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Philosophiae Doctor - PhD / Background: There is consensus internationally and among South African researchers that engagement in health risk behaviours amongst the youth is a concern from a public health perspective. It is evident that much health risk behaviours are established during adolescence, and may continue into adulthood, affecting health and wellbeing in later life, and some preventable health behaviours may be contributory causes of morbidity and mortality. Research into the development t of programmes can play a major role in reducing health risk behaviour amongst the youth and also provide a key learning opportunity should this be driven with bigger impetus by the building of research knowledge. Research knowledge needs to inform all stakeholders as to the best evidence-based possibilities that can assist in creating the behavioural change that is envisaged. This study therefore aimed to design, evaluate the feasibility of, and implement, a comprehensive youth development programme that will help to equip learners with the skills to change health risk behaviour in selected schools in the Paarl area, through input from all the stakeholders. The objectives of the study were to 1) obtain baseline information of grade 8 –10 learners about the health risk behaviours they engage in, and the extent to which learners manage personal situations; 2) explore the views of stakeholders regarding the type of health risk behaviours learners engage in, and reasons for engaging; 3) To determine the content of school-based interventions reported in literature, and its effectiveness in reducing or delaying these behaviours amongst the youth; 4) To design a youth development programme based on the views of the stakeholders and literature; 5) To evaluate the feasibility of the youth development programme designed in objective 4; 6) To implement a youth development programme. Method: This study adopted Intervention Mapping as a framework that translated into a five phase study. Each phase informed the next and the findings culminated in the proposed youth development programme for grade 8-10 learners in the Paarl area. Phase 1 used a survey to obtain baseline information about the health risk behaviours that youth engage in and the extent to which learners manage personal situations. The survey was administered using the face-face method and included a demographic questionnaire, the Youth Risk Behaviour Surveillance Survey and the Life Effectiveness Questionnaire. Descriptive statistics such as Frequencies and cross tabulations were performed, as well as inferential statistics including Multiple Regression analysis and Chi-square tests. Phase 2 entailed concept mapping using focus groups and individual interviews with stakeholders to determine their perceptions of the health risks learners engage in and the reasons for their behaviours. The sample included learners, teachers, and community representatives. Thematic analysis was conducted with transcriptions of the focus groups. Phase 3 entailed a systematic review of the literature reporting on interventions aimed at delaying and or preventing engagement in health risk behaviours amongst youth. Phase 4 entailed the triangulation of the findings from the first three phases into a draft programme. Phase 5 included a Delphi study with life skill trainers and experts in the field of health risk programming for adolescents. The Delphi survey was conducted in two rounds. After the feedback in round one, revisions were made to the draft programme to develop the final programme. Results: The results in phase 1 resonated with the findings in the existing body of literature with regards to the health risk behaviours that learners engaged in. Smoking, drinking, sexual activity, drug use, physical inactivity, crime and violence were the most prominent HRBs reported by learners in this sample. Regression analyses indicated that the combination of the LEQ`s life skill domains (Time management, Achievement, Emotional control, Social competence, Active initiative, Self-confidence, Intellectual flexibility and Task leadership) significantly explained between 25% and 56% of the variance in the health risk behaviours (smoking, drinking, drug use, sexual activity). Gendered patterns in engagement with drinking, drug use and risky sexual behaviour was empirically supported by the results of Chi square tests. Drinking and drug use was significantly more prevalent with male learners whilst risky sexual behaviour was significantly more prevalent amongst female learners. Results from phase 2, represented by a concept map suggested that the development of programme content should start with contextual relevance achieved by understanding the range of HRBs youth engage in. This in turn allows for an exploration of the pathways in which engagement has come about. The second and third quadrants illustrate this through their focus on the reasons why youth engage in HRBs and the places where they are exposed to HRBs respectively Once the content has addressed what they do and why they do it, the process of skills development can commence to combat engagement in HRBs. The resultant concept map has four quadrants where each quadrant represents a concept map that corresponded to the themes identified was conceptualized as interacting with one another. During the systematic review process it was identified that effective interventions included the following elements: multi-theoretical approaches, multiple HRBs as targets, gender differentiation, and life skills. In phase 4 a concept map was created that assisted with the design of the programme. The findings from the Delphi study ratified the components included and determined that it was feasible. The recommendations included independent facilitators who have been trained in a specific skill set, avoiding the blurring of the boundary between teachers and facilitators, and a distinction between grades for the purposes of conceptualizing and presenting the programme. This resulted in the researcher augmenting the proposed programme to include independent facilitators; peer mentors; a staggered or tiered programme. These augmentations were substantial and made an immediate implementation not feasible. The scope of the revisions for developing a tiered or staggered programme was adopted as a recommendation, but was outside the scope of the present study in fulfilment of the requirements for a doctoral degree. Thus the final or revised programme only represents the initial level for grade 8 learners and the development process will continue using the same methodology in post-doctoral research. These include the development and accreditation of the training resources, selection and training of faciltators, and the clarification of the relative standing of facilitators in the school environment. Discussion: Health risk behaviour engagement, the factors influencing that engagement and the development of a diverse youth development programme to delay, reduce or prevent it is in itself very complex. Add to it the fact that the youth live in an ever-changing environment where negative role modelling and exposure to health risk behaviour is an everyday occurrence. Structures have been identified in this study that can play a vital role in designing a youth development programme, as well as build on existing programmes. This study incorporated intervention mapping as a participatory design using both quantitative and qualitative methodologies that speak to a high level of rigour and methodological coherence. The study yielded a rich data base with clear directives for future research that will make a significant contribution to the attempts to impact youth development programming and health risk behaviour amongst adolescents. Conclusion: The findings of this study suggest that a multi-theoretical approach to programming that includes gender differentiation and the targeting of multiple HRBs is likely to be more effective in the reduction, delay and prevention of health risk behaviour amongst learners in grade 8-10. The resultant programme is tiered or staggered and differentiates between grades in conceptualization and implementation of the programme. The study presented the programme for the first tier with grade 8 learners and made clear recommendations for the way forward. The study makes an important contribution in its use of participatory methodology that includes stakeholder participation to create a more robust and comprehensive programme.

The majority of Swedish boys and girls have good psychosomatic health. Despite that the risk of mental health problems such as nervousness, feeling low and sleeping difficulties has increased steadily in recent decades. Moreover, previous surveys on health and well-being indicate that boys and girls of foreign extraction in Sweden are at increased risk of ill health compared to boys and girls of Swedish background.   The main aim of this thesis was to analyse health and social determinants among boys and girls of foreign extraction in Sweden. The factors explored in papers I–IV include parental background, family affluence and gender and their associations with subjective health complaints, psychosomatic problems or health risk behaviours. Other included risk factors for ill health were involvement in bullying, low participation and discrimination at school. This thesis takes an intersectional perspective, with ambitions to be able to emphasize the interplay between different power relations (i.e. gender, social class and parental background).   Two sets of cross-sectional data were used. Three papers were based on the Swedish part of the World Health Organization’s Health Behaviour in School-Aged Children. The sample consisted of 11,972 children (boys n = 6054; girls n = 5918) in grades five, seven and nine from the measurement years 1997/98, 2001/02 and 2005/06. The response rate varied between 85 and 90%. About one fifth of the included children were of foreign extraction. For the fourth paper regional data from Northern Sweden were used. Boys (n = 729) and girls (n = 798) in grades six to nine answered a questionnaire in 2011 and the response rate was 80%. About 14% of the included children were of foreign extraction. Statistical methods used were chi-square test, correlation analyses, logistic regression analyses, cluster analyses and test of mediating factor.   The results showed that girls of foreign background were at increased risk of subjective health complaints (SHC) and boys of mixed background were at increased risk of psychosomatic problems (PSP). Increased risk of allocation to the cluster profile of multiple risk behaviour was shown in boys and girls of mixed background, in girls of foreign background and in girls of low family affluence. Increased risk of allocation to the cluster profile of inadequate tooth brushing was shown in boys and girls of foreign background and in girls of low family affluence. General risk factors for increased risk of ill health for boys and girls in Sweden were: any form of bullying involvement, low family affluence, low participation and discrimination at school, of which the latter also was a mediating factor for ill health. Living with a single parent was a risk factor for ill health among girls.   The results can function as a basis for developing health promotion programmes at schools that focus on social consequences of foreign extraction, family affluence, participation as well as health risk behaviours and gender. / Majoriteten av flickorna och pojkarna i Sverige har en god psykosomatisk hälsa. Trots det har risken för psykiska hälsosymptom såsom nervositet, att känna sig nere och sömnsvårigheter ökat successivt de senaste årtiondena. Dessutom indikerar tidigare forskning angående hälsa och välmående att flickor och pojkar med utländsk härkomst har ökad risk för ohälsa jämfört med flickor och pojkar med svensk härkomst.   Denna avhandlings huvudsyfte var att analysera hälsa och sociala bestämningsfaktorer bland flickor och pojkar i Sverige, med fokus på föräldrabakgrund. Artiklarnas (I–IV) syften inkluderar föräldrahärkomst, familjens materiella tillgångar och genus samt dess samband med subjektiva hälsobesvär, psykosomatiska problem eller hälsoriskbeteenden. Andra riskfaktorer för ohälsa som inkluderades var inblandning i mobbning, lågt deltagande och förekomst av diskriminering på skolan. Denna avhandling beaktar ett intersektionellt perspektiv med ambitionen att kunna tydliggöra samspelet mellan olika maktordningar (dvs. genus, social klass och föräldrabakgrund).   Två dataset från tvärsnittsstudier har använts. I de tre första artiklarna användes World Health Organization – Health Behaviour in School-Aged Children, som i Sverige heter Svenska skolbarns hälsovanor. Studiepopulationen bestod av 11 972 barn (flickor n = 5918; pojkar n = 6054) i årskurserna fem, sju och nio undersöknings år 1997/98, 2001/02 och 2005/06. Svarsfrekvensen var mellan 85 och 90 %. Ungefär en femtedel av barnen som deltog hade utländsk härkomst. I den fjärde artikeln användes regional data från norra Sverige. Flickor (n = 798) och pojkar (n = 729) i årskurserna sex till nio deltog i studien år 2011, svarsfrekvensen var 80 %. Omkring 14 % av barnen hade utländsk härkomst. De statistiska metoder som användes var sambandstest (chi-två), test av linjära samband så kallade korrelationsanalyser, logistisk regressionsanalys, klusteranalys och test av medierande faktor.   Resultaten visade att flickor med utländsk bakgrund hade ökad risk för subjektiva hälsobesvär (SHC) och pojkar av mixbakgrund hade ökad risk för psykosomatiska problem (PSP). Ökad risk för att hamna i klusterprofilen multipelt hälsoriskbeteende hade flickor och pojkar med mixbakgrund, flickor med utländsk bakgrund samt flickor i familjer med låg nivå av materiella tillgångar. Ökad risk för att hamna i klusterprofilen bristande tandborstning hade flickor och pojkar med utländsk bakgrund och flickor i familjer med låg nivå av materiella tillgångar. Generella riskfaktorer för ohälsa bland flickor och pojkar i Sverige var: alla former av inblandning i mobbning, låg nivå av materiella tillgångar i familjen, lågt deltagande och förekomst av diskriminering på skolan, vilken den senare även var en medierande faktor för ohälsa. Att leva med en ensamstående förälder var en riskfaktor för ohälsa bland flickor.   Avhandlingens resultat kan ligga till grund för utformande av hälsofrämjande interventioner inom elevhälsan, till exempel interventioner som fokuserar på sociala konsekvenser av utländsk härkomst, familjens materiella tillgångar, deltagande och diskriminering samt hälsoriskbeteenden och genus.