ABSTRACT:

Introduction:

Health self-assessment (HSA) is a widely studied indicator among adults and the elderly, but not often explored in adolescents. This study aimed to estimate the prevalence of poor self-rated health in Brazilian schoolchildren and associated factors.

Methods:

Data from the 2015 National Adolescent School-based Health Survey (PeNSE) were analyzed; prevalences and their 95% confidence intervals (95%CI) were estimated for poor self-rated health and associated factors. Multiple logistic regression analysis was performed.

Results:

A total of 7.1% (95%CI 7.0 - 7.3) of the schoolchildren reported a poor self-assessed health status. Sociodemographic characteristics, such as female gender, 15 years of age or older, yellow, brown and indigenous race/skin color; risk behaviors such as regular alcohol consumption and drug experimentation, and issues related to physical and emotional health remained positively associated with the outcome studied. Protective factors identified were maternal schooling and demand for health services.

Conclusion:

The impact of risky behaviors on physical and emotional health need to be addressed among students. The school presents itself as a safe and opportune space for promoting a healthy lifestyle.

Keywords:
Adolescent; Self-Assessment; Health status; Health surveys

INTRODUCTION

Health self-assessment (HSA) objectively summarizes individuals’ expectations for their health and includes biological, psychological, and social dimensions¹1. Jylhä M. What is self-rated health and why does it predict mortality? Towards a unified conceptualmodel. Soc Sci Med. 2009; 69(3): 307-16. https://doi.org/10.1016/j.socscimed.2009.05.013
https://doi.org/10.1016/j.socscimed.2009... . It is a simple indicator measured by a question that expresses the individual’s perception of their health, mensurable by a five-point scale: very good, good, regular, poor, and very poor²2. Layes A, Asada Y, Kepart G. Whiners and deniers - what does self-rated health measure? Soc Sci Med. 2012; 75: 1-9. https://doi.org/10.1016/j.socscimed.2011.10.030
https://doi.org/10.1016/j.socscimed.2011... . Used since the 1970s³3. Idler TEL, Benyamini Y. Self Rated Mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997; 38(1): 21-37.^,44. Mossey JM, Shapiro E. Self-rated health: a predictor of mortality among the elderly. Am J Public Health. 1982; 72(8): 800-8., HSA is useful in diagnosing the health status of populations, as well as being a low-cost medium for application in health services and surveys⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... ^,66. Peres MA, Masiero AV, Longo GZ, Rocha GC, Matos IB, Najnie K, et al. Self-rated health among adults in Southern Brazil. Rev Saúde Pública. 2010; 44: 901-11. http://dx.doi.org/10.1590/S0034-89102010000500016
http://dx.doi.org/10.1590/S0034-89102010... ^,77. Pavão ALB, Werneck GL, Campos MR. Autoavaliação do estado de saúde e a associação com fatores sociodemográficos, hábitos de vida e morbidade na população: um inquérito nacional. Cad Saúde Pública. 2013; 29: 723-34. http://dx.doi.org/10.1590/S0102-311X2013000400010
http://dx.doi.org/10.1590/S0102-311X2013... ^,88. Pagotto V, Bachion MM, Silveira EA. Autoavaliação da saúde por idosos brasileiros: revisão sistemática da literatura. Rev Panam Salud Pública 2013;33:302-10..

Several studies indicate a high agreement between this indicator and health status⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... ^,66. Peres MA, Masiero AV, Longo GZ, Rocha GC, Matos IB, Najnie K, et al. Self-rated health among adults in Southern Brazil. Rev Saúde Pública. 2010; 44: 901-11. http://dx.doi.org/10.1590/S0034-89102010000500016
http://dx.doi.org/10.1590/S0034-89102010... , as well as outcomes related to morbidity⁹9. Svedberg P, Bardage C, Sandin S, Pedersen NL. A prospective study of health, life-style and psychosocial predictors of self-rated health. Eur J Epidemiol. 2006; 21: 767-76. https://doi.org/10.1007/s10654-006-9064-3
https://doi.org/10.1007/s10654-006-9064-... and mortality³3. Idler TEL, Benyamini Y. Self Rated Mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997; 38(1): 21-37.^,44. Mossey JM, Shapiro E. Self-rated health: a predictor of mortality among the elderly. Am J Public Health. 1982; 72(8): 800-8.. The literature shows several factors that influence health self-assessment. Among them are: sociodemographic factors, such as gender, age, schooling and income¹⁰10. Cureau FV, Duarte P, dos Santos DL, Reichert FF. Clustering of risk factors for noncommunicable diseases in Brazilian adolescents: prevalence and correlates. J Phys Act Health. 2014; 11(5): 942-9. https://doi.org/10.1123/jpah.2012-0247
https://doi.org/10.1123/jpah.2012-0247... ^,1111. Sentell T, Zhang W, Davis J, Baker KK, Braun KL. The influence of community and individual health literacy on self-reported health status. J Gen Intern Med. 2014; 29(2): 298-304. https://doi.org/10.1007/s11606-013-2638-3
https://doi.org/10.1007/s11606-013-2638-... , behavioral and lifestyle factors⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... ^,77. Pavão ALB, Werneck GL, Campos MR. Autoavaliação do estado de saúde e a associação com fatores sociodemográficos, hábitos de vida e morbidade na população: um inquérito nacional. Cad Saúde Pública. 2013; 29: 723-34. http://dx.doi.org/10.1590/S0102-311X2013000400010
http://dx.doi.org/10.1590/S0102-311X2013... , as well as those related to mental health⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... and the presence of morbidity¹²12. Barreto SM, Figueiredo RC. Doença crônica, autoavaliação de saúde e comportamento de risco: diferença de gênero. Rev Saúde Pública. 2009; 43(Supl. 2): 38-47. http://dx.doi.org/10.1590/S0034-8910200900090000
http://dx.doi.org/10.1590/S0034-89102009... .

In Brazil, there are several studies on HSA which are representative of the adult and elderly population, such as those that used data from the National Household Sample Survey (PNAD)¹³13. Dachs JNW, Santos APRS. Autoavaliação do estado de saúde no Brasil: análise dos dados da PNAD/2003. Ciênc Saúde Coletiva 2006; 11: 887-94. http://dx.doi.org/10.1590/S1413-81232006000400012
http://dx.doi.org/10.1590/S1413-81232006... , the Surveillance System for Risk and Protection Factors for Chronic Diseases by Telephone Survey (VIGITEL)⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... and the National Health Survey (PNS)¹⁴14. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol. 2015; 18(Supl. 2): 33-44. http://dx.doi.org/10.1590/1980-5497201500060004
http://dx.doi.org/10.1590/1980-549720150... .

International analyzes on HSA in adolescents have been carried out¹⁵15. Richter M, Erhart M, Vereecken CA, Zambon A, Boyce W, Nic Gabhainn S. The role of behavioural factors in explaining socio-economic differences in adolescent health: a multilevel study in 33 countries. Soc Sci Med. 2009; 69: 396-403. https://doi.org/10.1016/j.socscimed.2009.05.023
https://doi.org/10.1016/j.socscimed.2009... ^,1616. Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health. 2008; 36: 12-20. https://doi.org/10.1177/1403494807085306
https://doi.org/10.1177/1403494807085306... . However, in Brazil, such studies are still scarce and lack national coverage¹⁷17. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... . Previous publications on the subject have found results similar to those found among adults, pointing out that HSA is a good tool for health monitoring in this public, especially when the evaluation is negative or poor¹⁵15. Richter M, Erhart M, Vereecken CA, Zambon A, Boyce W, Nic Gabhainn S. The role of behavioural factors in explaining socio-economic differences in adolescent health: a multilevel study in 33 countries. Soc Sci Med. 2009; 69: 396-403. https://doi.org/10.1016/j.socscimed.2009.05.023
https://doi.org/10.1016/j.socscimed.2009... ^,1616. Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health. 2008; 36: 12-20. https://doi.org/10.1177/1403494807085306
https://doi.org/10.1177/1403494807085306... ^,1717. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... . Studies in adolescents have identified the association between poor HSA and lower income families¹⁵15. Richter M, Erhart M, Vereecken CA, Zambon A, Boyce W, Nic Gabhainn S. The role of behavioural factors in explaining socio-economic differences in adolescent health: a multilevel study in 33 countries. Soc Sci Med. 2009; 69: 396-403. https://doi.org/10.1016/j.socscimed.2009.05.023
https://doi.org/10.1016/j.socscimed.2009... , the use of alcoholic beverages¹⁸18. Johnson PB, Ritcher L. The relationship between smoking, drinking, and adolescents' self-perceived health and frequency of hospitalization: analyses from the 1997 National Household Survey on Drug Abuse. J Adolesc Health. 2002; 30: 175-83., tobacco¹⁶16. Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health. 2008; 36: 12-20. https://doi.org/10.1177/1403494807085306
https://doi.org/10.1177/1403494807085306... , and illicit drugs¹⁹19. Wade TJ, Vingilis E. The development of self-rated health during adolescence: an exploration of inter - and intra-cohort effects. Can J Public Health. 1999; 90: 90-4., low physical activity²⁰20. Pastor Y, Balaguer I, Pons D, García-Merita M. Testing direct and indirect effects of sports participation on perceived health in Spanish adolescents between 15 and 18 years of age. J Adolesc. 2003; 26: 717-3. and the negative self-perception of stress²¹21. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002; 93: 193-7..

In 2015, the National Adolescent School-based Health Survey (PeNSE) included the theme of HSA, allowing the exploration of aspects not yet studied nationally, with the purpose of supporting public policies aimed at adolescents. Thus, this study aimed to estimate the prevalence and factors associated with poor health self-assessment in Brazilian schoolchildren.

METHODOLOGY

This is a cross-sectional study using data from PeNSE 2015, carried out by the Brazilian Institute of Geography and Statistics (IBGE), in partnership with the Ministry of Health. The sample of 9th grade students was calculated in order to estimate population parameters in several geographical areas: each of the 26 Federative Units, the 26 Federative Unit capitals and the Federal District, the 5 geographic macroregions and the total of Brazil²²22. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, (PeNSE), 2015. Rio de Janeiro: IBGE; 2015..

A total of 102,301 students enrolled in the 9th year of elementary school participated in the survey, distributed in 3,040 schools and 4,159 classes throughout the country. Considering the students enrolled and the non-respondents, the sample loss was approximately 8.5%. All the students present in the classes drawn on the day of collection were invited to participate in the research²²22. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, (PeNSE), 2015. Rio de Janeiro: IBGE; 2015..

PeNSE constitutes the most extensive research on schoolchildren in the country, and addresses various aspects of adolescent health, such as eating habits, physical activity, substance use, family behavior, self-reported morbidity, and demand for health services. More details can be found in other publications²²22. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, (PeNSE), 2015. Rio de Janeiro: IBGE; 2015..

For the present analysis, the outcome investigated was an evaluation of the health status, through the question included in the 2015 questionnaire: “How would you rate your health status?”, with the following response options: very good, good, regular, poor, and very poor. For the construction of the investigated variable, the poor and very poor responses were aggregated.

The choice of independent variables was based on data from the literature that indicate that poorer assessment of health status is associated with sociodemographic factors, habits and behaviors, factors related to mental health, situations involving family members, morbidity, and demand for health services⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... ^,77. Pavão ALB, Werneck GL, Campos MR. Autoavaliação do estado de saúde e a associação com fatores sociodemográficos, hábitos de vida e morbidade na população: um inquérito nacional. Cad Saúde Pública. 2013; 29: 723-34. http://dx.doi.org/10.1590/S0102-311X2013000400010
http://dx.doi.org/10.1590/S0102-311X2013... ^,1212. Barreto SM, Figueiredo RC. Doença crônica, autoavaliação de saúde e comportamento de risco: diferença de gênero. Rev Saúde Pública. 2009; 43(Supl. 2): 38-47. http://dx.doi.org/10.1590/S0034-8910200900090000
http://dx.doi.org/10.1590/S0034-89102009... ^,1515. Richter M, Erhart M, Vereecken CA, Zambon A, Boyce W, Nic Gabhainn S. The role of behavioural factors in explaining socio-economic differences in adolescent health: a multilevel study in 33 countries. Soc Sci Med. 2009; 69: 396-403. https://doi.org/10.1016/j.socscimed.2009.05.023
https://doi.org/10.1016/j.socscimed.2009... ^,1616. Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health. 2008; 36: 12-20. https://doi.org/10.1177/1403494807085306
https://doi.org/10.1177/1403494807085306... .

The independent variables were distributed in five themes, as described below. Associations with the model variables were tested:

The variables that characterize behavior in relation to the poor health evaluation were described, and the prevalences and their respective 95% confidence intervals (95%CI) were calculated, according to the independent variables described. To explore factors associated with the outcome examined (poor self-rated health), bivariate analysis was initially performed by logistic regression, unadjusted odds ratios (OR) with their respective 95%CI values. Subsequently, the multivariate logistic regression model was used, considering the variables of interest that presented p < 0.20, and based on the literature. In the adjusted final model (ORa), the statistically significant variables remained at p < 0.05.

In these analyzes, the sample structure and the weights to obtain population estimates were considered²²22. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar, (PeNSE), 2015. Rio de Janeiro: IBGE; 2015.. Data were analyzed using the Statistical Package for Social Sciences (SPSS) version 20.

The students were informed about the research, about their free participation and that they could cease their involvement if they did not feel comfortable answering the questions. If they agreed to participate in the survey, students had to answer an individual questionnaire, on a smartphone, under the supervision of IBGE interviewers. PeNSE is in agreement with the Guidelines and Norms Regulating Research Involving Human Beings and was approved by the National Commission of Ethics in Research of the Ministry of Health (CONEP/MS) under a Certificate of Presentation for Ethical Appreciation (CAAE).

RESULTS

Poor self-rated health was reported by 7.1% (95%CI 7.0 - 7.3) of Brazilian schoolchildren. The prevalence was higher in females (7.7%; 95%CI 7.5 - 8.0), among schoolchildren aged 16 years or more (9.8%; 95%CI 9.2 - 10.4), among those currently working (8.7%; 95%CI 8.3 - 9.2) and the children of mothers without schooling (9.6%; 95%CI 8.7 - 10.6). The worst assessment was in schoolchildren with yellow (8.9%; 95%CI 7.7 - 10.2) and indigenous race/skin color (9.6%; 95%CI 8.7 - 10.7), with no difference between school types (Table 1).

The prevalence of poor self-reported health was higher among students who: did not live with at least one parent (9.5%, 95%CI 8.8 - 10.4), did not eat meals with their parents (14.2%; 95%CI 13.2 - 15.2), have used tobacco in the last 30 days (12.8%; 95%CI 11.9 - 13.7), have used alcohol in the last 30 days (9.5%; 95%CI 9.1 - 9.9), experimented drugs (11.8%; 95%CI 11.2 - 12.5), had sexual intercourse (9.7%; 95%CI 9.3 - 10.0), consumed soft drinks frequently (8.5%; 95%CI 8.2 - 8.8), did not eat breakfast (8.6%; 95%CI 8.2 - 8.9), felt lonely (12.9%; 95%CI 12.4 - 13.4), reported insomnia (14.4%; 95%CI 13.7 - 15.0), had no friends (10.9%; 95%CI 10.0 - 11.9), reported having asthma (9.6%; 95%CI 9.2 - 10.1), perceived themselves as fat (10.5%; 95%CI 10.1 - 11.0) and missed classes for health reasons, with 6.7% (95%CI 6.4 - 7.1) having 1 to 3 absences, and 11.8% (95%CI 11.3 - 12.2) having 4 or more absences. No difference was found according to frequent fruit consumption, daily physical activity practice, and demand for health services (Table 1).

Table 1 also shows the analyzes of the simple and multiple models. The characteristics of the students who remained associated with poor HSA after adjustment for all variables of the model were: females (PR: 1.12; 95%CI 1.06 - 1.20); aged 15 years (PR: 1.16; 95%CI 1.06 - 1.28) or 16 years or more (PR: 1.32; 95%CI 1.18 - 1.48); yellow (PR: 1.44; 95%CI 1.26 - 1.64), brown (PR: 1.11; 95%CI 1.04 - 1.19) and indigenous race/skin color (PR: 1.44; 95%CI 1.25 - 1.67). Being currently working did not remain associated in the multiple analysis. In relation to the family characteristics, a higher maternal schooling was a protective factor [primary (PR: 0.82; 95%CI 0.74 - 0.91), secondary (PR: 0.80; 95%CI 0.71 - 0.89) and higher education (PR: 0.72; 95%CI 0.65 - 0.81)]; the act of not having a meal with those responsible was positively associated with HSA (PR: 1.76; 95%CI 1.59 - 1.94). Alcohol consumption in the last 30 days (PR: 1.08; 95%CI 1.00 - 1.15), drug experimentation (PR: 1.14; 95%CI 1.04 - 1.25), having had sexual intercourse (PR: 1.29; 95%CI 1.20 - 1.38), frequent consumption of soft drinks (PR: 1.19; 95%CI 1.12 - 1.26), regular physical activity (PR: 1.14; 95%CI 1.06 - 1.22), feeling lonely (PR: 1.51; 95%CI 1.40 - 1.62), having insomnia (PR: 1.55; 95%CI 1.43 - 1.68), not having friends (PR: 1.38; 95%CI 1.22 - 1.55), asthma report (PR: 1.30; 95%CI 1.21 - 1.39), perceiving oneself as fat (PR: 1.42; 95%CI 1.31 - 1.54) and missing classes for health reasons (for 1 to 3 days [PR: 1.28; 95%CI 1.20 - 1.38] and for 4 days or more [PR: 2.15; 95%CI 1.99 - 2.32). Having sought health care services was a protective factor (PR: 0.83; 95%CI 0.78 - 0.88).

DISCUSSION

Poor self-rated health was reported by 7.1% of 9^th grade students. This finding was higher than that estimated for the adult population in the 2013 PNS¹⁴14. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol. 2015; 18(Supl. 2): 33-44. http://dx.doi.org/10.1590/1980-5497201500060004
http://dx.doi.org/10.1590/1980-549720150... . However, it was lower than in a study carried out among high school students of public schools in Santa Catarina between 2001 and 2002, in which the frequency of negative HSA was 14%¹⁷17. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... .

The sociodemographic characteristics associated with the poor self-rated health observed in the present study were female gender, age 15 years or older, yellow, brown and indigenous skin color/race. Studies performed in adolescents as well as in adults and the elderly also identified these differences⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... ^,1212. Barreto SM, Figueiredo RC. Doença crônica, autoavaliação de saúde e comportamento de risco: diferença de gênero. Rev Saúde Pública. 2009; 43(Supl. 2): 38-47. http://dx.doi.org/10.1590/S0034-8910200900090000
http://dx.doi.org/10.1590/S0034-89102009... ^,1313. Dachs JNW, Santos APRS. Autoavaliação do estado de saúde no Brasil: análise dos dados da PNAD/2003. Ciênc Saúde Coletiva 2006; 11: 887-94. http://dx.doi.org/10.1590/S1413-81232006000400012
http://dx.doi.org/10.1590/S1413-81232006... ^,1414. Szwarcwald CL, Damacena GN, Souza Júnior PRB, Almeida WS, Lima LTM, Malta DC, et al. Determinantes da autoavaliação de saúde no Brasil e a influência dos comportamentos saudáveis: resultados da Pesquisa Nacional de Saúde, 2013. Rev Bras Epidemiol. 2015; 18(Supl. 2): 33-44. http://dx.doi.org/10.1590/1980-5497201500060004
http://dx.doi.org/10.1590/1980-549720150... ^,1717. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... .

Maternal schooling, an important proxy for income, showed that the lower the mother’s schooling, the higher the prevalence of poor self-rated health. This finding was reported in surveys conducted with students from other countries¹⁵15. Richter M, Erhart M, Vereecken CA, Zambon A, Boyce W, Nic Gabhainn S. The role of behavioural factors in explaining socio-economic differences in adolescent health: a multilevel study in 33 countries. Soc Sci Med. 2009; 69: 396-403. https://doi.org/10.1016/j.socscimed.2009.05.023
https://doi.org/10.1016/j.socscimed.2009... ^,2121. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002; 93: 193-7.. Adolescents who reported not meals with their guardians had a higher prevalence of poor self-rated health. The habit of not having a meal with one of the guardians has been associated with other negative outcomes among adolescents, such as the use of alcohol, tobacco, and other drugs²³23. Malta DC, Campos MO, Prado RR, Andrade SSC, Mello FCM, Dias AJR, et al. Uso de substâncias psicoativas, contexto familiar e saúde mental em adolescentes brasileiros, Pesquisa Nacional de Saúde dos Escolares (PeNSE 2012). ver Bras Epidemiol. 2014; (Supl. 1): 46-61. http://dx.doi.org/10.1590/1809-4503201400050005
http://dx.doi.org/10.1590/1809-450320140... .

In the present study, tobacco consumption in the last 30 days did not remain associated with the outcome in the multiple analysis, contrary to what was observed in other studies¹³13. Dachs JNW, Santos APRS. Autoavaliação do estado de saúde no Brasil: análise dos dados da PNAD/2003. Ciênc Saúde Coletiva 2006; 11: 887-94. http://dx.doi.org/10.1590/S1413-81232006000400012
http://dx.doi.org/10.1590/S1413-81232006... ^,1616. Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health. 2008; 36: 12-20. https://doi.org/10.1177/1403494807085306
https://doi.org/10.1177/1403494807085306... ^,1717. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... ^,2121. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002; 93: 193-7.. However, alcohol consumption and drug experimentation were identified as independent factors, and these harmful habits were also associated with poor health status in other studies¹⁸18. Johnson PB, Ritcher L. The relationship between smoking, drinking, and adolescents' self-perceived health and frequency of hospitalization: analyses from the 1997 National Household Survey on Drug Abuse. J Adolesc Health. 2002; 30: 175-83.^,1919. Wade TJ, Vingilis E. The development of self-rated health during adolescence: an exploration of inter - and intra-cohort effects. Can J Public Health. 1999; 90: 90-4.. These associations have already been described in other studies using data from surveys conducted with Brazilian schoolchildren²³23. Malta DC, Campos MO, Prado RR, Andrade SSC, Mello FCM, Dias AJR, et al. Uso de substâncias psicoativas, contexto familiar e saúde mental em adolescentes brasileiros, Pesquisa Nacional de Saúde dos Escolares (PeNSE 2012). ver Bras Epidemiol. 2014; (Supl. 1): 46-61. http://dx.doi.org/10.1590/1809-4503201400050005
http://dx.doi.org/10.1590/1809-450320140... .

Schoolchildren reporting physical activity also reported a higher prevalence of poor self-reported health, as opposed to what was observed in a study among Thai adolescents who presented lower negative health perceptions when participating in vigorous physical activity, involving muscle strength or sports²⁴24. Page RM, Suwanteerangkul J. Self-rated health, psychosocial functioning, and health-related behavior among Thai adolescents. Pediatr Int. 2009; 51: 120-5. https://doi.org/10.1111/j.1442-200X.2008.02660.x
https://doi.org/10.1111/j.1442-200X.2008... . Brazilian studies with adolescents¹⁷17. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... and adults¹²12. Barreto SM, Figueiredo RC. Doença crônica, autoavaliação de saúde e comportamento de risco: diferença de gênero. Rev Saúde Pública. 2009; 43(Supl. 2): 38-47. http://dx.doi.org/10.1590/S0034-8910200900090000
http://dx.doi.org/10.1590/S0034-89102009... also found an association between poor health status and sedentary lifestyle, as opposed what was identified in this study. Therefore, the association found here still needs to be further investigated, as it may be a case of reverse causality.

In this study, both perceiving oneself fat and having negative eating habits (regular soda consumption and not eating breakfast regularly) remained strongly associated with the outcome.

To report episodes of insomnia and asthma, to seek health services and to miss classes for reasons related to one’s own health also remained associated with poor a self-rated health status. Studies with adults showed that the presence of diseases or disabilities was associated with the outcome studied⁵5. Barros MB, Zanchetta LM, Moura EC, Malta DC. Self-rated health and associated factors, Brazil, 2006. Rev Saúde Pública. 2009; 43(Supl. 2): 27-37. http://dx.doi.org/10.1590/S0034-89102009000900005
http://dx.doi.org/10.1590/S0034-89102009... ^,1212. Barreto SM, Figueiredo RC. Doença crônica, autoavaliação de saúde e comportamento de risco: diferença de gênero. Rev Saúde Pública. 2009; 43(Supl. 2): 38-47. http://dx.doi.org/10.1590/S0034-8910200900090000
http://dx.doi.org/10.1590/S0034-89102009... . In addition, it should be noted that, although HSA is an important proxy of mortality, presenting high reliability, it also reflects other constructs, such as well-being, satisfaction, control over life, and quality of life²⁵25. Höfelmann DA, Blank N. Auto-avaliação de saúde entre trabalhadores de uma indústria no sul do Brasil. Rev Saúde Pública. 2007; 41(5): 777-87. http://dx.doi.org/10.1590/S0034-89102007000500012
http://dx.doi.org/10.1590/S0034-89102007... . Thus, feeling lonely, having few friends and sexual activity in such a young age group showed a positive association.

It is necessary to emphasize that these behaviors must be observed and valued, since emotional behavior and interpersonal relationships suggest the presence of diseases such as depression, which is associated to a poor self-rated health status²⁶26. Molarius AL, Janson S. Self-rated health, chronic diseases, and symptoms among middle-aged and elderly men and women. J Clin Epidemiol. 2002; 55(4): 364-70.. In addition, these characteristics may reflect a state of stress experienced by schoolchildren. In studies carried out with students from Santa Catarina¹⁷17. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... and Canada²¹21. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002; 93: 193-7. it was identified that the level of stress was also associated with a poor self-rated health status. Adolescence is an important period of transformation, with increased personal responsibilities, as well as exposure to diverse experiences and new behaviors and practices that can increase the level of stress and, consequently, lead to a worse evaluation of the health status.

This study dealt with the factors associated with the self-rated health status of Brazilian schoolchildren. However, it is important to emphasize that, because it is a cross-sectional study, cause and effect are measured simultaneously, which may lead to reverse causality, as it possibly occurred in relation to the practice of physical activity.

The PeNSE sample is representative of schoolchildren, and the survey was performed in the school environment, which excludes out-of-school adolescents, who may present different risk profiles and even underestimate the outcome studied²⁷27. Oliveira MM, Campos MO, Andreazzi MARD, Malta DC. Características da Pesquisa Nacional de Saúde do Escolar-PeNSE. Epidemiol Serv Saúde. 2017; 26(3): 605-16. http://dx.doi.org/10.5123/s1679-49742017000300017
http://dx.doi.org/10.5123/s1679-49742017... . It is also important to emphasize that HSA in adolescents may represent the perception not only of physical health¹⁶16. Breidablik HJ, Meland E, Lydersen S. Self-rated health in adolescence: a multifactorial composite. Scand J Public Health. 2008; 36: 12-20. https://doi.org/10.1177/1403494807085306
https://doi.org/10.1177/1403494807085306... ^,2121. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002; 93: 193-7., but also of emotional health, with issues related to pessimism, optimism²⁸28. Appels A, Bosma H, Grabauskas V, Gostautas A, Sturmans F. Self-rated health and mortality in a Lithuanian and a Dutch population. Soc Sci Med. 1996; 42: 681-9. and self-esteem²¹21. Vingilis ER, Wade TJ, Seeley JS. Predictors of adolescent self-rated health. Analysis of the National Population Health Survey. Can J Public Health. 2002; 93: 193-7.. Finally, there is the possibility of under or overestimation¹⁷17. Sousa TFS, Silva KS, Garcia LMT, Del Duca GF, Oliveira ESA, Nahas MV. Autoavaliação de saúde e fatores associados em adolescentes do Estado de Santa Catarina, Brasil. Rev Paul Pediatr. 2010; 28(4): 333-9. http://dx.doi.org/10.1590/S0103-05822010000400008
http://dx.doi.org/10.1590/S0103-05822010... ^,2929. Farias Júnior JC, Mendes JK, Barbosa DB. Associação entre comportamentos de risco à saúde em adolescentes. Rev Bras Cineantropom Desempenho Hum. 2007; 9: 250-6., of other aspects, such as illicit drug use, smoking, alcohol consumption and physical activity, interfering with the associations found.

This study described the poor self-rated health status of Brazilian schoolchildren, and it is reiterated that it is an outcome that has not been explored in the country in this age group.

CONCLUSION

Less than 10% of 9^th grade schoolchildren self-rated their own health status as poor. However, this prevalence was higher than that observed in studies with the Brazilian adult population. In addition to sociodemographic characteristics, risk behaviors, such as alcohol and drug consumption, and issues related to physical and emotional health were associated with the outcome studied. The results found contribute to increase the knowledge on issues related to the life and health of schoolchildren in Brazil. Also, they contribute to the planning of health promotion and prevention actions in this population.

The school environment should be more explored to address these issues, as it presents itself as safe and opportune to promote a healthy lifestyle to these students, in order to prioritize access to information and to trigger changes in health-related behaviors.

ACKNOWLEDGEMENTS

To the National Council for Scientific and Technological Development (CNPq), for the productivity and postdoctoral fellowship; and the Minas Gerais Research Support Foundation (FAPEMIG), for the support to the Minas Gerais Researcher Program (PPM).

References

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