EUROPEAN JOURNAL OF PUBLIC HEALTH 2001; 11: 437-445
Q U A L I T Y
O F
L I F E
Quality of life among children aged
2-17 years in the five Nordic countries
Comparison between 1984 and 1996
LEENIT. BERNTSSON, LENNART KOHLER *
Keywords: children, comparative study, follow-up, Nordic countries, quality of life
e concept of quality of life (QoL) has gained increasing
importance in the evaluation of health care interventions
and systems of care in comparisons of disease groups and
other subgroups, and in descriptions of populations at a
specific point in time or over time. Recently new
definitions and applications have evolved considering
and evaluating the whole existence of the human being.
The literature covers a range of QoL definitions depending on the context and scientific discipline. In medicine
the focus is on health related QoL, • in philosophy on
'the good life', in economic science on welfare and
distribution,'1"7 in social science on objective and subjective well-being" and in psychology on psychological
well-being. ' T h e definitions may also be classified into
two main categories: objective and subjective. The former
indicates what the good life is whereas the latter indicates
the individual's own perception of it." According to
WHO's cross-cultural definition of QoL, health and QoL
are complementary and overlapping.12 Most of these
definitions are influenced by adult perspectives. The
* L.T. Berntsson', L Kohler1
1 The Nordic School of Public Health, Goteborg, Sweden
Correspondence: L.T. Berntsson, RN, MSc, MPH, The Nordic School
of Public Health, Box 12133, S-402 42 Goteborg, Sweden,
tel +46 31 693977, fax +46 31 691777, e-mail. leem@nhv.se
existing literature on QoL definitions from the child's
point of view suggests that children's health and wellbeing must be seen in its full social, economic and
political context. To reach such a broad goal there is need
for knowledge and research from many professions and
sciences. However, there are few studies of children's
QoL which include the combination of physical, social,
economic and personal factors. Such a broad definition
of QoL was used in a Nordic comparative study by Lindstrom 4 where QoL was defined as the essence of existence
of an individual, group or society as measured objectively
and perceived subjectively. The overall results showed
that Nordic children enjoyed a high standard of living,
that they were healthy, both physically, mentally and
socially, and that the differences between the countries
were small. Since then an economic recession has affected
the Nordic societies followed by social, political and
organisational changes, such as heavily increased unemployment rates, constrained public services and reduced social benefits. It seems that families with children
have suffered mostly by these cuts in social spending but
little is known how their well-being has been affected.15
There are also changes in family patterns. An important
feature of the Nordic family is that there are relatively few
children in each family and relatively many single-parent
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Background: The aim of the study was to analyse children's quality of life (QoL) in the five Nordic countries from
1984 to 1996, a period in which major economic recessions occurred. Methods: The study design was cross-sectional
based on a random sample of 3000 children in each country, aged 2 to 17 years, totalling 15,000 in 1984 and
15,000 in 1996. The data were collected by mailed questionnaires. QoL was analysed for three spheres of life:
external, interpersonal, personal including both factual and perceived variables. The external sphere represented
the socio-economic conditions for the child's family, the interpersonal sphere the structure and the function of the
child's social networks and the personal sphere the psychological well-being of the child. Results: The total QoL for
Nordic children from 1984 to 1996 increased, but there were differences in the development of QoL between the
countries. The objective QoL became better, at the same time the subjective QoL worsened, except in Denmark and
Iceland. The external QoL became better, whereas the interpersonal QoL was nearly unchanged but there were
differences in the development between countries. The personal QoL worsened slightly except for children in Iceland.
The ranking between countries changed. Danish children had the highest subjective and Norwegian children the
highest objective and external QoL. Swedish children had the highest personal QoL. Children 7-12 years had the
highest QoL. Girls had a tendency to higher QoL in all ages. Conclusion: Nordic children still enjoy a high standard
of living in spite of economic constraints, and the prerequisites for a high QoL are fulfilled. Further research is
suggested for clarifying the complex background of these results.
EUROPEAN JOURNAL OF PUBLIC HEALTH VOL. 11 2001 NO. 4
families. The number of divorces has increased from 1984
in all Nordic countries. To determine whether the
societal changes described above have been accompanied
by a change in children's quality of life a similar study was
carried out 12 years later, of the same age groups, and using
the same methods.
Aim
The aim of this study was to:
• analyse the QoL of children from 2 to 17 years in the
Nordic countries and its change from 1984 to 1996,
• analyse similarities and differences in the development
of QoL between the Nordic countries.
MODELS AND METHODS
QoL model
The QoL model of Lindstrom14 is developed from Naess'9
and Kajandi's models and influenced by Allardt's welfare
model. QoL consists of four spheres: global, external,
interpersonal and personal (table. 1). Objective (factual) conditions and perceived subjective satisfaction (expressions,
attitudes, values) are included in all dimensions.
Measures
The questionnaires, which were translated from Swedish
into the other four Nordic languages by researchers and
linguists in respective countries, were tested in pilot
studies in both years. A combined set of variables was used
to study the QoL of children. Each variable had a defined
base level (table 2), which was specified to meet the needs
Table 1 A general quality of life model, life spheres and
dimensions'1
Dimensions
(objective/subjective)
Examples
1 Macro environment
2 Human rights
3 Policies
1 Work
2 Economy
Clean environment
Democratic rights
Culture
Employment
Income
3 Housing
Type of housing
Interpersonal
1 Family
Personal
2 Intimate
3 Extended
1 Physical
2 Mental
3 Spiritual
Structure and function
of social relationships
Spheres
Global
External sphere
a: Lindstrom'4
Growth, development,
activity, self-esteem,
meaning of existence
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Questions
• Has children's QoL generally changed between 1984
and 1996?
• Are there differences in development of QoL in
different countries?
• Are there differences in QoL between the age groups
2-6 years, 7—12 years and 13—17 years?
• Are there differences in QOL between girls and boys?
of children in the Nordic countries.14 The same base
values were used for all countries. All the QoL-indicators
were represented by dichotomous variables, values one
and zero. One means exceeding the base value for a child's
well-being, and zero means that the child does not have
tesources over the base value. The total QoL included all
the spheres, 16 objective and 9 subjective measures.
The external sphere represented the socio-economic status
of the family and included nine variables (table 2). The
dimension work included three indicators: the parents'
education, profession and work satisfaction. Education
was classified into four groups based on the number of
years of education: i) more than 12 years, ii) 12 years, iii)
10-12 years and iv) 9 years or less. The cut-off point for
high/low education was between two and three. Social
class of the parents was based on the present or the last
held main occupation of at least 16 hours/week. A basic
distinction was made between employees and selfemployed, including fanners. The employees were first
divided into white-collat and blue-collar workers and
then into groups on the basis of theit skill level. Three
indicators were used to represent the family's economy:
nationally defined levels of disposable income classified
into six groups, income distribution (income per capita) and
satisfaction with economy. The cut-off point for high/low
income was between the two highest groups and the
others. Type of housing, space (number of rooms/family
size) and own room of the child represented the housing
dimension. The questions of subjective well-being had
alternatives from 'not at all satisfied' to 'satisfied'.
The interpersonal sphere represented the structure and
function of the child's networks and included nine variables. There were three measures of the family dimension:
number of siblings, the parents' available time (full-time
work/part-time work) with the child and satisfaction with
family life. The intimate dimension included family type
(one ot two parents), household size (more than three
persons) and major.negative life events of the child, such
as separation or death of the parents. The extended
networks included the family's support from society
(professional support) and from friends/relatives, and the
parents' satisfaction with their social contacts.
The personal sphere represented the child's psychological
well-being and included seven variables. The dimension
activities included the child's own activities and activities
together with the parents and the parents' satisfaction
with their activities. The measutes of the child's own
activities consisted of eight different items. The choice of
answers for each item was never, once or more times a
year (low activity level), a month, a week or a day (high
activity level). Activities together with the parents consisted of six items and for each item the respondent was
asked to give the frequency of the activity as above.
Further, die respondents were asked about dieir satisfaction
with leisure time. The child's self-esteem was measured
by six indicators: dependent/independent, passive/active,
lonely/not lonely, testless/calm, depressed/happy,
anxious/confident. All die items were scaled from 1-7
and the cut-off point was between 5 and 6.
Quality of life among children aged 2-17 years
The basic mood of the child was described with prevalence of psychosomatic complaints, satisfaction in
school and peer contacts. Psychosomatic complaints were
measured using six items: stomach complaints, headache,
sleeplessness, dizziness, backache and loss of appetite. The
respondents were instructed to make a cross only if the
complaints occurred every or every other week. The
child's satisfaction with nursery school /school/work was
scaled very well, well, not well. Peer acceptance was
measured with an item about being bullied, scaled often,
sometimes or seldom/never.
Variable
External sphere
Education
Profession
Work satisfaction
Statistical analyses
QoL-scores are the sums of simple variables over specific
subsets of QoL indicators. First, means of QoL-scores are
counted for each sphere, for subjective and objective
variables by age, country and year. Second, to compare
the mean scores in groups of children and development
of QoL between the years in respective countries, linear
Nature
Over base level
Under base level
Objective
Objective
12 years or more
White-collar worker
Less than 12 years
Blue-collar worker
Subjective
Objective
Satisfied
Dissatisfied
Two highest income classes
No
Four lowest income classes
Yes
Satisfied
Dissatisfied
Block of flats
Combined disposable income
Poverty (income/family member)
Satisfaction economy
Objective
Subjective
Type of housing
Objective
Detached house
Space
The child has own room
Objective
Objective
One inhabitant per room
Yes
More than one inhabitant per room
Objective
Objective
At least one sibling
An only child
Full-time work of both parents
No
Interpersonal sphere
Number of siblings
Available time
Satisfaction family
Family type
Household size
Life events
Satisfaction friends/relatives
Satisfaction social support
Satisfaction contacts
Personal sphere
Child's activity
Family activity
Activity satisfaction
Self-esteem
Psychosomatic symptoms
Peer acceptance
School satisfaction
a: Lindstrom14
Subjective
Part-time work of at least one parent
Satisfied
Objective
Objective
Cohabiting parents
At least four members
Objective
Subjective
No separation, death of the parents
Satisfied
Satisfied
Subjective
Subjective
Satisfied
Dissatisfied
One-parent family
Less than four members
Separation/death of the parents
Dissatisfied
Dissatisfied
Dissatisfied
Objective
High
Objective
Subjective
High
Low
Low
Subjective
Satisfied
High score
Dissatisfied
Low score
Objective
Objective
No
High
Yes
Low
Subjective
Satisfied
Dissatisfied
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Sampling
Data from two cross-sectional population surveys in the
five Nordic countries were analysed. The studies were
approved by the national ethics committees. The first
survey was performed in 1984 and was repeated in 1996.
In both studies, random samples of about 3,000 children
aged 2-17 years in each country were drawn from the
population registers of the respective National Bureau of
Statistics. Children in institutions were excluded. A
questionnaire was mailed in March 1996, and two
reminders were sent. The parent who was best familiar
with the child's situation was instructed to fill in the
questionnaire, together with the child, if possible. EightyTable 2 Quality of life indicators and base levels0
two percent of respondents were mothers in 1984 and
81% in 1996 but in most cases questionnaires were completed by both parents together with the child. There
were 10,219 completed forms in 1984 and 10,317 in 1996.
The response rates varied between countries, the mean
response rate was 67% in 1984 (Denmark 73%, Finland
83%, Iceland 60%, Norway 56%, Sweden 62%) and 70%
in 1996 (Denmark 69%, Finland 80%, Iceland 68%,
Norway 65%, Sweden 69%). The respondents by country,
age and gender in 1984 and 1996 are shown in table 3. An
analysis of the non-respondents was performed in both
years. There were no differences between respondents
and non-respondents in terms of age and sex but families
with low education (2-3,5%), working class (3-5%) and
one-parent families (3.5-10%) were over-represented
among non-respondents in both years. Otherwise
representativeness of the samples was high.
EUROPEANJOURNALOFPUBLICHEALTHVOL.il 2001 NO. 4
regression analysis and descriptive statistics controlling
for age and gender were used. Third, for multiple comparisons between countries, a one-way Anova post hoc
multiple comparison with Tuckey's test was used.1' The
results from a normal probability plot and a histogram of
residuals suggested that the errors were normally
distributed. The influence of random variation was
assessed by means of standard errors. The statistical
significance level used was 5%. For nine variables in both
studies the internally missing values (from 1.5 to 10%)
were substituted with the mean value for that variable in
its age group: 2-6 years, 7-12 years and 13-17 years. The
background variables were age, gender, country and study
year. The statistical analyses were all undertaken using
the software package SPSS/PC.
External sphere
Table 4 shows that the external QoL has increased for all
children in the Nordic countries but there are differences
in the development between countries. The mean scores
for Norwegian, Swedish and Danish children were quite
similar in 1984 and somewhat lower for Icelandic and
Finnish children. In 1996 Norway had the highest value
as of external conditions closely followed by Denmark.
The development was less favourable for Sweden and
Iceland whereas Finland is now closer to Sweden.
External indicators (tables not presented here) such as the
families' educational level, professional status and disposable income increased in all countries (except income
in Iceland). Danish and Icelandic families were more
satisfied with their work situation than 1984 whereas the
other countries were more dissatisfied. Although the
families' economic resources increased the families were
Table 3 Respondents by country, age and gender in 1984 and 1996
1984
N
Country
Sweden
Iceland
Norway
1,934
1,577
1,856
Finland
Denmark
2,705
2,219
2,034
2,169
10,291
10,317
3,600
13-17
All
3,783
2,908
3,351
3,816
3,022
10,291
10,189
Boys
5,183
Girls
All
5,097
10,280
5,248
4,968
10,216
All countries
Age (years)
Gender
1996
N
2,130
2-6
7-12
2,048
1,936
Interpersonal sphere
The interpersonal QoL was nearly unchanged for Nordic
children as a whole but there were differences in the
development between countries. Icelandic and Danish
children had the highest score values. The greatest downward change in scores was estimated for Norway and the
greatest upward change for Iceland followed by Denmark.
There were more children who had no siblings and the
parents had less time to spend with their children. Most
children were living with two parents in both years but
there were more children who had experienced major
negative life events in all countries in 1996. Satisfaction
with family life increased for Icelandic and Danish parents
and decreased for the other countries. The societal support increased in all countries except in Norway. Families
were also more satisfied with the support from relatives
and friends except in Norway and Finland. Only Icelandic
families were more satisfied with the support in general.
Personal sphere
The personal QoL scores for Nordic children were slightly
lower in 1996 except for Icelandic children. Sweden
ranked in first, Denmark second and Norway third place
in both years. Iceland ranked fourth and Finland slightly
lower. Children's own activity level and together with
parents increased in the Nordic countries (except family
activities in Sweden and Finland) but families were more
dissatisfied with their leisure time except in Iceland.
Children's self-esteem decreased in Sweden, Norway and
Finland and increased in Iceland and Denmark. Despite
an increase in bullying and psychosomatic complaints
more children enjoyed school in 1996 except in Finland.
Total, subjective and objective QoL
Total QoL increased for Nordic children as a whole but
there were changes in the development between countries.
The highest total QoL was found in Denmark and the
lowest in Finland. The greatest upward changes in scores
were found in Iceland and Denmark.
There was no significant change in subjective QoL for
Nordic children as a whole, but, again, there were
differences between countries. For Icelandic and Danish
children the subjective scores increased, while they
decreased for the other countries. Danish children had
the highest subjective QoL. Objective QoL increased for
Nordic children as a whole but there was a difference in
the development between countries. Norway had the
highest scores and Finland the lowest.
Are there differences in QoL between the age groups
2-6 years ,7-12 years and 13-17 years?
Table 5 shows that the external QoL was higher in older
children, and increased significantly in all ages from 1984.
The youngest age group had the lowest external score
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RESULTS
Table 4 presents the development of QoL adjusted for age
and gender for each country. In table 5 the development
of QoL is presented separately for the three age groups,
and in table 6 for boys and girls.
more dissatisfied with their economy except in Iceland
and Denmark. The housing conditions were generally
better in 1996 than in 1984 but there were minor
differences between countries.
Quality of life among children aged 2-17 years
value. The interpersonal QoL was highest in the youngest
age group in both years and there was a significant
increase between the years in this age group. QoL in the
personal sphere worsened significantly from 7 to 17 years
of age. Total QoL increased in all age groups. In both years
children of age 7-12 years had the highest QoL scores.
There was a tendency to lower subjective QoL scores for
the two older age groups in 1996. Objective QoL scores
were significantly higher for all ages as they were on the
external sphere.
Are there differences in QoL
between girb and boys?
DISCUSSION
The Nordic countries are
known for a long history of
affluence, which is reasonably well distributed in the
population. The political development has favoured the
creation of strong welfare
states, assuring all citizens a
wide social protection and
an adequate standard of
living. The results from the
QoL study in 1984H confirmed that the majority of
Nordic children had the prerequisites required to enjoy a
high QoL. The Welfare
States,
however,
were
shaken in the economic recessions of the 1990s. The
main objective of this new
study was to examine if the
social changes had affected
the high level of QoL. The
results show that citizens in
the Nordic countries still
Table 4 Mean quality of life scores by country in 1984 and 1996, adjusted for age and gender
Sphere (number
of variables)
External (9)
Interpersonal (9)
Personal (7)
Mean
6.02
Norway
Finland
Denmark
6.21
6.23
5.49
6.01
(1.96)
***
5.86
7.02
(2.17)
(1.92)
***
All countries
5.89
(2.04)
***
Sweden
(172)
*
Iceland
Norway
6.67
6.40
7.12
(1.70)
(1.62)
***
Finland
Denmark
6.49
6.46
(1.60)
(170)
All countries
6.61
(1.68)
Sweden
5.30
***
Iceland
Norway
4.18
(1.24)
(1.36)
(1.27)
*
(1.34)
(1.30)
(1.35)
***
Sweden
Iceland
Norway
Finland
Denmark
All countries
Sweden
Iceland
Norway
Finland
Denmark
All countries
Objective (16)
Mean
**
All countries
Subjective (9)
(SD)
(2.10)
(1.88)
Finland
Denmark
Total (25)
1996
1984
Country
Sweden
Iceland
Sweden
5.83
4.97
4.78
***
***
***
***
***
5.99
6.85
6.38
(SD)
(2.00)
(1.99)
(172)
(2.03)
(1.77)
(1.96)
6.54
6.78
(1.74)
(1.72)
6.54
6.41
6.67
6.59
(1.73)
5.12
4.65
(1.34)
(1.25)
(1.32)
4.87
4.60
(1.67)
(1.71)
(1.72)
(1.37)
(1.35)
*
5.01
4.85
(1.34)
(3.44)
(3.32)
(3.35)
***
17.79
17.20
(3.44)
(3.30)
*
18.40
(3.20)
(3.31)
17.47
17.30
(3.51)
***
16.87
18.46
(3.45)
***
17.74
6.18
4.75
(1.78)
(1.95)
***
5.90
5.66
6.51
6.25
(1.84)
(1.81)
(1.89)
5.16
4 90
17.88
16.25
18.19
16.72
6.09
6.02
Iceland
11.71
11.50
Norway
11.68
(3.32)
***
***
***
***
(1.94)
(2.42)
(2.35)
(2.32)
***
6.07
5.86
(1.91)
(1.78)
(1.86)
(1.88)
6.50
6.00
(1.90)
(1.89)
11.89
(2.37)
(2.35)
11.53
***
(3.36)
(3.38)
12.33
11.02
Finland
Denmark
10.47
11.39
(2.48)
(2.42)
***
***
11.95
(2.17)
(2.33)
(2.28)
All countries
11.28
(2.47)
***
11.74
(2.34)
Statistically significant differences, * p<0 05," p < 0 0 1 , *** p<0.001 be cween years 1984 and 1996
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There were no significant
gender difference in QoL in
external and interpersonal
scores (table 6). In the
personal sphere girls aged
2-12 years had significantly
higher QoL scores than boys
in both years. Both boys and
girls in the oldest age group
had the lowest scores in
1996. Girls had a tendency
to higher total QoL in all
ages and in the middle age
group significantly higher
total QoL in both years. Girls
in the youngest age group
had the highest subjective
QoL in both years.
enjoy a high standard of living and that the prerequisites
required for a high QoL are fulfilled, also for children.
Actually, the total QoL has increased for Nordic children
in general, but there are differences in the development
between the countries, and their relative order has
changed. The objective part of QoL also improved in all
countries, but, at the same time, the subjective part
worsened for all countries except for Denmark and Iceland, where it improved.
In terms of total QoL Norwegians and Danes are now
closer to each other than to the Icelanders and Finns, and
EUR0PEANJOURNALOFPUBLICHEALTHVOL.il 2001 NO. 4
shown that subjective wellbeing and happiness are not
directly related to external
conditions.
Americans
whose income increased
over a 10-year period were
not happier than those
whose income was stagnant.
Correlation between income
and well-being is important
only in the poorest countries
of the world and where the
income inequality in society
is large.24'7
Age differences in QoL were
found in all spheres. This can
Total (25)
2-6
7-12
13-17
2-17
Subjective (9)
Objective (16)
17.04
17.81
(3.31)
(3.52)
***
16.94
17.30
(3.47)
(3.45)
***
17.84
18.04
17.25
***
17.74
(3.37)
(3.37)
(3.39)
6.10
6.02
(1.87)
(1.88)
5.87
6.00
(1.93)
(1.89)
11.75
12.02
(2.37)
(2.35)
4*S
11.39
***
11.74
(2.26)
(2.35)
**
2-6
6.05
(1.90)
7-12
13-17
2-17
6.07
5.92
(1.97)
(1.93)
6.02
(1.94)
10.99
(2.40)
***
11.74
11.03
11.28
(2.50)
(2.42)
(2.46)
***
2-6
7-12
13-17
2-17
Statistically significanidifferences, • p<0.05, «p<0.01, •** p<0.001 between years 1984 and 1996
(3.38)
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be explained by developmental, social and behavioural
Swedes have a middle position. In terms of subjective QoL
factors. Children in the age group 2-6 years, who have
the differences between countries are quite similar in
the youngest parents, had the lowest external QoL. Due
1984 and 1996 except that Iceland has approached the
to the higher number of parents still studying, the proother Nordic countries. It may be surprising that the
portion of low-income families has increased in the age
substantial economic recession has not noticeably
band 18-29 years.25
affected the QoL. It could, however, very well be that the
welfare systems are so stable and protective that the
The changes in the interpersonal and personal QoL inrecession did not reach the core issues as expressed in the
dicate that the child's intimate networks have worsened.
QoL scores, at least not in this time span.19 UnThe parents' decreased time with children, fewer siblings,
employment rates and subsides increased in all countries
increased bullying and negative life events may explain
except in Denmark.20-21 The study results showed a
an increase in psychosomatic complaints and the lower
higher educational level and professional state in
self-esteem in children. These interpersonal and personal
families. The disposable income and its distribution
factors form the child's mental well-being.
increased in all countries except in Iceland. This
The interpersonal QoL was lowest in the oldest age group.
might explain the higher external and objective QoL.
According to a Swedish welfare study the family situation
The standard deviations of the mean scores do not
has changed at least three times for about 30% of children
show widening socio-economic gaps, except in Iceland
13—17 years old, whereas for 10% of children 3-6 years
in the external sphere. But other studies, both from
old the family situation has changed once.26 The close
this project and from others, confirm that there is a
relation between the families' QoL and the children's
widening socio-economic health gap among Nordic
well-being is again clearly documented. ' The oldest
children. 2 ' " The results in this study represent the
children had also the lowest value of personal QoL.
overall population. In a future paper disadvantaged groups
Several studies report a higher prevalence of psychowill be analysed.
somatic complaints and bullying among adolescents.28
Another possible explanation for the fact that the Table 5 Mean quality of life scores by age in 1984 and 1996, adjusted for age and gender
economic recession did not
1996
1984
show decrease in QoL-scores Sphere (number of
variables)
Mean
(SD)
Mean
Age (years)
(SD)
might be that people refrain
***
(2.06)
External (9)
2-6
6.02
5.57
(2.04)
from having children until
***
7-12
5.99
(1.96)
6.38
(2.07)
the economy is more stable.
***
(1.79)
13-17
6.15
(1.95)
6.75
Thus, there were more
***
5.89
(1.96)
6.38
2-17
(2.04)
children without siblings in
1996, and consequently
*
2-6
(1.60)
(1.61)
6.95
6.87
fewer individuals to share Interpersonal (9)
7-12
6.79
(1.68)
6.71
(1.63)
the family income.
13-17
6.08
(1.73)
6.05
(1.74)
The results also indicate that
6.62
6.59
2-17
(1.68)
(1.71)
the perceived part of QoL
has worsened. The lack of
***
2-6
(1.25)
4.95
(1.24)
4.74
association between object- Personal (7)
***
7-12
5.01
(1.35)
5.13
(1.39)
ive and subjective scores is
***
(1.40)
13-17
4.80
(1.38)
4.55
not new. American re*
24
2-17
4.90
(1.35)
4.85
(1.34)
searchers have in several
representative
samples
Quality of life among children aged 2-17 years
Study strengths and weaknesses
It may be questioned if the QoL model used here really
captures all aspects of QoL. Physical health components
of the child were not included. Although it is probably
safe to assume that people who have fewer symptoms,
more happiness, and better functioning in daily activities
have a better QoL, there is still confusion whether these
concepts are components of QoL or determinants of
QoL.31 It may also be questioned if social well-being and
socio-economic factors should be considered as a part of
QoL or predictors of QoL. Here QoL was defined as the
essence of existence of the individual, which presupposes
Table 6 Mean quality of life scores by age and gender in 1984 and 1996
1996
1984
Sphere (number
of variables)
Age
(years)
External (9)
Total (25)
Subjective (9)
Objective (16)
Boys
(SD)
Mean
2-6
7-12
5.59
5.99
(2.04)
(2.10)
5.55
5.98
13-17
2-17
6.16
5.89
(1.94)
(2.05)
6.15
5.88
6.90
(1.59)
6.83
(1.59)
6.74
6.06
6.59
(1.61)
(1.67)
(1.72)
(1.69)
6.70
6.05
4.66
(1.26)
5.01
13-17
6.83
6.09
2-17
6.65
2-6
7-12
4.82
5.19
(1.23)
(1.38)
***
**
13-17
2-17
4.80
4.95
(1.39)
(135)
***
4.85
2-6
7-12
17.17
17.93
(3.27)
(3.51)
*
*
16.90
13-17
2-17
16.96
17.39
(3.43)
(3.43)
*
2-6
6.15
(1.88)
**
7-12
13-17
6.13
5.95
(1.97)
(1.92)
2-17
6.08
(193)
2-6
11.01
11.81
(2.37)
(2.50)
11.01
11.30
(2.41)
(2.46)
7-12
13-17
2-17
(1.74)
(1.67)
**
5.06
4.81
Boys
Girls
Mean
Interpersonal (9) 2-6
7-12
Personal (7)
G iris
(SD)
(2.05)
Mean
6.05
(2.04)
(197)
6.44
6.73
6.40
(2.04)
(1.40)
6.96
6.59
(SD)
(2.07)
(1.95)
(1.76)
(1.95)
(1.64)
(166)
(1.74)
(1.72)
(1.23)
(1.33)
Mean
6.01
6.32
(2.04)
(198)
6.77
6.36
(1.81)
(1.97)
6.87
6.71
6.05
6.58
(1.68)
(1.76)
(1.72)
*
4.90
***
4.89
4.53
4.78
(SD)
(1.60)
(1.24)
(1.36)
(1.39)
(1.37)
(1.36)
5.14
4.57
4.93
(1.39)
(1.34)
***
(3.34)
(3.52)
17.93
18.23
(3.41)
(3.40)
17.76
(3.36)
**
17.85
(3.38)
(3.51)
17.24
(3.48)
17.84
(3.34)
(3.39)
**
17.27
17.65
(3.39)
(3.38)
5.94
6.01
(1.92)
6.15
5.88
5.95
(1.95)
6.07
5.95
6.04
5.98
(1.86)
(1.96)
(1.94)
6.06
(1.87)
10.97
11.68
11.05
(2.41)
(2.49)
11.78
(2.38)
11.26
(2.47)
12.16
11.56
11.78
(2.34)
(2.36)
(2.36)
17.70
16.93
17.21
(2.43)
Statistically significant differences, * p<0.05, **p<0.01,*** p<0 001 between girls and boys in 1984 and 1996
(1.88)
(1.86)
(1.89)
*
**
5.80
5.95
11.72
(134)
(1.89)
(196)
(1.90)
***
11.88
(2.34)
(2.37)
*
11.47
11.70
(2.24)
(2.32)
Downloaded from http://eurpub.oxfordjournals.org/ by guest on March 6, 2016
necessary internal and external resources for a good life.14
Every child has a personal sphere that is experienced in a
context of social relationship and support. This in turn
has a socio-economic context and beyond this a macro
level (society). One of the key variables for changes in
the interpersonal sphere was the families' satisfaction
with the social support, which might be dependent on the
family policy in respective countries. The QoL instrument used here is a generic one, which refers to a general
approach available to all types of people regardless of their
condition or situation. The concept is attuned to the
WHO definition of QoL12 and its questionnaire for adults
that includes six domains: physical, psychological, level
of independence, social relationships, environment and
spirituality. There are few QoL instruments for children
that have been tested and validated in a large population
study like this. It is designed specifically for children in
the Nordic countries. The instrument has been recommended for its broad aspects in two recent overview
articles of children's QoL.33'34 Pal's review33 revealed that
most QoL instruments use a simple concept of health.
Only five instruments included broader definitions.
The least favourable personal QoL was seen in children
aged 7-17 years. Gender differences on the personal
sphere may be explained by social and behavioural factors.
School dissatisfaction and bullying are more prevalent
among boys than girls.28 Boys in puberty are more extrovert and behave more aggressively29 whereas girls are
more introvert. A Finnish follow-up study concludes that
boys have more health problems than girls, caused by
social factors and school problems.30
EUROPEANJOURNALOFPUBLICHEALTHVOL.il 2001 NO. 4
Another problem in the present study is children and
parents as respondents. But it was necessary to get the
parents' view of the child in the family and the society
context according to the model. This may bias the results,
especially for differences between age groups and over
time. In a Dutch study of health-related QoL research35
the children reported a significantly lower health-related
QoL than their parents on the physical complaints, motor
functioning and positive emotion scales. The parent
report might provide a substitute for children's healthrelated QoL at a group level, but large differences can exist
in proxy agreement at the individual child-parent level.
In the present study the self-esteem of the child and
symptoms may be underestimated if the child alone has
filled in the questionnaire. Another aspect that might
influence the results is the respondent's gender. In the
WHO study32 significant gender differences were found
in physical, psychological, social and spiritual domains.
In this study social support, economy and mental and
spiritual dimensions might be overestimated but the proportion of the mothers as respondents was the same (about
82%) in both years. In future studies information should
be collected using a separate questionnaire for older
children and parents.
Finally, many of the significant differences between years,
countries and groups of children may seem to be trivially
small in terms of their contribution to the variation of
QoL. However, even small changes in a negative direction might be a warning sign to observe and follow up
what is happening in society.
CONCLUSIONS
The total QoL for Nordic children is very high, and
increased from 1984 to 1996, although there were
differences in the development of QoL between
countries. The objective QoL for children became better
in all countries, at the same time the subjective QoL
• I worsened, except in Denmark and Iceland. The external
QoL became better, whereas the interpersonal QoL was
nearly unchanged for Nordic children as a whole but there
were differences in the development between countries.
The personal QoL worsened slightly except for children
in Iceland. The ranking between countries changed.
Danish children had the highest subjective and
Norwegian children the highest objective and external
QoL. Swedish children had the highest personal QoL.
Children of age 7-12 years had the highest QoL. Girls had
a tendency to higher QoL in all ages.
It may be concluded that QoL for children is reflected by
the societal context with its external, interpersonal and
personal resources. Further research using other variables
is needed to clarify the complex background of these
results. Based on these quantitative findings, a new indepth study of QoL of children will be performed later,
using qualitative methodology.
We are grateful for research support from the Joint Committee of the
Nordic Social Science Research Councils.
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Our first study was carried out already in 1984- It may be
that the people have other values for their lives to day.
Nevertheless, the standard deviations of QoL scores do
not differ significantly over years. In a future study the
QoL of children with long-term illness will be studied. In
another study socio-economic conditions will be treated
as an external factor for interpersonal and personal QoL.
Although mailed questionnaires have certain limitations
in revealing complex and sometimes sensitive conditions
of family life it was the only possible method in such a
large sample. Questionnaires may also have problems of
non-respondent, interpretations of text and translations
of questionnaires in comparative studies. The translations
were performed both by the specialist in child health and
linguists, which should minimise errors. The nonrespondent rate was higher among one-parent families in
both studies and in all countries. It may influence the
results in the interpersonal sphere. The study design was
cross-sectional which limits the analysis to the two points,
1984 and 1996. A longitudinal study could highlight
development of QoL better.
Quality of life among children aged 2-17 years
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