Education system stratification and health complaints among school-aged children.

Research shows that the school environment is an important social determinant of health among children and adolescents. However, we know virtually nothing of the health consequences of national education systems and policies, for example the stratification of pupils by academic ability. This study aimed to investigate if education system stratification is related to self-reported psychological and somatic health complaints of pupils aged 11 to 15, and social inequalities in such health complaints. Survey data from the Health Behaviors of School-aged Children (HBSC) survey, covering 33 countries and more than 180 000 pupils in primary and lower secondary school, were used. Multilevel models showed that education system stratification was not associated with the average levels of health complaints of pupils, but cross-level interaction effects showed that stratification moderated the relationship between social background and health complaints, such that inequalities in health complaints were smaller in countries with more stratified systems. Moreover, this moderating effect was mediated by the school learning environment and social relations in school. Specifically, social inequalities in school pressure, academic self-concept, school climate, and school satisfaction were smaller in more stratified education systems, which in turn accounted for smaller inequalities in health complaints in these countries.