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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:
What Was Left Out | U.S. Specific Items | Bias | References


This chartbook highlights and discusses only those health measures that show important differences for U.S. students in comparison to other students in the HBSC countries as described in an international report for the 1997/98 survey. The full international report includes many measures where U.S. students were not different, but which revealed attributes of adolescent health that are common to all countries.

The HBSC international report includes topics selected primarily from the mandatory questions required for all participating HBSC countries or regions. Due to space limitations and complexity, U.S. chartbook comparisons are shown only for 15-year-old students even though the larger international report and additional HBSC study data also include 11- and 13-year-olds. When comparative rankings or analyses of HBSC data indicate that the international comparisons for younger students are different from those for 15-year-olds, the age-related issues are discussed here. However, it is important to note that a cross-sectional school-based study, such as the HBSC, reflects student status at only one point in time. Many researchers have shown that student health and related behaviors must be considered within a developmental context, consistent with the goal of the HBSC study. While the HBSC study includes young teens from ages 11 to 15 to incorporate these developmental stages, it cannot take the place of analysis based on longitudinal follow-up of individual students to document determinants of health and related behaviors over time. Where nationally representative research from longitudinal studies or from validated studies of U.S. youth are available, those findings have been addressed in discussing the background issues on each topic.

Not all mandatory questions were included in the international report or this U.S. comparison. Other optional standardized questions were asked by fewer countries for topics they considered important enough to include for the limited class time available to complete a survey. If space is available, a country might include questions asked by no other countries, but these questions do not allow comparisons to be made. The following include some important health-related areas that are covered by fewer countries or left out entirely:

Analysis of the eleven countries combined shows that increased perception of family affluence is consistently and positively associated with such positive health behaviors as exercising and eating more fruit. At the same time, health-compromising behaviors, such as smoking and being drunk, either display no relationship or have a heightened association with affluence. Since the analysis combines the 11 countries, including the U.S., this counter trend to usual U.S. findings on socioeconomic status and smoking behavior among both U.S. youth and adults may be because heavy smoking rates among the other ten countries probably carried the heaviest weight in the findings. As noted in the chapter on smoking, U.S. youth are among the least likely to smoke among all HBSC countries.

Among indicators of well-being in the 11 country analysis, perceived health, happiness with life, and self-confidence are related to increased family affluence in seven to eight of the countries, while a greater incidence of daily symptoms and feelings of helplessness are associated with lower family affluence in about half of the countries. Perceived family wealth shows a pattern similar to that for the affluence scale but with a far more consistent association with both the positive and negative health behaviors and feelings of health and well-being.

One HBSC question asked about parental occupations, a question often used in European adult studies to reflect social class or affluence. It was not used in the chartbook because many students don't know what their parents do at work. Also, social class in the U.S. may be less likely to reflect affluence or a sense of social position than does income when compared to more traditional social class measures in many European countries. Besides the mandatory questions on affluence, the U.S. included questions on the highest educational level attained by parents. Comparisons could not be made to other countries on this variable, however. Regardless of how socioeconomic status is measured in the HBSC, these limited results indicate that health behavior and well-being indicators vary with affluence in the expected directions among all the countries analyzed - except for smoking in Europe and drinking in all countries. Clearly, smoking and drinking are influenced more strongly by other factors such as peer group, culture, media, or parental modeling. Still, this limited HBSC analysis appears to indicate that greater wealth is generally associated with positive health attributes in all of the countries.

U.S. specific items:

Race/ethnicity, immigration, and acculturation: Only the U.S. questionnaire addressed racial and ethnic status, immigration, and acculturation (as measured by primary language spoken in the home and place of birth). The U.S. questionnaire includes the same questions as used in the 2000 Census to allow national estimates for African-American and Hispanic students oversampled in the HBSC with large enough numbers to perform analyses for these and other groups, such as Asian-Americans. Other U.S. surveys of adolescents of other ages and vital records show differences in health-related attributes, behaviors, and outcomes by race and ethnicity.7 However, one contextual analysis from the Add Health study which controls for race/ethnicity, family structure, gender, and income indicates that these factors explain no more than 10 percent of the variance in predictions of smoking, alcohol use, involvement with violence, suicidal thoughts or attempts, and sexual intercourse.9 Another AddHealth study finds that parental supportiveness and expectations are more positively associated with adolescent health behavior.10 Future studies of interactions of race/ethnicity with supportive networks in the U.S. HBSC may provide further evidence for understanding disparities in health in order to provide effective services.

Similar supportive network concerns are critical for providing appropriate health services to our large immigrant populations. As noted in topical chapters, historical immigration patterns in the U.S. are quite different from those in most European countries. There is little research on health effects of acculturation among immigrant youth,11 although one AddHealth study shows immigrant children born in other countries generally have significantly fewer physical health problems and risky behaviors than either native born children of immigrants or non-Hispanic white youth.12 A contextual analysis of acculturation in the U.S. HBSC data offers new insights on health-related influences13 for adolescents who usually speak another language at home. They face a greater risk for poor health factors, psychosocial and school risk factors, and less parent support, regardless of race or ethnicity.

Adolescents in the workforce: Only the U.S. survey included a question about work, allowing no international comparisons. Work-related injuries and deaths are not uncommon for youth working both legally and illegally.14,15 The injuries and deaths often occur in jobs declared to be hazardous, or typically prohibited for 14- and 15-year-olds, under Federal child labor laws. Research on job safety among youth has been reviewed by the National Academy of Sciences Committee on the Health and Safety Implications of Child Labor.16 Long work hours during the school year are associated with problem behaviors, including substance abuse and minor deviance, and with insufficient sleep and exercise. The intensity of work during the school year may affect academic performance and social development, together with the possibility that young students who work 'off the books', avoiding labor regulations or payment of required taxes, may be exposed to more dangerous or inappropriate working conditions. At the same time, working may provide many young people with valuable lessons about responsibility, punctuality, dealing with people and money management, while increasing their self-esteem and helping them become independent and skilled.

The U.S. Labor Department estimates that 57 percent of 14-year-olds and 64 percent of 15-year-olds worked for pay in 1994-97 at some time during the year, either during the school year, in the summer or both.17 These estimates are based on self-reports in the National Longitudinal Survey of Youth 1997 (NLSY97) and are higher than time worked by young teens as reported by parents in the Current Population Survey. Youth younger than 16 may work legally under special regulations to guard their health or safety but many work in casual employment arrangements (freelance). Legally, children of any age may work in family-owned businesses and on family farms. Casual (freelance) arrangements are more likely for those age 14, while at age 15, the youth are more likely to have ongoing formal employment arrangements. Work is very common during the school year and the majority of youths with employee jobs work during both the school year and summer. At ages 14 and 15, youths are most frequently employed in the retail trade and services industries.

Using somewhat different definitions of work, an AddHealth analysis finds that 40 percent of 7th and 8th graders were employed during the school year.10 This analysis found that young adolescents who work may be more likely to be injured and are more likely to use tobacco and alcohol than students who don't. The report by the National Academy of Sciences Committee on the Health and Safety Implications of Child Labor recommends review of what circumstances cause working to be detrimental, what can be done to avoid those circumstances, and how working can be made more beneficial.

Other items: The HBSC study asked about time spent watching TV or playing computer games. The survey didn't include questions about time spent on the Internet at home that may include school-related activities or recreational pursuits. U.S. students may have different levels of access to the Internet than do students in Europe due to the cost of non-mobile phone time, indicating possibly different influences among U.S. and European students. There may be a trade-off between using the Internet at home and time spent on after-school activities or other pursuits.

U.S. students are also more likely to require extensive time in transportation to and from school than students in Europe. The current HBSC study does not include a complete overview of time spent with TV, Internet, after school activities, athletic or recreational activities, or with friends. The study asked about time spent exercising but didn't ask about time spent walking or biking as part of daily activities, such as going to school or working around the home and elsewhere. In many European countries, cars are much less likely to be used as part of daily transportation than in the U.S. Increasing trends toward overweight and preliminary analysis of comparable overweight patterns among 15 of the HBSC countries indicate that daily activities of U.S. youth may not encourage expenditure of physical energy.18


Several limitations to the HBSC survey data should be noted. First, because the survey was conducted in schools, the study population excludes such high-risk populations as teens who have dropped out of school or who are in the juvenile justice system. Students in special education classes were also less likely to be interviewed. Students with language difficulties or learning disabilities may have been less likely to complete the questionnaires. Students who were absent on the day of the survey may be more likely to have chronic illnesses or have higher risks associated with truancy and related factors assessed here. Students in alternative schools are not included in the sample and have been shown to have higher levels of health-related risk behaviors than high school students surveyed in the YRBS.19 Thus, the levels of risk reported here may be lower than those of the adolescent population as a whole. Assessment of effects of absenteeism on adolescent reports of health-behaviors in the U.S. have not shown it to be a problem.20 The costs of follow-up on students absent during the survey are extensive. School administrators were not asked for demographic profiles or reasons for absences of students in the HBSC sample, similar to practices in most other school-based surveys, so that analysis of differences among students present to complete the survey and those absent cannot be performed.

U.S. prevalence estimates based on adolescent reports in school-based anonymous settings compared to parent reports in household surveys show higher risk levels on most health-related behaviors when teens report for themselves.21 On similar health measures and risk behaviors such as unintentional injuries, violence, tobacco use, alcohol and other drug use, sexual behaviors, dietary behaviors and physical activity, almost all of those reported by students in the school-based study produce estimates indicating higher risk than in the parental reports. Parents may be less aware of some teen health symptoms such as headaches, feeling low, and feeling tired, resulting in lower estimates from parental reports than from direct reports from teens. However, we know very little about the way that adolescents conceptualize their health and whether their conceptualization parallels that of adults. Adolescent assessment of whether or not they feel healthy may also change over time in a development sequence. We do not know whether those who rate themselves as healthy tend to maintain that self-image, or whether the self-image varies over time, in a manner similar to adults, as they begin to experience a greater number of symptoms. This may be an important research question for assessing the functional health status of our teens.

In addition to potential bias issues, research is needed on how well teens report on health symptoms and behaviors. Besides the AddHealth study, the YRBS and Monitoring the Future, most U.S. national measures on teen health and related behaviors are based on parental reports.22 As youth move through natural developmental processes with increasing age, they usually become more independent of their families with the potential for less parental knowledge of youth symptoms and behaviors. Yet, little testing has been done to contrast measures reported by parents compared to reporting by the teens themselves. Analysis of student reporting taken on two time points for the YRBS indicates that students tend to report health risk behaviors reliably over time.23 The prevalence estimates differed most when the behaviors are either socially stigmatized or illegal, suggesting that students' perception of privacy may be a critical determinant for adolescent reporting, and possibly, parental knowledge of the activities.

Differences in proportions and rankings may exist among countries based on access to health care for treatment of health symptoms and injuries, referral patterns related to use of substances, or management and expectations related to the school or home environment. For example, students may view bullying differently depending on the social norms either at school or home. A preliminary analysis comparing U.S. and Canadian data on medically attended sports and recreational injuries finds that U.S. students are less likely to be hospitalized overnight for similar injuries, even those resulting in comparable activity limitation or time lost from usual activities. HBSC researchers only asked about injuries for which attention was received from a doctor or nurse because most HBSC countries have some form of national health care systems. HBSC researchers generally didn't feel that any other measure was needed to obtain the prevalence measures for injuries. U.S. studies have shown that students without health insurance are less likely to report a medically attended severe injury compared to students with health insurance.24 A survey of U.S. adolescents ages 13-17 who participated through invitations via the Internet and weighted to be as nationally representative as possible, given the sampling source, found that teens report sub-optimal experiences with health care providers.25 The implications for seeking treatment, communication with health care providers, and consultation for risky behaviors were considered problematic, particularly for teens with the greatest needs for health care services.

The HBSC data can support a number of analyses not yet completed that address the relationships across both items left out of the international report and relationships among the many variables included in the report. The topics covered so far are just highlights based on research findings that U.S. students differ from their European and Canadian counterparts. Many commonalities among students throughout the HBSC countries can be found in the larger international report, available at the HBSC website: In addition, the differences may tend to emphasize the negative aspects of student lives, while the positive health-related factors do not receive the attention warranted to help us understand what we are doing well to improve the lives of our youth. One example of this is our relative position on smoking behavior. Overall, the health-related factors included in this report or studied in separate analyses of the HBSC data do direct our attention to what we know from other research in order to improve programs directed to U.S. youth.


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  1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS). (Available at; last accessed July 2002.)
  2. Hingson RW, Heeren T, Jamanka A, Howland J. Age of drinking onset and unintentional injury involvement after drinking. JAMA 2000;284:1527-1533.
  3. Scheidt PC, Harel Y, Trumble AC, Jones DH, Overpeck MD, Bijur PE. Epidemiology of non-fatal injuries in children and youth. Am J Public Health 1995;85:932-938.
  4. Burt CW, Overpeck MD. Emergency visits for sport-related injuries. Ann Emerg Med 2001;37:301-308.
  5. Pickett W, Schmid H, Boyce WF, Simpson K, Scheidt PC, Mazur J, Molcho M, King MA, et al. Multiple risk behavior and injury: An international analysis of young people. Arch Pediatr Adolesc Med 2002;156:786-793.
  6. Ross J, Wyatt W. Sexual behavior. In: 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, 1998. (Available on the HBSC website at
  7. MacKay AP, Fingerhut LA, Duran CR. Adolescent Chartbook. Health, United States, 2000. Hyattsville, MD: National Center for Health Statistics, 2000. Hyattsville, MD: National Center for Health Statistics. 2000.8
  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. Blum RW, Beuhring T, Shew ML, et al. The effects of race/ethnicity, income, and family structure on adolescent risk behaviors. American Journal of Public Health 2000;90:1879-1884.
  10. 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.
  11. Research Forum on Children, Families and the New Federalism. Lack of appropriate research leads to gaps in knowledge about children in immigrant families. The Forum 2002;5(1).
  12. Harris KM. The health status and risk behaviors of adolescents in immigrant families. In: Hernandez DJ (Ed), National Research Council and Institute of Medicine. Children of Immigrants: Health, Adjustment, and Public Assistance. Washington, DC: National Academy Press, 1999;pages 286-315.
  13. Yu SM, Huang ZJ, Schwalberg R, Overpeck MD, Kogan MD. Acculturation and the health and well-being of U.S. immigrant adolescents. J Adolescent Health (in press).
  14. Knight EF, Castillo DN, Layne LA. A detailed analysis of work-related injury among youth treated in emergency departments. Am J Industrial Medicine 1995;27:793-805.
  15. Castillo DN, Malit BD. Occupational injury deaths of 16 and 17 year olds in the US: Trends and comparisons with older workers. Injury Prevention 1997;3:277-81.
  16. National Academy of Sciences Committee on the Health and Safety Implications of Child Labor. Protecting Youth at Work: Health, Safety, and Development of Working Children and Adolescents in the United States. Washington DC: National Academy Press, 1998.
  17. U.S. Department of Labor. Report on the Youth Labor Force. Online report released June 2000 and revised, November 2000. (Available at; last accessed January 2003.)
  18. U.S. Department of Health and Human Services. The Surgeon General's call to action to prevent and decrease overweight and obesity. Rockville, MD: U.S. Public Health Service, 2001.
  19. Grunbaum JA, Kann L, Kinchen SA, Ross JG, Gowda VR, Collins JL, Kolbe LJ. Youth risk behavior surveillance: National Alternative High School Youth Risk Behavior Survey, United States, 1998. J School Health 2000;70:5-17.
  20. Guttmacher S, Weitzman BC, Kapadia F, Weinberg SL. Classroom-based surveys of adolescent risk-taking behaviors: Reducing the bias of absenteeism. Am J Public Health 2002;92:235-7.
  21. Kann L, Brener ND, Warren CW, et al. An assessment of the effect of data collection setting on the prevalence of health risk behaviors among adolescents. J Adolescent Health 2002;31:327-335.
  22. MacKay AP, Fingerhut LA, Duran CR. Adolescent Health Chartbook. Health, United States, 2000. Hyattsville, MD: National Center for Health Statistics, 2000.
  23. Brener ND, Kann L, McManus T, Kinchen SA, Sundberg EC, Ross JG. Reliability of the 1999 Youth Risk Behavior Survey questionnaire. J Adolescent Health 2002;31:336-342.
  24. Overpeck MD, Kotch JB. Effect of access to care on medical attention for injuries. Am J Public Health 1995;85:402-404.
  25. Foundation for Accountability. A Portrait of Adolescents in America, 2001: A report from the Robert Wood Johns Foundation National Strategic Indicator Surveys. Princeton, NJ: The Robert Wood Johnson Foundation, 2002.

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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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