Ability to Maintain and Improve Health and Socio-Demographic Correlates among Children in Albania

The study population consisted of a nationwide sample of Albanian schoolchildren attending grades 6–9 (age-group: 12–15 years). The sampling frame (registered schoolchildren pertinent to grades 6–9) is available from the General Directorate of Pre-University Education. WIN-PEPI (http://www.brixtonhealth.com/pepi4windows.html) was used to calculate the sample size based on different hypotheses tapping selected aspects of children’s knowledge and practices regarding healthcare services. Based on conservative assumptions, the minimum required sample size was estimated at around 1,400 participants. However, we decided to invite all registered schoolchildren belonging to grades 6–9 in Albania (N=123,998), as this was an online survey. However, as the survey was available online for the whole duration of September 2022, the number of participants substantially exceeded the minimum required sample size.

At the end of September 2022, when the online survey was closed, there were 7,928 participants (6.4% of all registered schoolchildren in grades 6–9) who had completed the questionnaire. Of these, 97 questionnaires were either partially completed (n=59), or invalid (n=38). The final sample included in the analysis thus consisted of 7,831 schoolchildren (about 54% girls) aged 12–15 years (grades 6–9). Participating children (n=7,928) had similar socio-demographic characteristics (gender, age, place of residence) as the overall number of registered schoolchildren belonging to grades 6–9 (N=123,998).

Data collection consisted of the use of Google Forms (a survey administration platform), and self-administration by the children of an online structured and anonymous questionnaire that was hosted there. The schoolchildren used the computer labs available at their respective schools and/or their personal/family devices (PCs, tablets, or smartphones) to complete the survey.

Health promotion (ability to maintain and improve health) was assessed based on the following four items/statements (all measured using a Likert-scale ranging from 0 [strongly disagree] to 3 [strongly agree]): i)

“Healthy nutrition is important for children’s health and wellbeing”;

A summary score was calculated based on each of the four statements about schoolchildren’s attitudes to health promotion (ability to maintain and improve health). The summary score for each participant ranged from 0 (strongly disagreeing with all four statements on health protection) to 12 (strongly agreeing with all four statements about health protection). In the analysis, the summary score was dichotomized into: “best attitudes” including children who strongly agreed with all four statements (score: 12) vs. “poor attitudes” consisting of children with a range of scores from 0 to 11.

In addition, the questionnaire asked about the children’s knowledge of their rights to healthcare services, barriers to accessing healthcare services, knowledge on obtaining healthcare services, knowledge about the location of healthcare facilities in the children’s respective home areas, and visits/consultations with health professionals, excluding the mandatory vaccination calendar. Potential responses to each of these items were: “yes” vs. “no”.

Socio-demographic information was also collected, including gender (“boys” vs. “girls”), age (in the analysis dichotomized into: “12–13 years” vs. “14–15 years”), place of residence (“urban” vs. “rural” areas), ethnicity (ethnic “Albanians” vs. “Roma/Egyptian” communities), maternal education (in the analysis dichotomized into: “high” vs. “middle/low”), and family economic situation (in the analysis dichotomized into: “not poor” vs. “poor/very poor”).

Fisher’s exact test was employed to compare the distribution of socio-demographic factors between schoolchildren with “best attitudes” vs. those with “poor attitudes” toward health promotion (ability to maintain and improve health) [Table 1]. Likewise, Fisher’s exact test was used to compare the distribution of selected key dimensions on knowledge and practices regarding healthcare services between children with “best attitudes” vs. those with “poor attitudes” toward health protection (Table 2).

Conversely, binary logistic regression was employed to assess the association of attitudes toward health promotion (ability to maintain and improve health) [dependent variable] with socio-demographic characteristics (gender, age, place of residence, ethnicity, maternal education, and family economic situation) [Table 3]. Initially (left panel), crude (unadjusted) odds ratios [OR: “poor attitudes” vs. “best attitudes” toward health promotion (ability to maintain and improve health)], their respective 95% confidence intervals (95%CIs) and p-values were calculated. Next (right panel), all sociodemographic factors were entered simultaneously into the binary logistic regression models and multivariable-adjusted ORs, and their respective 95%CIs and p-values were calculated.

Subsequently (Table 4), all sociodemographic characteristics and the other important dimensions of knowledge and practices regarding healthcare services (knowledge about rights to healthcare; knowledge about obtaining health-care; knowledge about the location of health facilities in their respective home areas; perceived barriers to health-care services; and consultations/visits with a health professional, excluding vaccinations) were entered into the logistic regression models in a backward stepwise elimination procedure with a P-value to exit set at P>0.10. Multivariable-adjusted ORs, their respective 95%CIs and p-values were calculated from the final models. The Hosmer-Leme-show test was used to assess the overall goodness-of-fit of the multivariable-adjusted regression models, and the final model fit the criterion (footnote to Table 4).

For all the statistical analyses, a p-value <0.05 was considered as statistically significant. The Statistical Package for Social Sciences (SPSS, version 19.0) was employed for all the statistical analyses.

The study was approved by the Albanian Ministry of Education and Sport in June 2022. All schoolchildren were informed by their respective teachers about the aim and procedures of the study, and all the aspects of the survey were explained in sufficient detail, including the aim and objectives, the content of all sections of the questionnaire and particularly the aspects related to the anonymity of the survey and the successive aggregated data analysis. Passive consent was sought from the parents through teachers from each of the schools involved.

The main finding of this study, which included a nationwide sample of Albanian schoolchildren aged 12–15 years old, consists of the fact that almost 1/3rd of participants did not exhibit the best attitudes toward health promotion (ability to maintain and improve health). It also found that the best attitudes toward health promotion (ability to maintain and improve health) were positively and significantly related to younger age, a higher maternal education, a more favourable economic situation, and a range of dimensions related to adequate knowledge and practices regarding healthcare services.

The ability to protect and/or maintain health is important for children, since the behavioural patterns instilled during childhood will most likely be carried out in later life, and thus be associated with long-term health outcomes (20,21,22). Children’s health attitudes and behaviour are formed gradually alongside the growing process and under the influence of formal education, experience and interaction with close family members and other individuals and the environment on multiple levels (23), not forgetting the role of the genetic uniqueness of every child, which largely determines their temperament and learning style (24, 25). These complex and dynamic factors will ultimately determine the attitudes, literacy, health literacy, health protection and health maintenance profiles of children, a profile that is unique for every child.

In this context, our findings might also be largely a reflection of such processes occurring in Albanian settings. We found that children of less educated mothers were significantly more likely to have suboptimal attitudes towards health promotion (ability to maintain and improve health) compared to children of highly educated mothers, which is in line with previous research (15).

Children’s attitudes towards health are largely shaped by their parents’ attitudes toward health (26, 27). More specifically, behaviour is determined generally by attitude and social/normative factors, interplaying with the motivation to comply, and changing/adapting to specific situations (28). Since parents’ attitudes are rather stable over time and children have continuous direct experience with them, the attitudes and behaviour of the children are more likely to be influenced by their parents independently of other factors (29). In addition, parenting style also has psychological consequences for children’s behaviour (25, 30), further highlighting the multiple influences of parents’ attitudes/behaviours on children’s attitudes/behaviours.

As for the association of low maternal education level with the suboptimal health attitudes of their children, this might be explained by the association of maternal education with health behaviour and attitudes: lower education among mothers is associated with lower use of health services (31), higher risk of smoking (32), harmful alcohol use (33), lower physical activity (34), poor nutrition (35), poorer mental health (36), and so on, and such practices (and other associated behaviours) will be conveyed to their children. This thus generates a relationship between a mother’s education level and her children’s attitudes to health promotion (ability to maintain and improve health). However, this relationship was weak in the present study (Table 4).

In our study, older children were significantly more likely to have suboptimal attitudes toward health promotion (ability to maintain and improve health) compared to younger children. This finding might also be explained by the parents’ effect on their children’s attitudes, beliefs and behaviours, which tends to diminish as children grow older and other factors take precedence in shaping their attitudes. Indeed, while a child’s behaviour is influenced by their parents’ attitudes and attributes (accounting for 20%–50% of child behaviour variation), children also have the freedom and power to select which aspects of parental input they will attend and conform to (25). Hence, while growing, children learn and are willing to rely more often on other influences rather than their parents’ system of attitudes, beliefs and behaviour, and so they come to rely more and more on their friends (37), or social networks and social support for their wellbeing as they grow older (38, 39).

The inverse significant association of children’s suboptimal attitude toward health promotion (ability to maintain and improve health) with economic situation might also be explained through the influence of parental education, economic status and social class on children’s behaviour, fitting the pathways discussed earlier. The socioeconomic-parenting association is likely to be mediated and moderated by parental knowledge and expectations, parental mental health, access to resources and cultural norms and values (40). Hence, poorer children are more likely to adopt suboptimal attitudes toward health promotion (ability to maintain and improve health).

As expected, significant associations were identified between suboptimal attitudes toward health promotion (ability to maintain and improve health) and children’s knowledge of health rights, knowledge about where to receive healthcare and previous contacts with a health professional. These findings are compatible with the theory of parental influence over their children (26, 27). In addition, children are also able to understand, process and apply information and health information received through varies sources (12). Young children (aged 8–11 years) have considerable knowledge about health, diseases and risks, they are health conscious and have positive attitudes toward health and health promotion (41). Hence, children who pay more attention, or are more interested in knowing about health issues have, logically, the best attitudes toward health promotion (ability to maintain and improve health), in addition to the parental effects.

Our study may have some limitations related to sample representativeness, possibility of information bias, and the study design. Our study included a nationwide sample of schoolchildren aged 12–15 years. Of note, all registered schoolchildren of this age-group were invited to participate over a one-month period (September 2022). During this time period, 6.4% of schoolchildren (N=7,831) completed the online survey, which constitutes a much larger sample than the minimum required sample size (of ≈1,400 participants). Moreover, teachers had no role in the selection process. However, the respondents may still have been self-selected, an issue which may compromise the sample representativeness. Still, there were no significant differences regarding the distribution of socio-demographic factors between survey participants and the overall number of registered schoolchildren attending grades 6–9, which is reassuring. Furthermore, the instrument of data collection consisted of a previously validated, simple and anonymous questionnaire, although the possibility of information bias cannot be excluded completely. In particular, self-assessment of maternal education and especially economic status may have been subject to differential reporting. In addition, the findings from cross-sectional studies are not assumed to be causal.