse, the environment surrounding the health dialogue and an open question on the pupils' assessment of health dialogue with their school health nurse. This article focuses on selected data from Denmark's survey in 1994 (13).

The independent variables were sex, age, geographical area, type of family and social class. The geographical area was categorized according to the five categories mentioned previously. The type of family was categorized based on with whom the pupil said he or she lived (parents, siblings, stepparents and others):

• one adult and one child;
• one adult and two or more children;
• two adults and one child;
• two adults and two or more children.

Social class was based on information from the respondent on the parent with the highest social class coded according to categories I to V of the Danish National Institute of Social Research plus a sixth group of families in which the parents were outside the labour market and subsiding on transfer payments.

The independent variable was ''Think about your last dialogue with the school health nurse. Was it: (very good, good, fair, poor, do not know)?'' In addition, the pupils were encouraged to explain in writing what made the health dialogue positive or negative. The predictors were the following questions: ''Could you determine what topic you discussed?'' and ''Did the school health nurse determine what topic you discussed?'' (options: yes, no, do not know). ''Were you alone or together with other pupils?'' (options: alone, together with boys, together with girls, together with both boys and girls). ''Did you decide that you wanted to see the school health nurse or did she or he ask you to come in?'' (I decided, the school health nurse asked, do not know).

The statistical analysis includes bivariate and trivariate contingency tables that combine background factors and predictors. All analyses were tested for homogeneity with chi-square, and significance was set at P¡0.05.

Results

Most pupils considered the health dialogue to be very good or good. Both boys and girls were mostly positive, but the boys were more positive, and more girls than boys considered the quality of the last health dialogue to be fair or poor (Table I).

TABLE 1. ASSESSMENT OF THE QUALITY OF HEALTH DIALOGUE WITH A SCHOOL HEALTH NURSE BY A SAMPLE OF SCHOOLCHILDREN. PER CENT
Assessed quality	Girls (n=2000)	Boys (n=1980)
Very good	26,3	29,7
Good	38,9	41,7
Fair	23,6	17,5
​Poor	​ 4,2	​ 2,9
​Do not know	​ 7,0	8,2​
​	​100 %	​100 %

The percentage of pupils who considered the health dialogue to be fair or poor was positively correlated with the following factors: the pupil did not determine

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 the topic; the school health nurse determined the topic; girls were in a dialogue group with other girls; boys were with girls; and boys and girls said that they did not know whether the school health nurse had asked them to come in or not (Table II).

TABLE 2. FACTORS THAT ADVERSELY AFFECTED THE SELF-ASSESSED QUALITY OF HEALTH DIALOGUE WITH A SCHOOL HEALTH NURSE AMONG GIRLS AND BOYS. PER CENT
	Girls rating health dialogue as fair or poor	Boys rating health dialogue as fair or poor
	%	(n)	p	%	(n)	p
Pupil:
Determined the topic	24	(736)	<0,001	16	(650)	<0,001
Did not determine the topic	44	(566)	33	(668)
Did not know	39	(651)	37	(638)
Nurse:
Determined the topic	38	(771)	<0,001	29	(792)	<0,001
Did not determine the topic	26	(566)	20	(556)
Did not know	39	(603)	37	(601)
Pupil:
Individual dialogue	33	(1049) NS	29	(1063)	¡0,05
Group dialogue with same sex only	37	(811)	29	(745)
Group dialogue with opposite sex only	14	(21)	48	(48)
Group dialogue with others of both sexes	34	(90)	19	(117)
Pupils:
Was asked to come in	34	(1722)	<0,01	27	(1783)	<0,001
Came spontaneously	32	(103)	23	(106)
Did not know	49	(144)	49	(106)

NS: not significant.

The P-values apply to the effect of the factor shown in creating a difference between a self-assessment of very good or good versus fair or poor theat varies from the mean percentage for all the pupils in the group (girls in one column and boys in the other).
The table shows that the opinions of boys and girls as to whether a health dialogue is very good or good versus fair or poor is associated with the factors: pupils' influence on the topics of the health dialogue, influence of the school health nurse on the topics of the health dialogue, whether the pupils participated individually or in groups and whether the pupils were asked to come in or came in spontaneously.

Boys' assessment of the quality of the dialogue was strongly influenced by whether they determined the topic. When the boys did not determine the topic, 33 pct. considered the dialogue to be fair or poor, whereas only 16 pct. considered it fair or poor when they determined the topic. The corresponding percentages for girls were 44 pct. and 24 pct. When the school health nurse determined the topic, the percentages rating the dialogue fair or poor were 38 pct. for girls and 29 pct. for boys versus 26 pct. for girls and 20 pct. for boys when the school health nurse did not determine the topic. When the pupils were uncertain as to who determined the topic, 39 pct. of girls and 37 pct. of boys considered the dialogue fair or poor.

More girls than boys considered the quality of the dialogue to be fair or poor, both when they felt they had determined the topic and when they felt that the school health nurse had done so. In individual dialogue, 33 pct. of girls and 29 pct. of boys said that the quality of the dialogue was fair or poor. When girls were in a group with other girls, the percentage that considered the dialogue fair or poor increased. In mixed-sex groups, girls had nearly twice the proportion of fair or poor dialogue as boys. Boys reported more positive health dialogue than girls when they visited the school health nurse spontaneously, and the boys felt less positive about the dialogue when the school health nurse asked to see them. The girls' opinions of the dialogue were not correlated with whether they came spontaneously or were asked to come in. Forty-nine percent of both sexes considered the dialogue to be fair or poor when they did not know whether they came in spontaneously or were asked to come in.

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Discussion

Most of the respondents considered that the health dialogue was positive, but a large number did not feel this way. The structure of the health dialogue influenced the pupils' opinions of quality among both boys and girls, but boys seemed to have experienced higher quality in the health dialogue than did girls. This was unexpected and paradoxical in relation to other studies showing that girls discuss more topics and learn more from the dialogue (2,3). Borup (4) found that boys tend to have a more positive opinion of a health dialogue when they are either very satisfied or very dissatisfied with school but not if they were in between. This supports the finding that boys benefited from the health dialogue when certain conditions were met. For example, boys found it more important than did girls to determine the topic and to engage in dialogue with both boys and girls. The boys thus considered dialogue in a group with both boys and girls to be of higher quality than did girls. Boys tend to be more oriented towards the group in their play and social interaction than girls, who tend to be more oriented towards relationships (15). Ross-Petersen et al. (5) found that more girls than boys assess their health negatively and that adults seem to teach girls to assess their health more negatively than boys. This phenomenon may influence girls so that they consider health dialogue to be of poorer quality than do boys. Other explanations include girls and boys discussing different types of topics and having different expectations and attitudes. Kolip & Schmidt (6) showed in a 1998 survey of the Health Behaviour in School-Aged Children Study that pupils' health complaints differ according to sex. Boys tend to be more positive towards self-assessed health than are girls but have more back pain and participate in more demanding sports. Girls are generally less positive about their health and have more complaints such as frequent stomachache, headache, insomnia and nervousness. This agrees with Borup's finding that girls discuss more about feeling sad and boys more about the areas in which they excel. The girls' symptoms are more psychosocial than the boys' complaints and therefore do not present such simple and specific opportunities to act to change the situation as with boys. This can be one reason why girls consider the health dialogue to be of poorer quality. This study cannot determine the causal relationships but indicates correlations. 

Pupil or school health nurse determined the topic

The extent to which the pupils determined the topic greatly influenced their assessment of quality. Nevertheless, the pupils' assessment implies that more boys than girls could accept that the school health nurse determined the topic. Several researchers (8,16,17) have found that traditional health education probably does not have the desired effects and are unanimous in emphasizing that the pupils benefit more when they participate in setting the agenda. Several studies (2,16,17,18) show that pupils from lower social classes benefit from both health education and health dialogue with a school health nurse when these pupils contribute to creating the agenda. This is supported by the principles of empowering children and adolescents of Kalnins et al. (9), who indicate that the problems discussed have to arise from children's everyday life to be relevant and for the children to benefit. 

Group versus individual dialogue

Boys considered the quality of health dialogue to increase when they were in a group with other boys and girls. Girls' opinions about quality were more negative when they were in a group with other girls. Girls seemed to be more dissatisfied than were boys. This difference may be related to differences in development (15). The pupils who attend grades 5, 7 and 9 are between 10 and 16 years old and in prepuberty and puberty. Nielsen & Rudberg (15) have studied what happens in school classes and found that teachers have differing expectations for girls and boys. This may also apply to school health nurses, but investigating this hypothesis requires another type of study, such as qualitative interviews. 

Spontaneous or planned dialogue

The likelihood that the quality of the health dialogue was assessed as being fair or poor increased when pupils were asked to come in and increased further when the pupils said that they did not know whether they had been asked to come in or came in spontaneously. More boys than girls had dialogue of high quality, both spontaneous visits and ones they were asked to make. Uncertainty was the factor that was most clearly associated with assessment of poor quality in health dialogue: both uncertainty about who determined the topic and who took the initiative for the dialogue. Since uncertainty had such an adverse effect on quality, making the principles for dialogue more clear would probably contribute to increasing quality. Informing pupils that they can participate in health dialogue is insufficient. The offer needs to be concretized in how the dialogue is organized. This is supported by the principles of empowerment of Kalnins et al. (9): pupils must be partners in health dialogue and not merely recipients of health information.

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Borup (10) has shown that the extent to which the school health nurse is visible in pupils' daily lives influences contact between the nurses and the pupils: pupils and their partners must know what these nurses do if the pupils are to benefit. Lightfoot & Bines (19) indicate that pupils must develop confidence in a school health nurse. As one pupil said, ...'' if you do not know her, then you don't tell her your secrets....'' Bremberg (16,17) and Arborelius (18) argue that voluntary participation increases pupils' interest and their benefits. Municipalities in Denmark are obligated to offer public health nursing to pupils (1). The school health nurses carry out this task within the framework established by each municipality. 

Strengths and weaknesses

The strengths of the survey include: the pupils' perspectives are in focus, the Health Behaviour in School-Aged Children Study has been replicated five times, the survey included a broad cross-section of a large population group (despite the cluster selection), the questions are well tested and the response rate was high.

One weakness is that the survey is cross-sectional and therefore does not show causation but focuses exclusively on correlations. The cluster selection increased the response rate but also the risk for peer influence in the responses, as individual classes and schools with special characteristics among the pupils can disproportionately influence the results. The cluster sampling gives relatively more uncertainty than a random sample of individuals but also a higher response rate. The questions about the school health nurses were not tested but are the same type of questions that the pupils otherwise respond to in the questionnaire. Girls and boys may have responded differently because expectations differ according to sex or because they perceive the questions differently. The pupils could write about what they considered a good health dialogue to be. Their responses support the hypothesis that the pupils understood the questions.

Conclusion and future school health nursing

This study showed the perspectives associated with pupils' opinions about the quality of health dialogue with school health nurses. The boys considered the quality of the dialogue to be higher than did the girls. This phenomenon was somewhat surprising and prompts a search for reasons. About one third of the pupils did not feel that the quality of the dialogue was adequate. Uncertainty was the strongest indicator of poorer perceived quality. These results can contribute to providing school health nurses with a tool for setting new, realistic measurable targets for developing the quality of health dialogue and health-promoting activities. Is it satisfactory that between one third and one fourth of the pupils do not experience high-quality health dialogue? What is a realistic target? How should school health nurses develop the health dialogue so that these pupils have the opportunity to experience high-quality health dialogue? Answering these questions requires that school health nurses practise several alternative methods in carrying out health promotion initiatives among preadolescent and adolescent girls and boys.

Further research aiming at revealing the more fundamental causes of the variation in benefits among pupils can help to explain the paradoxes found in this survey. The mechanisms are not known but can be studied using qualitative methods.

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