Skip Navigation
Link to the Home Page of U.S. Teens in Our World

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:
Introduction | Background | Statistical Methods | References


The international research study of Health Behavior in School-aged Children (HBSC) has conducted nationally representative surveys every four years since the 1985-86 school year. A growing number of countries in Europe, North America, and the Middle East are participating. In 1997-98, the U.S. performed their first national survey to obtain comparable measures. Like other international studies, such as those on math and science achievement, the HBSC produces comparative international data that allow participating nations to identify their strengths and weaknesses and to develop strategies for improving their performance.1 Beyond comparisons of individual health-related behaviors, the goal of the HBSC is to gain new insight into, and increase understanding of, adolescent health behaviors, health, and lifestyles in their social context for the purpose of providing scientific evidence for program and policy efforts.

The purpose of this chartbook is to investigate areas where U.S. adolescents' health or health-related behaviors emerged as significantly different from those of adolescents in other countries. A much more comprehensive international report includes comparisons of student attributes and some limited analyses across these attributes to describe consistent health and behavioral patterns for adolescents in the 29 countries or regions performing the survey in 1997-98.1 Differences pertinent to U.S. students, such as those highlighted in this chartbook, raise critical questions about the underlying factors resulting in health and health behaviors that affect our students. In some cases, the health behavior of U.S. students may be better than in most other countries and we can assess the efforts successfully applied to achieve our position. In other cases, the health and behaviors are much worse, and we may be able to look at related characteristics of students in other countries to understand more about the effects of our own culture. Specifically, we are asking:

  1. What important information did we learn about U.S. adolescents that we didn't already know; and
  2. What relevant U.S. or international rsearch addresses the factors underlying the highlighted health issues?

By viewing the adolescent in a developmental continuum nested within the context of family, school, peers, and culture, the HBSC offers opportunities to understand the larger community within which U.S. research and programs must work to be effective. Students in the study represent average ages of 11, 13, and 15 years, allowing international comparisons beginning at early pubertal development stages through mid-adolescence, when choices and behaviors are more entrenched. By age 15, many health-related attributes, such as nicotine addiction or being overweight, have become precursors of adult diseases, including respiratory afflictions, cancer, and heart disease. As a research consortium, the HBSC investigators emphasize the need to understand how the developmental stages of adolescence interact with the cultural, social, and physical community.

HBSC goals are consistent with the developmental emphasis of the two agencies sponsoring the HBSC in the U.S.: the Health Resources and Services Administration’s Maternal and Child Health Bureau (HRSA/MCHB) and the National Institute of Child Health and Human Development (NICHD). A recent report sponsored by HRSA/MCHB on research priorities for adolescent health stressed understanding interactions of physical, psychological, and social development within social and environmental contexts.2 The Strategic Plan of 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.3

A recent report on current knowledge of the interplay of biological, behavioral, and societal influences on links between health and behavior emphasized the complexity of relating these multiple influences to specific interventions to reduce unhealthy behavior.4 The HBSC research study, which compares adolescent health and behaviors within the social context of multiple cultures and country structures, cannot address this complexity either. However, it does provide new suggestions to help us understand how our own U.S. culture and the structure of family and schools may influence adolescent health and behavior. Programs to promote healthy youth development are fielded and supported at many levels, but their effectiveness is difficult to determine. The National Research Council and Institute of Medicine established a committee to identify community programs with sufficiently strong evidence of success to suggest that they could serve as models for enhancing youth development programs.5 They found that the research base is just becoming comprehensive enough to allow tentative conclusions about how individual student assets lead to positive development and the characteristics that support these assets. Again, the HBSC study, describing individual health behaviors within the family, peer, and school social context, will not provide sufficient information to validate intervention programs. However, much of the research addressed in the HBSC is based on studies in both North America and Europe that have indicated how supportive social environments influence the individual adolescent health behaviors described in this chartbook.

The U.S. sponsors several other continuous surveys to monitor changes in adolescent health indicators for the older age ranges, including the Youth Risk Behavior Survey (YRBS) and Monitoring the Future.6,7 The indicators from these and other surveys or vital records are used to perform surveillance and measure progress toward our goals for adolescent health, as described in Healthy People 2010 and America's Children.8,9,10 Research findings from the nationally representative National Longitudinal Study of Adolescent Health (AddHealth), a school-based survey based on follow-up of students and their parents initiated in 1994, are adding both contextual and developmental depth.11 HBSC data complement these surveillance systems and provide family, peer, school, and community context for research on attributes influencing the currently available indicators by which we measure progress in the U.S. As a cross-sectional study of students at ages 11, 13 and 15 years, the HBSC does not follow individual students through their developmental stages for an in-depth understanding of the interface between biological and social influences. Although such longitudinal studies have been conducted on the community level, national studies are needed.

The HBSC data presented in this chartbook are based on nationally representative school-based surveys performed in 29 countries or regions in the 1997-98 school year. An extensive comparison of health-related measures collected for the three age groups is available for reference and further detail in an international HBSC publication or from specific research based on fewer countries who asked optional topic-specific questions in a consistent manner.1 This chartbook highlights and discusses only those health measures that show important differences for U.S. students. Graphical presentation is limited to age 15 to conserve space. In instances where cross-country comparisons varied across the ages of 11, 13 and 15, the differences are noted, with reference made to the larger international report. Specifically, the measures are organized within the topics of general health and well-being, fitness, family and peer relationships, school relationships, smoking and alcohol use, and violence. A synthesis of current programs and the research underlying the programs addresses whether program and/or research objectives are specific to documented underlying factors affecting the measures.

Our goal is to learn more about U.S. adolescent health status as highlighted through comparisons to other developed countries and describe current U.S. research which addresses these health-related measures in order to improve adolescent health. The target audiences of this chartbook include program and policy officials, researchers, health professionals, school administrators, school health educators and staff, parents, and students. As with most successful changes in the health of our population, multifaceted efforts incorporating education, support of the individual to access means for change, and legislation require that we all work together to improve adolescent health. Support for our children, adolescents, and families in maintaining healthy lives within the larger community should be assisted by HBSC research, based on seeing ourselves from the outside.


The HBSC study includes nationally representative surveys of students at ages 11, 13, and 15 years of age across countries.1 The HBSC has been conducted every four years, starting in 1985-86, with a growing number of countries involved. Twenty-nine countries and regions participated in the 1997-98 school-year survey. NICHD sponsored the 1997-98 U.S. survey, in collaboration with HRSA/MCHB, which has responsibility for fielding the HBSC study for future survey rounds.

The survey performed in the 1997-98 school year included questions that were mandatory for all 29 participating countries and regions. The questions were pretested and translated into country-specific language to measure the same construct in each country, if possible.12 Any deviances from the exact wording of the questions are noted, if any. Wording was changed only if the definitions were different; e.g., 'chips' is the name used in most European countries for potatoes fried in a manner similar to french fries in the U.S. while 'potato crisps' are the equivalent of potato chips in the U.S. These deviances are described further in HBSC documentation, which is available elsewhere.1,5 In addition to the mandatory questions, optional questions on specific topics were fielded in some countries yielding comparisons for fewer countries, but allowing each country to address issues considered to be of high importance. The U.S. included questions on violence and injury, with comparisons to countries collecting the same data presented here.13

Topics in the chartbook were selected based on the general criterion that the U.S. measures fall in the top or bottom third of the 29 countries, with generally significant differences among countries when ranked by proportions of 15-year-old students with the particular attribute. If most of the countries, including the U.S., have similar attributes of a general topic, they are not included in the chartbook but may be found in the complete international report.1


Significant differences between an attribute measured across countries are based on the sample design requirements for participation in the HBSC. Surveys are performed in a single classroom within a school. Student characteristics within a single classroom tend to be similar (clustered). Given a clustered school-based representative sample design, countries are required to include a minimum sample size for each of the three age groups (about 1,500 per age group), estimated to produce a 95 percent confidence interval of +3 percent around a proportional estimate of 50 percent and a design factor of 1.2. The design factor is a ratio estimate of amount of variance due to the clustered sample design compared to the variance if the surveys were based on simple random samples of individual students. The sample design criteria can be found, with examples, in the international report for 1997/98, referenced above. Variance estimates obviously vary for each variable and within each country. However, the following guidelines may be used for very approximate 95 percent confidence intervals around proportions shown in the chartbook:

Proportion of
Interest (%)
Interval (%)






















* Note: If you used a link in the text to reach these footnotes, please use the "Back" button on your browser to return to the text you were reading.

  1. Currie C, et al. (eds.) Health and Health Behaviour among Young People (International Report from the HBSC 1997/98 Survey). WHO Policy Series: Health policy for children and adolescents. Issue 1, 2000. (Available on the HBSC Website at
  2. 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.
  3. National Institute of Child Health and Human Development. From Cells to Selves: Strategic Plan 2000. (Available at
  4. 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
  5. National Research Council and Institute of Medicine. Community Programs to Promote Youth Development. Committee on Community-Level Programs for Youths. Eccles J, Gootman JA, eds. Washington, DC: National Academy Press, 2002.
  6. National Center for Chronic Disease Prevention and Health Promotion. Youth Risk Behavior Survey. Atlanta, GA: Centers for Disease Control and Prevention. (Description available at
  7. National Institute on Drug Abuse and University of Michigan Institute for Social Research. Monitoring the Future Study. (Description available at and
  8. U.S. Department of Health and Human Services. Healthy People 2010: Understanding and Improving Health. 2nd ed. Washington, DC: U.S. Government Printing Office, November 2000.
  9. MacKay AP, Fingerhut LA, Duran CR. Adolescent Health Chartbook. Health United States, 2000. Hyattsville, MD: National Center for Health Statistics, 2000.
  10. Federal Interagency Forum on Child and Family Statistics. America's Children: Key national indicators of well-being, 2001. Washington, DC: U.S. Government Print Office, 2002.
  11. Bearman PS, Jones J, Udry JR. The National Longitudinal Study of Adolescent Health: Research Design. (Available at
  12. Currie C. Health Behaviour in School-Aged Children. Research protocol for the 1997-98 survey. A World Health Organization Cross-National Study. Edinburgh: University of Edinburgh, 1998. (Available on the HBSC Website at
  13. DataSpeak videocast of International Perspectives on Youth Violence. (Available at

* Note: If you used a link in the text to reach these footnotes, please use the "Back" button on your browser to return to the text you were reading.


This chartbook is the product of the efforts of many authors and editors, including Mary Overpeck, Dr.P.H., Trina Menden Anglin, M.D.,Ph.D., Michael Kogan, Ph.D., Sharon Adamo, M.S., M.B.A., R.D., Michelle Lawler, M.S., R.D., Laura McNally, M.P.H., R.D., F.A.D.A., Denise Sofka, R.D., M.P.H., Audrey Yowell, Ph.D., and Stella Yu, Sc.D. of the Health Resources and Services Administration, Maternal and Child Health Bureau; Christine Bachrach, Ph.D., Peter Scheidt, M.D., M.P.H. and Bruce Simons-Morton, Ed.D., M.P.H. of the National Institute for Child Health and Human Development; Claire Brindis, Dr.P.H. of the National Adolescent Health Information Center; Renee Schwalberg, Jennifer Dunbar, Isha Fleming and Dorothy Borzsak of the Maternal and Child Health Information Resource Center; and Ryan Lalonde of Vanguard Communications (cover design).


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

Top of Page