Abstract

The objective of the prospective cohort study (the DESKcohort project) is to describe and monitor health, health behaviors, and their related factors among 12 and 19-year-old adolescents schooled at centers of Compulsory Secondary Education or post-compulsory secondary education in Central Catalonia, considering social determinants of health. The DESKcohort survey is administered biannually between the months of October and June, and the project has been running for three years. We have interviewed 7319 and 9265 adolescents in the academic years 2019/20 and 2021/22, respectively. They responded a questionnaire created by a committee of experts, that included the following variables: sociodemographic factors, physical and mental health, food, physical activity, leisure and mobility, substance use, interpersonal relationships, sexuality, screen use and digital entertainment, and gambling. The results are presented to educational centers, county councils, municipalities, and health and third sector entities to plan, implement, and evaluate prevention and health promotion actions that address the identified needs.

Keywords:
Cohort studies; Research design; Public health surveillance; Adolescent; Health behavior; Social determinants of health

Resumen

El objetivo de este estudio prospectivo de cohortes (proyecto DESKcohort) es describir y monitorizar la salud, los comportamientos de salud y sus factores asociados en los adolescentes de entre 12 y 19 años escolarizados en centros de Educación Secundaria Obligatoria o secundaria posobligatoria de la Cataluña Central, considerando los determinantes sociales de la salud. La encuesta DESKcohort se realiza bianualmente, entre los meses de octubre y junio, y el proyecto lleva 3 años en marcha. Se ha entrevistado a 7319 y 9265 adolescentes en los cursos 2019/20 y 2021/22, respectivamente. Respondieron un cuestionario creado por un comité de expertos, que incluía las siguientes variables: sociodemográficas, salud física y mental, alimentación, actividad física, ocio y movilidad, consumo de sustancias, relaciones interpersonales, sexualidad, uso de pantallas y entretenimiento digital, y juegos de azar. Los resultados son presentados a los centros educativos, las diputaciones, los municipios y las entidades sanitarias y del tercer sector para planificar, implementar y evaluar acciones de prevención y promoción de la salud que aborden las necesidades identificadas.

Palabras clave:
Estudio de cohortes; Diseño de investigación; Vigilancia de salud pública; Adolescentes; Comportamientos de salud; Determinantes sociales de la salud

Introduction

Adolescence is characterized by risk-taking and experimentation of new environments and behaviors, and health habits developed during this period have an impact on long-term health and well-being.¹1. Dahl RE. Adolescent brain development: a period of vulnerabilities and opportunities. Keynote address. Ann N Y Acad Sci. 2004;1021:1-22.^,22. Barkin SL, Smith KS, DuRant RH. Social skills and attitudes associated with substance use behaviors among young adolescents. J Adolesc Health. 2002;30:448-54. These behaviors, such as alcohol consumption or tobacco use, are not only related to individual factors, but also to social factors.³3. Teixidó-Compañó E, Sordo L, Bosque-Prous M, et al. Individual and contextual factors related to binge drinking among adolescents in Spain: a multilevel approach. Adicciones. 2019;31:41-51.

4. Bosque-Prous M, Kuipers MAG, Espelt A, et al. Adolescent alcohol use and parental and adolescent socioeconomic position in six European cities. BMC Public Health. 2017;17:646.^-55. Blanch C, Fernández E, Martínez-Sánchez JM, et al. Impact of a multi-level intervention to prevent secondhand smoke exposure in schoolchildren: a randomized cluster community trial. Prev Med. 2013;57:585-90.

However, adolescents have the potential for successful and healthy development because human development is not predefined.⁶6. Lerner RM, Lerner JV, Lewin-Bizan S, et al. Positive youth development: processes, programs, and problematics. J Youth Dev. 2011;6:38-62. In this sense, it is important to collect information on the health status of the population and its determinants.⁷7. Espelt A, Continente X, Domingo-Salvany A, et al. [Monitoring social determinants of health]. Gac Sanit. 2016;30 Supl 1:38-44. Although health behavior monitoring tools for young people have been used over the years, they have mostly focused in urban populations.⁸8. Sánchez-Ledesma E, Serral G, Ariza C, et al. La salut i els seus determinants en adolescents de Barcelona. Enquesta FRESC 2021. Barcelona: Agència de Salut Pública de Barcelona; 2022. However, in rural environments, the social, demographic, and geographic characteristics are distinct, and adolescents behave differently from their peers in urban areas.⁹9. Font-Ribera L, Garcia-Continente X, Pérez A, et al. Driving under the influence of alcohol or drugs among adolescents: the role of urban and rural environments. Accid Anal Prev. 2013;60:1-4. In this context, there is a need to create a surveillance system to monitor health behaviors and their determinants among adolescents in rural settings. Also, health behaviors are mostly investigated through cross-sectional surveys; therefore, it is important to implement longitudinal studies to analyze current health behaviors, how they change in the same adolescents, and their determinants over time. As proposed, in order to carry out a good surveillance of the determinants of health, the social determinants of health must be taken into account.⁷7. Espelt A, Continente X, Domingo-Salvany A, et al. [Monitoring social determinants of health]. Gac Sanit. 2016;30 Supl 1:38-44. The conceptual framework of reference is the Conceptual Framework of the determinants of social inequalities in health of the Commission for the Reduction of Health Inequalities in Spain.

The objective of the prospective cohort study (the DESKcohort project) is to describe and monitor health, health behaviors, and their related factors among 12 and 19-year-old adolescents schooled at centers of Compulsory Secondary Education or post-compulsory secondary education in Central Catalonia (Spain), considering social determinants of health.

Method

The Determinants of Health in Secondary School Students in Central Catalonia (DESKcohort) project is a prospective longitudinal study with successive waves that provide comparable cross-sectional information and allow longitudinal assessment of changes in health behaviors (see table I in online Appendix). Participants are interviewed biannually (Table 1), creating a cohort of adolescents. To link students from one wave to the next and do a follow-up, a unique identifier was created for each student.

The geographical scope of the survey is Central Catalonia, which comprises the counties of Anoia, Bages, Berguedà, Moianès, Osona, and Solsonès, including 165 of the 947 municipalities in Catalonia. In this territory, there are currently 96 educational centers of Compulsory Secondary Education and two centers of post-compulsory education (baccalaureate and formative cycles). The study population consists of students in 2^nd and 4^th of compulsory secondary education (CSE); 2^nd of post-compulsory secondary education (PCSE); and 2^nd of Intermediate Level Training Cycles (ILTC). The DESKcohort project is a collaborative project led by the Fundació Universitària del Bages (FUB) with the participation of the Subdirectorate General for Addictions, HIV, Sexually Transmitted Infections and Viral Hepatitis; the Departament d’Educació; the Centre d’Estudis Epidemiològics sobre el VIH/SIDA de Catalunya (CEEISCAT); the Universitat Oberta de Catalunya (UOC); the Autonomous University of Barcelona; the Universidad de Alicante (UA); and the Consorcio de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP).

Participant recruitment

Before the end of the academic year and prior to data collection (around May-June), we send a letter to all educational centers in the region to invite them to participate in the project. To the ones agreeing to participate, we also send informed consent forms to be signed by the adolescents’ legal guardians. Adolescents over 14 years of age can sign the informed consent themselves, according to the Spanish Official Personal Data Protection Act. Then, at the beginning of the academic year in which the data collection will take place (September), we contact the schools to schedule a date for administering the questionnaire.

Data collection tools and procedures

The initial DESKcohort questionnaire was elaborated by was prepared by researchers from the University of Bages Foundation, the Open University of Catalonia, the CEEISCAT and the Public Health Agency of Catalonia on the basis of other questionnaires on health behaviors during adolescence⁸8. Sánchez-Ledesma E, Serral G, Ariza C, et al. La salut i els seus determinants en adolescents de Barcelona. Enquesta FRESC 2021. Barcelona: Agència de Salut Pública de Barcelona; 2022.^,1010. Agència de Salut Pública de Catalunya, Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya. Estudi de prevalenc¸ a de la infecció per Chlamydia trachomatis i altres ITS en adults-joves (16-35 anys). 2018.

11. Plan Nacional Sobre Drogas. Encuesta Estatal sobre el Uso de Drogas en Enseñanzas Secundarias (ESTUDES), 1994-2018. Madrid: Ministerio de Sanidad Servicios Sociales e Igualdad; 2018.^-1212. González-Casals H, Rogés J, Bosque-Prous M, et al. Comportaments i necessitats de salut de l'alumnat de secundària, cicles formatius i batxillerat de la Catalunya Central. 1a Onada DESKcohort 2019/20. Manresa: Fundació Universitària del Bages; 2022. with high validity and reliability, from studies with a long track record (see table II in online Appendix).¹³13. Liskola J, Haravuori H, Lindberg N, et al. AUDIT and AUDIT-C as screening instruments for alcohol problem use in adolescents. Drug Alcohol Depend. 2018;188:266-73.

14. Cuenca-Royo AM, Sánchez-Niubó A, Forero CG, et al. Psychometric properties of the CAST and SDS scales in young adult cannabis users. Addict Behav. 2012;37:709-15.

15. Carbonell X, Chamarro A, Oberst U, et al. Problematic use of the internet and smartphones in university students: 2006-2017. Int J Environ Res Public Health. 2018;15:475.^-1616. Clarke A, Friede T, Putz R, et al. Warwick-Edinburgh Mental Well-being Scale (WEMWBS): validated for teenage school students in England and Scotland. A mixed methods assessment. BMC Public Health. 2011;11:487. The successive versions were produced by the scientific committee (http://deskcohort.cat/en/scientific-committee/). The questionnaire had different sections: sociodemographic factors, physical and mental health, food, physical activity, leisure and mobility, substance use, interpersonal relationships, sexuality, screen use and digital entertainment, and gambling (see table I in online Appendix). The scientific committee meets every year to review the questionnaire and decide whether to add a section with new questions or the required improvements between waves. For example, in the 2020/21 academic year, questions on COVID-19 were introduced.

Data collection is performed biannually between the months of October and June, corresponding to the academic calendar of the Catalan educational system (1^st wave in the academic year 2019-20; 2^nd wave in the academic year 2021-22). The questionnaire is online and self-administered in the classrooms. It is built with the Redcap (Research Electronic Data Capture) software.¹⁷17. Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: building an international community of software platform partners. J Biomed Inform. 2019;95:103208. Of the students in the 2nd year of ESO and 4th year of ESO, 46.7% were followed.

Ethical aspects

The project was approved by the Ethics Committee of the Universitat de Vic-Universitat Central de Catalunya (UVic-UCC) (96/2019). All the information is stored online in a secure server of the Fundació Universitària del Bages, guaranteeing confidentiality according to the Official Personal Data Protection Act. Data with identification codes are dissociated from the responses to the questionnaire, and only the principal investigator has access to the database with the identification codes.

Data analysis

To analyse the data in the cross-sectional and longitudinal studies we will calculate the prevalence and cumulative incidences of the health conditions or behaviours to be studied, respectively. These prevalence and incidence will be calculated for the total and for each category of the different independent variables. To analyse the relationship between both proportions and the different independent variables we will estimate Poisson regression models with Robust variance obtaining Prevalence Ratios or Relative Risks with their respective 95% confidence intervals.¹⁸18. Espelt A, Mari-Dell'Olmo M, Penelo E, et al. Applied prevalence ratio estimation with different regression models: an example from a cross-national study on substance use research. Adicciones. 2017;29:105-12. All the analyses were performed using STATA17 software.

Results

Sixty-five (71.4%) and 84 (85.7%) centers have participated in the first and second waves, respectively. Table 1 describes the participation rate in each county. In the first wave, 7319 adolescents out of 11943 have participated (61.3%), and in the second wave, 9265 out of 14342 (64.6%). Table 2 describes the characteristics of the participants in the two waves of the DESKcohort project, in terms of sex, course grade, self-reported socioeconomic level, region of residence, and type of educational center (public or private). In the second wave, the prevalence of risky behaviors was higher than in the previous one; in both waves we generally observe that girls have engaged more in less healthy behaviors than boys. Of the 2505 people followed between the 1st and the follow-up period, 56.0% are girls. Also, within the cohort, 56.1% of people have been followed from 2^nd to 4^th year of CSE, 43.6% from 4^th year of CSE to 2^nd year of PCSE or 2^nd year of ILTC. Therefore, we have included a table (see table III in online Appendix) detailing the sociodemographic characteristics of the people who in the first wave were likely to be followed up in the second wave, and the people who are followed up in the 2^nd wave.

Expected outcomes

Young people have different health-related behaviors from adults, but there are few data about youth health needs over the years. The DESKcohort project contributes to the characterization of health behaviors and their changes throughout adolescence and studies the determinants of these changes. Our initial descriptive results indicate that with age, behaviors become less healthy in terms of mental health, wellbeing, physical activity, and diet; and risky behaviors like problematic use of addictive substances increase. Several scientific papers have already been published with DESK data. They have estimated poly-consumption of cannabis and tobacco,¹⁹19. Codinach-Danés E, Obradors-Rial N, González-Casals H, et al. Polydrug use of tobacco and cannabis in a cohort of young people from central Catalonia (2012-2020). Adolescents. 2022;2:350-7. found socio-economic differences in nutrition during COVID-19 confinement,²⁰20. Aguilar-Martínez A, Bosque-Prous M, González-Casals H, et al. Social inequalities in changes in diet in adolescents during confinement due to COVID-19 in Spain: The DESKcohort Project. Nutrients. 2021;13:1577. found social inequalities in skipping breakfast²¹21. Esquius L, Aguilar-Martínez A, Bosque-Prous M, et al. Social Inequalities in breakfast consumption among adolescents in Spain: The DESKcohort Project. Nutrients. 2021;13:2500. and reported a decrease in substance use during COVID-19²²22. Rogés J, Bosque-Prous M, Colom J, et al. Consumption of alcohol, cannabis, and tobacco in a cohort of adolescents before and during COVID-19 confinement. Int J Environ Res Public Health. 2021;18:7849. confinement as well as changes in their mental health and social conditions.²³23. González-Casals H, Vives J, Bosque-Prous M, et al. Gender inequalities in the prevalence of low mood and related factors in schooled adolescents during the 2019-2020 school year: DESKcohort project. J Affect Disord. 2023;333:305-12.^,2424. Folch C, González-Casals H, Colom J, et al. Mental well-being during the COVID-19 confinement among adolescents in Catalonia: the role of demographic and other COVID-related variables. Children. 2022;9:783. So, it is important to identify in what groups and at what ages these changes occur and to detect risk factors to promote healthy behaviors and prevent risky behaviors at later stages.

The DESKcohort is expected to be a leading monitoring project in Catalonia. Between the 1^st and 2^nd waves, the participation increased by 14.3%, and it is expected to continue increasing in the successive ones. This will allow to increase the sample size, increase variability of the sample, and make more accurate inferences on the population.

Discussion

During the first three years of the DESKcohort project, data from 7319 and 9265 students in Central Catalonia have been analyzed for the 2019/20 and 2021/22 school years, respectively. Specifically, we performed a descriptive cross-sectional analysis and an analytic longitudinal analysis of the health behaviors of students in 2^nd and 4^th year of CSE, 2^nd year of PCSE, and 2^nd year of ILTC.

One limitation of this project is the exclusion of adolescents outside the formal educational system; therefore, the representativeness of the sample is limited to students enrolled in educational centers of the territory. However, education in our country is compulsory until the age of 16; therefore, this limitation would be relevant only for adolescents in the 2^nd year of post-compulsory secondary education, a fact that is minimized by including adolescents in the 2^nd year of ILTC. Another limitation is that not all educational centers invited to participate did participate in the end. Moreover, nor all students in the participating educational centers responded to the questionnaire. However, in five of the six counties, in the 2^nd wave over 90% of the educational centers decided to participate in the study (Table 1). The fact that participation may vary in each wave makes it difficult to establish a stable cohort that monitors individuals from 2^nd year of CSE to 2^nd year of PCSE or 2^nd year of ILTC. This can lead to a low follow-up rate throughout the entire academic trajectory, and individuals are followed intermittently without sustained progress. Finally, responses to the questionnaire are self-reported and data could suffer some information bias (for example, because of social desirability and recall bias). However, the questionnaire included questions with a high validity for adolescents: for example, CAST and AUDIT-C¹³13. Liskola J, Haravuori H, Lindberg N, et al. AUDIT and AUDIT-C as screening instruments for alcohol problem use in adolescents. Drug Alcohol Depend. 2018;188:266-73.^,2525. Engs R, Hanson D. Gender differences in drinking patterns and problems among college students: a review of the literature. J Drug Alcohol Educ. 1990;35:36-47. in the case of substance use; and other tests in the case of bullying, mental health, and problematic screen use²⁶26. Carbonell X, Chamarro A, Griffiths M, et al. Uso problemático de Internet y móvil en adolescentes y jóvenes españoles. An Psicol. 2012;28:789-96.

27. Fargues MB, Lusar AC, Jordania CG, et al. Validación de dos escalas breves para evaluar la adicción a Internet y el abuso de móvil. Psicothema. 2009;21:480-5.

28. Dhir A, Chen S, Nieminen M. Psychometric validation of the compulsive internet use scale: relationship with adolescents' demographics, ICT accessibility, and problematic ICT use. Soc Sci Comput Rev. 2016;34:197-214.^-2929. Tennant R, Hiller L, Fishwick R, et al. The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health Qual Life Outcomes. 2007;5:63..

As a strength of the DESKcohort project, we highlight the importance for the region to have monitoring data on the health behaviors of adolescents, and to be able to analyze the effect of contextual factors and social determinants on them, besides the high participation rate and sample size. Also, after each wave, we returned the results to participating educational centers and regional institutions. This allows the educational centers to detect and identify health needs to implement programs adapted to these needs among their students. In addition, a general results report is published biannually, which allows the identification of the health needs of the population. Finally, as a longitudinal monitoring tool, the DESKcohort project complements other information systems to understand health and its determinants among adolescents in Catalonia. It represents a crucial source of information for both local (educational centers, county councils, municipalities, and health and third sector entities) and national policy making institutions (Health Department, Education Department). This allows them to improve health promotion strategies and public health programs to address the identified needs and evaluate future interventions.

Acknowledgements

The authors wish to thank the educational centers that agreed to collaborate with the project and all the students that participated in the study. We are also thankful for the support of the Departament de Salut and the Departament d’Educació de la Generalitat de Catalunya. Additionally, authors are thankful to CERCA Programme/Generalitat de Catalunya for institutional support. Finally, we want to acknowledge the DESK-Cohort Project Working Group (in alphabetical order): Aguilar, Alicia; Àlvarez, Anaís; Angulo-Brunet, Ariadna; Arechavala, Teresa; Baena, Antoni; Barón-García, Tivy; Bartroli, Montse; Borao, Olga; Caberol, Ariadna; Campoy, Mireia; Clotas, Catrina; Colillas-Malet, Ester; Díaz-Geada, Ainara; Espino, Sandra; Esquius, Laura; Gontié, Rémi; Jubany, Júlia; Majó, Xavier; Manera, Maria; Munné, Carles; Muntaner, Carles; Obradors-Rial, Núria; Puigcorbé, Susanna; Riera, Carlota; Saigí, Francesc; Torralba, Mireia; Torruella, Anna; Vaqué, Cristina.

This paper is part of the doctoral Dissertation of J. Rogés at the Universitat Oberta de Catalunya.

Availability of databases and material for replication

Data collected and generated in the DESKcohort project are available free of charge for scientific research. Following the data cleaning, processing and the generation variables of each wave, people can ask for obtain some modules of variables. To obtain data, researchers could be addressed DESKcohort website (http://deskcohort.cat/en/databases/). Then, DESKcohort checks the purpose of the request and the affiliation of the applicant and provides the database, always without the identification code data created. As of January 2023, data from the first waves 1 and 2 are available (transversal and longitudinal data).

References

Appendix A. Supplementary data

Supplementary data associated with this article can be found, in the online version, at doi: 10.1016/j.gaceta.2023.102316..

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