The methodology of the Italian Health Behaviour in School-aged Children (HBSC) 2018 study and its development for the next round


Healthy behaviour
epidemiological surveillance


Introduction - The Italian “Health Behaviour in School-aged Children” (HBSC) is a national surveillance system that collects data on health and well-being among adolescents aged 11, 13 and 15 years attending school. It is part of the HBSC Research Network, an international alliance of researchers from 45 European and North American countries and regions started in 1982.

Methods - All countries and regions participating in HBSC must adhere to a common international standard protocol developed and systematically updated by the entire HBSC Network. Data collection occurs every four years. Italy joined the international Network in 2000 and, to date, five waves (in 2002, 2006, 2010, 2014 and 2018) have been carried out. From 2010 the Italian HBSC is representative at regional level and in 2017 became the base of the “Surveillance system for risk behaviours in 11-17 year-olds”, part of the Prime Ministerial Decree “Identification of surveillance systems and registries of mortality, tumours and other diseases”. Cluster sampling is used, with school class as primary sampling unit, and two validated questionnaires are used to collect the information.

Results - In 2018, the Italian HBSC involved 3,608 classes and 58,976 students. The average response rates were 86% of sampled classes and 97% of students achieving a national and regional representative sample for youths of all age groups (19,504 eleven-year-old, 20,554 thirteen-year-old and 18,918 fifteen-year-old). The national coordination group prepared a standardized format for disseminating the results locally and indicating areas for intervention. A national report and some articles have been published. The next round, which will take place in the 2021-2022 school year, will also involve a representative sample of students of grade four of secondary schools (adolescents aged 17 years) and use on line questionnaires.

Conclusions - Over 3 decades at international and 2 decades at national level have demonstrated that HBSC methodology and its results are useful for monitoring and deepening the knowledge on the most critical issues of adolescents’ well-being.


1. Dietz WH. Periods of risk in childhood for the development of adult obesity. What do you need to learn? J Nutr 1997;127: S1884-6.
2. Engels RC, Scholte RH, Van Lieshout CF, De Kemp R, Overbeek GJ. Peer group reputation and smoking and alcohol consumption in early adolescence. Addict Behav 2006;31:440-9.
3. Patton GC, Coffey C, Cappa C, et al. Health of the world’s adolescents: a synthesis of internationally comparable data. Lancet 2012;379:1665-75.
4. Poikolainen K, Tuulio-Henriksson A, Aalto-Setäläet T, Marttunen M, Lönnqvist J. Predictors of alcohol intake and heavy drinking in early adulthood: a 5-year follow-up of 15-19 year-old Finnish adolescents. Alcohol Alcohol 2001;36(1):85-8.
5. Utter J, Scragg R, Schaaf D. Associations between television viewing and consumption of commonly advertised foods among New Zealand children and young adolescents. Public Health Nutr 2006;9(5):606-12.
6. Bel-Serrat S, Huybrechts I, Thumann BF, et al. Inventory of surveillance systems assessing dietary, physical activity and sedentary behaviours in Europe: a DEDIPAC study. European Journal of Public Health 2017;27 (4):747–755.
7. Health Inequalities Impact Assessment – an approach to fair and effective policy making: guidance, tools, and templates. Edinburgh, NHS Health Scotland, 2013. Available at:
8. Aaro LE, Wold B, Kannas L, Rimpela M. Health behaviour in school-children. A WHO cross-national survey. Health Promotion 1986;1:17–33.
9. Smith C, Wold B, Moore L. Health behaviour research with adolescents: a perspective from the WHO cross-national Health Behaviour in School-aged Children study. Health Promotion Journal of Australia 1992;2:41–44.
10. Cavallo F, Santinello M, Eds. Stili di vita e salute dei giovani italiani, 11-15 anni. Rapporto sui dati italiani dello studio internazionale HBSC 2001-2002. Torino: Minerva Medica, 2003. Available at:
11. Cavallo F, Lemma P, Santinello M, Giacchi M, Eds. Stili di vita e salute dei giovani italiani, 11-15 anni. II Rapporto sui dati italiani dello studio internazionale HBSC 2006. Available at:
12. Cavallo F, Giacchi M, Vieno A, Galeone D, Tomba A, Lamberti A, Nardone P, Andreozzi S, Eds. Studio HBSC-Italia (Health Behaviour in School-aged Children): rapporto sui dati 2010. Roma: Istituto Superiore di Sanità (Rapporti ISTISAN). Available at:
13. Report Nazionale dati HBSC Italia 2014. Available at:
14. Nardone P, Pierannunzio D, Ciardullo S, Spinelli A, Donati S, Cavallo F, Dalmasso P, Vieno A, Lazzeri G, Galeone D (editors). La Sorveglianza HBSC 2018 - Health Behaviour in School-aged Children: risultati dello studio italiano tra i ragazzi di 11, 13 e 15 anni. Available at:
15. Currie C, Grieber R, Inchley J et al, Eds. Health Behaviour in School-aged Children (HBSC) Study Protocol: Background, Methodology and Mandatory Items for the 2009/10 Survey. Edinburgh: CAHRU, 2010.
16. Roberts C, Freeman J, Samdal O, et al. The Health Behaviour in School-aged Children (HBSC) study: methodological developments and current tensions. Int J Public Health 2009;54(Suppl 2): 140-50.
17. Bennet S, Woods T, Liyanage WM, Smith DL. A simplified general method for cluster-sample surveys of health in developing countries. World Health Stat Q 1991; 44: 98-106.
18. Lazzeri G, Giacchi MV, Dalmasso P, Vieno A, Nardone P, Lamberti A, Spinelli A, Cavallo F, HSBC 2010 Group. The methodology of the Italian HBSC 2010 study (Health Behaviour in School-aged Children). Annali di igiene: medicina preventiva e di comunità 2013;25(3):225-233.
19. Regional HBSC Italian Report. Available at:
20. Nardone P, Pierannunzio D, Ciardullo S, Lazzeri G, Cappello N, Spinelli A; 2018 HBSC-Italia Group; the 2018 HBSC-Italia Group. Dietary habits among Italian adolescents and their relation to socio-demographic characteristics. Ann Ist Super Sanita. 2020 Oct-Dec;56(4):504-513. doi: 10.4415/ANN_20_04_15. PMID:33346179
21. Borraccino A, Lo Moro G, Dalmasso P, Nardone P, Donati S, Berchialla P, Charrier L, Lenzi M, Spinelli A, Lemma P; 2018 HBSC-Italia Group; the 2018 HBSC-Italia Group. Sexual behaviour in 15-year-old adolescents: insights into the role of family, peer, teacher, and classmate support. Ann Ist Super Sanita. 2020 Oct-Dec;56(4):522-530. doi: 10.4415/ANN_20_04_17. PMID: 33346181.
22. Charrier L, Canale N, Dalmasso P, Vieno A, Sciannameo V, Borraccino A, Lemma P, Ciardullo S, Berchialla P; 2018 HBSC-Italia Group; the 2018 HBSC-Italia Group. Alcohol use and misuse: a profile of adolescents from 2018 Italian HBSC data. Ann Ist Super Sanita. 2020 Oct-Dec;56(4):531-537. doi: 10.4415/ANN_20_04_18. PMID: 33346182
23. Marino C, Lenzi M, Canale N, Pierannunzio D, Dalmasso P, Borraccino A, Cappello N, Lemma P, Vieno A; 2018 HBSC-Italia Group; the 2018 HBSC-Italia Group. Problematic social media use: associations with health complaints among adolescents. Ann Ist Super Sanita. 2020 Oct-Dec;56(4):514-521. doi:10.4415/ANN_20_04_16. PMID: 33346180.
24. Clark H, Coll-Seck AM, Banerjee A et al. A future for the world's children? A WHO–UNICEF–Lancet Commission. Lancet 2020;395:605-658.
25. Elgar F, Moore L, Roberts C, Tudor-Smith C. Validity of self-reported height and weight and predictors of bias in adolescents. J Adolesc Health 2005;37:371-5.
26. Himes JH, Hanna P, Wall M, Neumark-Stzainer D. Factors associated with errors in self-reports of stature, weight, and body mass index in Minnesota adolescents. Ann Epidemiol 2004;15:272-8.
27. Magaly AM, Whitehead R, Inchley J, Giralt M, Currie C, Solà R. Self-reported weight and predictors of missing responses in youth. Nutrition 2018;53:54-58. doi: 10.1016/j.nut.2018.01.003.
28. Schnohr C, Molcho M, Rasmussen M, Samdal O, de Looze M, Levin k, Roberts C, Ehlinger V, Krølner R, Dalmasso P, Torsheim T. Trend analyses in the health behaviour in school-aged children study: methodological considerations and recommendations. European Journal of Public Health 2015; 25(S2):7–12.
29. Thomas JR, Nelson JK, Silverman SJ. Research methods in physical activity. Seventh edition. Champaign, IL: Human Kinetics 2015. 2..
30. Thomas JR, Mann CJ. Observational research methods. Research design II: cohort, cross sectional, and case-control studies. Emerg Med J 2003;20(1):54-60.
31. Menard S. Longitudinal research. 2nd ed. Thousand Oaks: Sage; 2002.
32. Laursen BP, Little TD, Card NA. Handbook of developmental research methods. New York: Guilford Press; 2012.
33. Lazzeri G, Dalmasso P, Berchialla P, Borraccino A, Charrier L, Giacchi M.V, Simi R, Lenzi M, Vieno A, Lemma P, Cavallo F. Trends in adolescent overweight prevalence in Italy according to socioeconomic position. Annali dell'Istituto superiore di sanita 2017;53(4):283-290.
34. Lazzeri G, Panatto D, Pammolli A, Azzolini E, Simi R, Meoni V, Giacchi MV, Amicizia D, Gasparini R. Trends in overweight and obesity prevalence in Tuscan schoolchildren (2002–2012). Public health nutrition 2015;18(17):3078-3085.
35. Vieno A, Lenzi M, Gini G, Pozzoli T, Cavallo F, Santinello M. Time trends in bullying behavior in Italy. Journal of school health 2015;85(7):441-445 doi: 10.1111/josh.12269.
36. Vieno A, Altoè G, Kuntsche E, & Elgar FJ. (2018). Do public expenditures on health and families relate to alcohol abstaining in adolescents? Multilevel study of adolescents in 24 countries. Drug and Alcohol Review, 37, S120-S128. DOI: 10.1111/dar.12696.
37. F Cavallo, P Dalmasso, V Ottova-Jordan, Brooks F, Mazur J, Välimaa R, Gobina I, Gaspar de Matos M, Raven-Sieberer U, Positive Health Focus Group. Trends in self-rated health in European and North-American adolescents from 2002 to 2010 in 32 countries. Eur J Public Health 2015;25(suppl_2):13-15.
38. Cavallo F, Dalmasso P, Ottova-Jordan V, Brooks F, Mazur J, Välimaa R, Gobina I, Gaspar de Matos M, Raven-Sieberer U, Positive Health Focus Group. Trends in life satisfaction in European and North-American adolescents from 2002 to 2010 in over 30 countries. Eur J Public Health 2015;25(suppl_2):80-82.
39. Ahluwalia N, Dalmasso P, Rasmussen M, Lipsky L, Currie C, Haug E, Kelly C, Damsgaard MT, Due P, Tabak I, Ercan O, Maes L, Aasvee K, Cavallo F. Trends in overweight prevalence among 11-, 13-and 15-year-olds in 25 countries in Europe, Canada and USA from 2002 to 2010. Eur J Public Health 2015;25(suppl_2):28-32.