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U.S. Teens in Our World

Understanding the Health of U.S. Youth in Comparison to Youth in Other Countries

Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary


In this section:
Executive Summary | References


The international Health Behavior in School-aged Children (HBSC) study has coordinated comparable, nationally representative school-based surveys of teens every four years since 1985-86. The overarching goal of the HBSC study is to understand adolescent health and health-related behavior in the context of family, school, and peers, using international comparisons to demonstrate common factors and highlight differences associated with cultural influences. These international comparisons show health-related characteristics that are common to adolescents at specific developmental stages regardless of nationality. Individual differences between countries highlight the health attributes and behaviors that suggest more local cultural, environmental, or socio-demographic influences. The United States participated in the HBSC study for the first time in 1998 in order to improve adolescent health through programs and research targeted to provide appropriate health-related services. An international report includes comparisons of student attributes and some limited analyses across these attributes to describe consistent health and behavioral patterns for teens in the 29 countries or regions performing the survey in 1997-98.1 By viewing our youth's health within the context of family, school, peers, and culture, we learn more about the larger community within which U.S. programs must work to be effective.This chartbook investigates areas where U.S. adolescents' health or health-related behaviors emerged as significantly different from those of adolescents in other countries in positive, negative, or suggestive directions. Specifically, we ask:

Comparisons in this report are limited to age 15 due to space restrictions, although the study addresses teens through developmental stages at ages of 11, 13 and 15 years. The international report describes all ages, including developmental aspects. This U.S. report discusses pertinent age-related differences, particularly when trends for U.S. students differ from patterns in other countries. Findings are organized within the topics of general health and well-being, fitness, family and peer relationships, school relationships, smoking and alcohol use, and violence.

Relative country rankings of student attributes show a number of commonalities across countries, including consistent gender differences. The differences found for U.S. students may direct us to areas requiring further research and programmatic attention. They also point to areas where U.S. programs and policies appear to show successful reductions in unhealthy behaviors. Some of the more important differences are highlighted below:

Analyses based only on U.S. HBSC survey data have already refocused our attention to issues affecting U.S. students. For example, studies on the prevalence and psychosocial effects of bullying behavior in U.S. teens, together with violence related to bullying, support work to mitigate this behavior. Our data show about 30 percent of U.S. students in grades six to ten report moderate or frequent (weekly) involvement in bullying, either at school or away.2 This study demonstrates the differences in psychosocial attributes of students who bully others, are bullies, or are both bullies and victims of bullying. U.S. students involved in bullying are more likely to participate in violent behavior, including weapon carrying and frequent fighting.3 Students involved in frequent bullying (as either the bully or the victim) are more likely than other students to report carrying a weapon for protection either at school or away. The likelihood of weapon-carrying is particularly high when students either bullied others or were bullied away from school grounds. Bullies (including bullies who are also bullied) were most likely to carry weapons for self-defense.

The international study does not address issues related to race, ethnicity, or immigration. Historical immigration patterns and the extent of diversity is quite different in the U.S. compared to most European countries. Both published4 and preliminary analysis of the U.S. HBSC data on youth living in homes where the primary language spoken is other than English shows they are more likely to have psychosocial problems and feel a lack of connectedness compared to non-Hispanic white English-speakers. Adolescents who speak other languages at home, exclusively or in combination with English, are particularly likely to report feelings of vulnerability, exclusion, and lack of confidence, such as alienation from classmates, being bullied at school, and concerns about school and parental support. However, preliminary analysis of the U.S. HBSC data on Asian American students who spoke languages other than English at home also shows them to be less likely to use substances such as cigarettes, chewing tobacco, marijuana, or to have ever experimented with alcohol, indicating that lower levels of acculturation may also be protective for some high-risk behaviors.

International and U.S. analyses from the HBSC and the more in-depth longitudinal, multi-level research of the U.S. Adolescent Health Study show that feelings of support and connectedness to family, school, and peers are highly associated with positive health and behaviors.1,5,6 Whether addressing health and depressive symptoms, fitness, diet, attitudes toward school, smoking and alcohol use, or violence, research demonstrates that students' feeling of being connected to positive support systems-families, schools, neighborhoods and communities-makes a difference.7,8

The interactions among personal attributes, health behaviors, family and peer networks, and larger cultural influences are difficult to measure.9 Adolescent health behaviors measured between ages 11 and 15 years reflect not only genetic, family, and early and middle childhood exposures,10 but individual effects, such as puberty and maturation, and direct interactions with peers, neighborhoods, and communities. The HBSC is attempting to measure the maturational and neighborhood effects in subsequent surveys to address the complex interactions of biological, social, and physical environmental factors through the various developmental stages of children and youth. The Strategic Plan of National Institute of Child Health and Human Development (NICHD) states that there is little comprehensive research on adolescence, despite the many important neurobiological, hormonal, and social behavior interactions to be addressed during transitions into, from, and throughout this developmental period.11 Recommendations synthesizing lessons learned in a review of research study findings were published in a report sponsored by the Health Resources and Services Administration's Maternal and Child Health Bureau (HRSA/MCHB).12 Cross-cutting themes identified as priorities for directions of future adolescent research include: 1) applying a developmental perspective; 2) emphasizing health; 3) using multiple influence models for understanding and improving health and development; and 4) recognizing the diversity of the adolescent population.

Differences pertinent to U.S. students, such as those highlighted in this chartbook, direct attention to U.S. programs and support their attempts to address health-related factors based on appropriately targeted research which has been evaluated for effectiveness. Prevention strategies and interventions targeted to teens become more complex when considering the issues identified as priorities for research listed above and the multiple venues within which youth interact. A national committee of experts assessed programs that may serve as models to promote positive outcomes in youth by identifying community interventions with sufficiently strong evidence of effectiveness.7 These programs are located in communities in which youth live, including both geographic communities and those based on family connections and shared interests or values, including schools, since many of the best-regarded programs craft explicit links with both home and school. For example, two U.S. studies on bullying using HBSC data show that the risk of weapon carrying and fighting are higher for students involved in bullying away from school grounds than at school.2,3 International comparisons and studies of violence or bullying occurring only at school do not provide sufficient breadth to understand bullying and violence within the context of a youth's activities away from school, in the community, and at home. Not only do we need to address bullying behavior in school, but the findings direct us to learn more about where, how, and why these events occur in order to address future preventive program efforts effectively. The school environment as either a formal or informal venue for promoting healthy behaviors is appropriate and necessary, but probably not fully sufficient for successful interventions.7

HBSC comparisons of smoking behavior are a good example of positive changes resulting from effectively targeted research and programs. At age 15, U.S. students are ranked among those least likely in all HBSC countries to smoke daily, consistent with U.S. surveillance reports of decreases in teen smoking during the last several years.13,14 U.S. students' ranking for daily smoking at age 15 is low, even though our students are as likely to experiment with smoking as students in other countries. After 25 years of attempting to reduce smoking among our youth, evaluation of interventions concludes that no single strategy has been successful, and multiple approaches at the population and individual levels have the greatest chance of success.7

A joint effort of HRSA/MCHB and the Centers for Disease Control and Prevention supports collaborative action at the community, State, and national levels to elevate the national focus on the health and well-being of adolescents and young adults through the National Initiative to Improve Adolescent Health.15 Together with NICHD, they are addressing the underlying supportive networks required to improve adolescent health, as demonstrated through the research and findings described in this chartbook. The two sponsoring agencies of the HBSC study, NICHD and HRSA/MCHB, are responsible, respectively, for conduct of research on the causes and prevention of disease and health behaviors leading to poor adolescent health11 and for promoting and improving the health of adolescents through effectively targeted programs.16 The HBSC focus on adolescents within the context of family, school, peers, neighborhood, community and culture contributes to the efforts to provide targeted research to aid effective programs.


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  1. Currie C, et al. (eds.) Health and Health Behaviour among Young People. WHO Policy Series: Health Policy for Children and Adolescents, Issue 1. (Available at
  2. Nansel TR, Overpeck MD, Pilla RS, Ruan WJ, Simons-Morton BG. Bullying behaviors among the U.S. youth: Prevalence and association with psychosocial adjustment. JAMA 2001; 285(16):2094-2100.
  3. Nansel TR, Overpeck MD, Ruan WJ, Haynie DL, Scheidt PC. Relationships between bullying and violence among US youth. Arch Pediatric Adolescent Medicine (in press).
  4. Yu SM, Huang ZJ, Schwalberg RH, Overpeck M, Kogan MD. Acculturation and the health and well-being of U.S. immigrant adolescents. J Adolescent Health (in press).
  5. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: Findings from the National Longitudinal Study on Adolescent Health. JAMA 1997; 278:823-832.
  6. McNeely CA, Nonnemaker JM, Blum RW. Promoting school connectedness: Evidence from the National Longitudinal Study of Adolescent Health. J School Health 2002; 72:138-146.
  7. National Research Council and Institute for Medicine. Community Programs to Promote Youth Development. Committee on Community-Level Programs for Youth. J Eccles and JA Gootman, eds. Board on Children, Youth and Families, Division of Behavioral and Social Sciences and Education. Washington DC: National Academy Press, 2002.
  8. Demographic and Behavioral Sciences Branch. Research on Today's Issues: Strong school, family ties protect teens from violence, drugs, suicide and early sex. Briefing Papers, Issue No. 8. Bethesda, MD: National Institute of Child Health and Human Development, 1998.
  9. National Academy of Sciences Committee on Health and Behavior. Health and Behavior: The interplay of biological, behavior, and societal influences. Washington, DC: National Academy Press, 2001. (Available at
  10. National Research Council and Institute of Medicine Committee on Integrating the Science of Early Childhood Development. From Neurons to Neighborhoods: The Science of Early Childhood Development. Washington, D.C.: National Academy Press, 2000.
  11. National Institute of Child Health and Human Development. From Cells to Selves: Strategic Plan 2000. (Available at
  12. Millstein SG, Ozer EM, Brindis CD, Knopf DK, Irwin CE. Research Priorities in Adolescent Health: An analysis and synthesis of research recommendations. San Francisco, CA: University of California, San Francisco. National Adolescent Health Information Center, 1999.
  13. National Institute on Drug Abuse and University of Michigan Institute for Social Research. Monitoring the Future Study. (Available at: and
  14. Centers for Disease Control and Prevention. Youth Risk Behavior Surveillance-United States, 2001. Morbidity and Mortality Weekly Report 2002; 51(SS-4).
  15. Healthy People 2010. Critical Objectives for Adolescents and Young Adults. (List available at
  16. Health Resources and Services Administration Maternal and Child Health Bureau. (Program goal descriptions available at:

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Table of Contents | Executive Summary | Introduction | Chapter 1 | Chapter 2 | Chapter 3 | Chapter 4 | Chapter 5 | Chapter 6 | What Was Left Out | Summary

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