A Pilot Study for Socioeconomic Inequalities in Health among Jordanian Adolescents

Background & Objective(s): Socioeconomic inequalities play an important role in health. Although studies report less inequalities in adolescent health compared to other age groups, there may be differences in their health behavior and mental health. This cross-sectional pilot study aimed to analyze these associations. Methods: Using a sample of students (n = 112, aged 13 - 18 years) data were collected from public and private schools in Irbid governorate, Jordan, November, 2018. Measurements included socioeconomic status indicators (education and income of the parents, assessed by the adolescent), the Global School-based Student Health Survey, health behaviors (tobacco use, personal hygiene, dietary behavior), Satisfaction with Life Scale, Center for Epidemiological Studies Depression Scale for Children. Results: The results indicated that there was a significant association between the family affluence and both paternal ( p = 0.003) and maternal educational levels ( p =0.008). There was a relationship between paternal education and not having enough food at home ( p = 0.006), adolescents’ eating fruit per week ( p = 0.037), and washing their hands before eating (p = 0.004). Maternal education level was related to the students’ eating vegetables ( p = 0.011) and fruits ( p = 0.030) per week. The association of family affluence with eating fast food was significant ( p = 0.05). The relationship of depression and family affluence was linear. Conclusion: Our findings suggest that adolescents’ health behavior may dominantly be related to paternal education, while their mental health may be related to family affluence. The data of this study will help in establishing effective and efficient counseling and support intervention programs.


INTRODUCTION
ocioeconomic inequalities play an important role in health. (1)Despite health progress and development into modernity worldwide, inequalities in health continue to exist among populations within the same society and there are inequalities between nations in both developing and developed countries. (2)Health inequalities refer to differences including the access to treatment, prevention, or rehabilitation; inequalities in mortality and morbidity.They often stem from variations in lifestyle and social circumstances. (3)Socioeconomic indicators include social and economic circumstances, level of education, occupation, gender, family income (affluence), and family sizeboth objective and subjective measurements. (4)hile several studies have justified the associations between socioeconomic status (SES) and health across the life course, health inequalities are not consistent through different age groups. (5)Some previous studies support the relative lack of social inequalities (that is a certain level of equalization) in adolescents' health (e.g.occurrence of diseases). (6)However, there might be associations with their health behaviors (such as substance use or dietary habits) or mental and psychosomatic health complaints.While in health behavior, parental schooling seems to be an important determinant, in mental health, subjective family affluence (self-assessed financial situation) may have a greater role. (5,7)dolescents are relatively free of serious illness and their morbidity and mortality rates are less as compared to other parts of the life course; however, there are also considerable biological and psychosocial changes which need severe adjustment. (8)This is the time period of getting familiar with substance use; and also there are changes in S Original Article adolescents' health behaviors, such as dietary habits or sports. (9)Psychosomatic and depressive symptoms tend to increase, particularly among females. (5)Unfortunately, many adolescents do not care about the correct directions for healthy behavior, and health risk behaviors often occur simultaneously. (10)These phenomena can be attributed to neurodevelopmental processes (discrepancy between the prefrontal cortex and limbic system) and adolescents tend to make irrational decisions based on the lack of appropriate risk evaluation and perceived invulnerability. (11)Some recent studies argued that there may be great differences in these reactions depending on social environment and cultural contexts. (12)In addition, recent findings suggest that inequalities in adolescent health (e.g.depression, life satisfaction, self-esteem, problem behaviors) may be rising in Europe (12,14,15) or beyond (16) .
In Jordan, health care should face many challenges in terms of inequalities between different groups of the population according to socioeconomic status including the level of education, affluence, and regional residency. (17,18)In children's health and cognitive development, the family's socioeconomic status plays an important role.Family affluence and higher parental education can be beneficial. (19)However, studies among adolescents in Jordan and nearby countries show considerable controversial results.In a study among Jordanian adolescents aged 12 -17 years, physical activity behavior was associated with higher levels of both paternal and maternal education. (20)A study of Iranian youth suggests that students whose parents had higher education tend to eat more fast foods, while other studies did not confirm this finding. (21)Social inequalities in adolescent mental health (e.g.24) This pilot study is part of a research project on mental health and health behavior among Jordanian adolescents.Therefore, the main objective of the present pilot study was to get a preliminary picture on social inequalities in adolescents' health using a smaller sample of Jordanian students before the large-scale project.This study aimed to test inequality (using parental education and family affluence) in students' health behaviors (namely, their dietary habits and hygienic behavior) and certain indicators of mental health, such as depression, self-esteem and life satisfaction.

METHODS
A descriptive, cross-sectional design was conducted in November 2018.As usual in feasibility studies, we applied a pilot sample (n= around 100).The pilot study was conducted on 112 students aged 13 -18 years.A multistage random sampling technique was used with a selection basis of the type of school (private, public, male, female schools).We selected the students randomly from grades 8-12.Socioeconomic variables included age, gender, class, family affluence, number of siblings, father and mother education.Family affluence was measured by self-assessment of the students identified as charity, low, moderate, accepted, and high.Parental education was assessed as having less than primary education, primary education, secondary education, graduate and postgraduate education.
The modified Arabic version of Global School-based Student Health Survey (GSHS) questionnaire was used to measure health behaviors.The instrument includes 29 items in the four domains of dietary behavior (eight items), personal and oral hygiene (nine items), tobacco use (six items) and physical activity (six items). (25)The validity and reliability of the Arabic version of the GSHS were assessed by numerous studies conducted in different Arabic countries including Jordan. (26)In this pilot phase, variables were chosen as examples from different fields of health behavior.
The Satisfaction with Life Scale contains 5 items designed to measure global cognitive judgments of one's life satisfaction.Participant indicate how much they agree or disagree with each of the 5 items using a 7-point scale that ranges from 1 (strongly disagree) to 7 (strongly agree). (27)The Arabic version of the scale was used. (28)The Cronbach's alpha value of reliability with the current sample was 0.83.
Rosenberg's Self-Esteem Scale contains 10 items that measures global self-worth by measuring both positive and negative feelings about the self. (29)The Arabic version of the scale was applied. (30)The scale is believed to be unidimensional.All items are answered using a 4-point Likert scale format ranging from strongly agree to strongly disagree.The reliability value was 0.65 with the sample.
As a measurement of depression, the Arabic version of Center for Epidemiological Studies Depression Scale for Children (CES-DC) was used. (31,32)The instrument contains 20 items.Each response to an item is scored as follows: 0 = "Not at all", 1 = "A little", 2 = "Some", 3 = "A lot".The (CES-DC) is shown to be a valid and reliable measure of depression.The Cronbach's alpha value was 0.85 with the sample.Study Procedure First, the researcher gave simple explanation of the importance of research, then students had the freedom to participate in research without any pressure from school or parents, and they had the right to refuse to answer any question and to withdraw from the study at any time without any penalties.All students recruited for participating in the study were invited to voluntarily assent and obtain signed consent forms from their parents.On the following day, written consent forms, which were signed by parents, were collected from students by the researchers.Data were collected in the computer labs during the leisure or sports classes for the students through an online survey which was developed by the researchers using Google drive forms.

Statistical analysis
Data were analyzed using IBM, SPSS statistics version 23.Descriptive statistics were used to describe the study demographics using frequencies (No.), percentages (%), means, and standard deviation (SD).Chi-square (χ 2 ) tests, t-tests and ANOVA (F-test) were used to determine statistically significant differences or relationships.The significant level of acceptance was 0.05.

Ethical considerations
This research and all study procedures were approved by the Institutional Review Board (IRB) of University of Szeged, Hungary and the Ministry of Education in Jordan.Informed consents were taken from parents/ guardians of the students.Confidentiality and anonymity were carefully protected and ensured during all stages of the study.

RESULTS
Regarding frequencies of socioeconomic variables in the study sample, frequencies of parents' education seem rather similar.Regarding the self-assessed financial situation, only nine of them reported belonging to the high category, and most students were categorized as moderate.Using Chi-square test, there was a close relationship between family affluence and paternal education (χ 2 = 19.48,p= 0.003) as well as maternal education (χ 2 = 17.34, p= 0.008) (Table 1).Regarding gender differences, more girls ate fruits (χ 2 = 14.43, p< 0.01) and vegetables (χ 2 = 15.51,p< 0.001), while more boys were physically active (χ 2 = 17.41, p= 0.001).No gender differences could be justified in the patterns of drinking carbonated soft drinks or eating fast food, brushing teeth or washing hands before eating, being physically active or lacking food at home (p> 0.05).Although more boys smoked cigarettes than girls (16.4% vs. 6.0%), this difference was not significant due to the small sample size (p= 0.09).
Table 3 presents results of relationship between health behaviors and paternal education.Significant associations were found in three cases.There were more students who reported not having enough food at home and whose parents had lower educational level (χ 2 = 17.99, p= 0.006).Likewise, students whose fathers had higher education reported eating more fruits (χ 2 = 13.42,p= 0.037).They students also reported more frequent washing hands before eating (χ 2 = 15.64,p= 0.004).
Concerning maternal education, there were only two significant results justified by Chi-square test (Table 4).Similar to the role of paternal education, maternal education also played a role in children's fruit consumption (χ 2 =13.99, p=0.030).Difference of vegetable consumption by maternal education was also statistically significant (χ 2 = 16.63,p= 0.011).
Among the results of the relationships between the children's health behavior variables and self-assessed family affluence, only one variable proved to be statistically significant (Table 5).Those belonging to the highest category reported the most frequent consumption of fast food (χ 2 = 20.68,p= 0.047).
In terms of mental health indicators, no gender differences could be justified in depression scores (boys: 27.2, girls: 28.2).However, girls reported higher levels of satisfaction with life compared to boys (t= -4.298, p< 0.001).Likewise, their self-esteem was also higher (t= -3.788, p< 0.001) (data not shown).
Levels of life satisfaction significantly differed according to paternal education.Those whose father had secondary education reported the highest level (F= 7.37, p= 0.001).In terms of maternal education, differences did not reach the statistically significant level (p> 0.05).In levels of depressive symptoms, no gender differences could be detected in either paternal or maternal education.Self-esteem varied only in the case of maternal education.Students whose mothers were highly educated reported the highest level of self-esteem (F= 7.17, p= 0.001) (Table 6).According to family affluence (Table 7), those who assessed themselves as belonging to the highest group, reported the highest level of life satisfaction and the lowest level of depression scores.However, the differences proved to be statistically significant only in the latter case (F= 2,752, p= 0.046).In terms of self-esteem, those who were categorized as accepted reported the lowest level that differed from other categories (F= 3,806, p= 0.012).

DISCUSSION
While at international level there are debates about social inequalities in adolescents' health, in Jordan this field is rather unexplored yet.(7) Recent studies suggest, however, that social inequalities in adolescents' health is underestimated in many domains of adolescent health. (12,15)any studies provided evidence about the relationship between socioeconomic inequalities in health among Jordanian adolescents. (20,22,23)Although in a non-consistent way, results of our study support this evidence.Students who reported not having enough food at home were those whose parents had lower education level.Likewise, students with highly educated fathers and mothers reported eating more fruits, while in vegetable consumption, maternal education was statistically significant.These findings suggest that parental education may play an important role in their children's dietary patterns.This is consistent with other studies, e.g.children who have parents with high education level eat more vegetables and fruit as compared to children who have parents with low and medium levels of education. (33,34)In line with modernization, fast food restaurants become a symbol of wealth; social inequalities in fast food consumptions are rather controversial.Some studies support that children from wealthier families consumed more. (21)Our findings confirm this: those from the highest category of family affluence reported the highest frequencies of fast food consumption.
Besides dietary patterns, certain aspects of hygienic behavior were also related to socioeconomic status.In the current study, most students with highly educated fathers always washed their hands before eating.This is consistent with another study in Turkey which revealed that students whose fathers had a high school degree or higher education had better hand washing skills as compared to those whose fathers had only primary school education. (35)In Jordan, 39.3% of school children aged 6 -12 did not always wash their hands before eating (36) compared to only 25% in the present study.In addition, findings of the current study also suggest that parental (particularly paternal) education plays a role in this skill.Since social inequalities in mental health and psychological well-being seemed relevant for adolescents in earlier studies, (5)(6)(7)12) indicators such as selfesteem, depressive symptoms and satisfaction with life were included in the present study. Som previous studies found evidence for a relationship between socioeconomic inequalities and mental health among adolescents.For example, family economy was a significant predictor of mental health problems as measured across a wide range of symptom dimensions (namely, emotional, conduct or attention problems) among European adolescents.(14,15) Socioeconomic differences may vary by the indicator used but as it seems that family affluence can have a deeper impact than other SES measurements (e.g.paternal education).(37) Results of the present study support this evidence.