U.S. Teens in Our World

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

SUMMARY

SUMMARY

The U.S. participates in the HBSC study in order to improve adolescent health through programs and research targeted to provide appropriate health-related services. 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. International comparisons show underlying characteristics that are common to adolescents within developmental stages that are common to all nationalities. Individual country differences highlight health measures and related behaviors that suggest more local cultural, environmental, socio-demographic influences. This report responds to two questions:

What important information did we learn about common adolescent health characteristics, and about U.S. adolescents specifically, that we didn't already know?
What relevant U.S. or international research addresses the factors underlying the highlighted health issues?

Previous chapters summarize some of the relevant research for each topic, using primarily U.S. studies performed at the national level or studies based on HBSC research. The following summary presents highlights of HBSC findings addressing the question about what we learned.

What did we learn?

Overall health and well-being:

Adolescence is generally considered a time of good health; levels of illness and chronic disease are generally low, and injuries present the greatest threat to adolescents' health. However, how students feel on a daily basis, both physically and psychologically, may directly affect the success of their transition through adolescence. Their perceptions of health, self-confidence and satisfaction with life reflect the level of biological and psychosocial stress and anxiety that they experience.

Boys tend to report somewhat better health than girls in all countries, with the proportions not feeling healthy increasing between ages 11 and 15 years for both genders. The U.S. ranks among the leading countries in reports of not feeling healthy, ranking seventh highest for boys and thirteenth for girls (at 8 percent and 13 percent, respectively). Other countries (or regions) with such high levels are primarily Eastern European and in the Russian Federation.

Similar comparison levels are shown in reports of not feeling happy, with the girls less likely to feel happy in all countries as students age. U.S. boys rank seventh among countries for not feeling happy (at 9 percent), and girls rank eleventh (at 25 percent) with proportions ranging across countries from 5 percent to 42 percent of boys and 9 percent to 47 percent of girls. At the same time, U.S. students are no more likely to feel lonely than students in other countries.
Students in the U.S. rank highest or among the top four countries in prevalence of stomachache, backache, headache, difficulty sleeping, feeling tired in the morning and feeling low at least once a week. More than 40 percent of U.S. females report backaches or stomachaches at least weekly; 57 percent report equally frequent headaches. Almost half of U.S. girls and one-third of boys report feeling low once a week or more. More than one-fourth of both girls and boys report having sleep difficulties at least once a week. Relatively high reporting of medication use by U.S. students for headache, stomachache, and difficulty sleeping support the reports of elevated U.S. levels of physical symptoms.

Fitness

Fitness contributes to overall health and well-being through exercise, diet, lifestyle factors, and maintaining a healthy body and body image.

Most U.S. students exercise twice a week or more but still rank in the bottom among all countries for frequency of exercise. Of those who exercise, U.S. students rank in the middle for time spent exercising.
U.S. students are more likely to consume french fries and soft drinks with sugar than students in almost all other countries. U.S. students are also among the lowest-ranking in the proportion who eat fruit daily, but are in about the middle range for daily consumption of candy or chocolate. Throughout HBSC countries, students who spend more hours watching TV or playing computer games are more likely to consume soft drinks, sweets and potato chips, particularly among younger students and boys.
Across all countries girls are more likely than boys to diet or feel that they should, and those who diet are more likely to eat fruit. U.S. students were more likely to be on a diet, or to feel that they should, than students in all other countries: 62 percent of U.S. girls and 29 percent of boys. Dieting may be based on a positive desire to change behavior and to reduce risk of being overweight, or it may reflect unreal istic self-images. The latter may result in unhealthy behaviors, such as anorexia and bulimia, that deprive girls of necessary nutrients, leading to long-term risk of osteoporosis and other serious conditions.

Family and Peer Relationships

Parent-child relationships, family structure, and peer group relations are associated with adolescent health and health behaviors. Family and peer relationship measures are indicators of current social resources, support, and communication. Family structure and stability in living arrangements are also strong predictors of supportive resources and family communication. Positive, supportive family and peer relationships are needed to maintain health and healthy behaviors. Time spent with friends after school may reflect a number of different activities within the peer environment, depending on how the time is used. It may also reflect time available to students for after-school gatherings, including the effects of transportation systems.

The proportions of 15-year-old students living with both parents ranged from 89 percent in Israel and Greece to 53 percent in Greenland. U.S. students rank third from last in the proportion of students who live with both parents at age 15 (at 62 percent), with slight decreases from age 11 (at 67 percent). The U.S. has the highest proportion of students at age 15 years who live with single parents (23 percent) and ranks fourth for the proportion living with step-parents (13 percent).
About one-third of U.S. students have difficulty talking to their mothers about things that really bother them, with increasing difficulties as they grow older. While ranking among the top three countries for difficulty with maternal communication at all ages, U.S. proportions are only slightly higher than average among all countries. Across countries, 28 percent of 15-year-olds on average reported difficulties talking to their mothers, ranging from 16 to 36 percent. Few countries show marked gender differences for difficulty talking with mothers.
Across all countries, girls have more difficulties talking to fathers about things that really bother them than boys, and more students of both genders report difficulties talking to fathers than to mothers. The difficulties increase with age in all countries. The U.S. ranking compared to other countries deteriorates with age, with 53 percent of U.S. girls and 42 percent of boys at age 15 reporting difficulty communicating with their fathers, proportions much higher than reported for maternal communication.
U.S. students rank comparatively high in finding it easy to make new friends (at about 85 percent of students). At the same time, they are among the least likely to find the students in their classes to be kind and helpful. Slightly more than one-third of U.S. students report that other students in their classes are always or often kind and helpful, compared to about 90 percent in Portugal and an average of about 50 percent among all countries. These findings raise questions about the social context in which students make friends and other school-related factors that may inhibit a supportive peer environment.
Across all countries, boys are somewhat more likely than girls to spend time with friends after school at least 4-5 days a week. About one-third of U.S. students spend this much time with friends after school, ranking in the lowest third of countries. Across countries, the ranges are from 30 percent of boys and 18 percent of girls in Denmark to 68 percent of boys and 51 percent of girls in Greenland.

School Environment

Research emphasizes the link between students' perceptions of school and their motivation, achievement, and behavior.^1,2,3 Students who like and feel connected with school may be more motivated to achieve academically and less motivated to engage in anti-social behavior than students who feel disconnected from it. Schools also provide a health-promoting environment, both directly through health education and indirectly by providing opportunities for healthy nutrition and physical activity.⁴

A cross-country HBSC analysis of students' perception of school shows that they are satisfied with school when they take part in setting school rules, get needed support from teachers or other students, and perceive high expectations from teachers and parents.⁵ Across countries, students report a lower quality of life when they are not satisfied with school and do not feel supported by other students.
Across countries, girls like school more and consider rules to be fair more often than boys. Liking school a lot tends to decrease with age. Among all countries, less than half of students report that they like school a lot, ranging from 40 percent of girls and 34 percent of boys in Latvia to 5 percent or less for either gender in the Czech Republic and Finland. The proportion of U.S. students who are enthusiastic about school is among the best of countries, at 18 percent, even though about four out of five U.S. students like school only a little, not very much, or not at all.
Pressure from school work increases with age across all countries. U.S. students rank second in reports of feeling a lot of pressure from school. U.S. students report perceptions of their own performance as very high compared to other students in their class (ranking fourth among countries). However, U.S. students are no more likely than students in other countries to feel that either teachers or parents expect too much of them at school; and rank tenth in feeling that students are treated too severely or strictly at their school.
U.S. students at all ages are among the least likely to feel that their classmates are kind and helpful, ranking third from last. Only 39 percent of U.S. girls and 35 percent of boys find students in their classes to often or always be helpful. The range across countries is from about 30 percent to 90 percent with a median of more than 50 percent.
U.S. students are among the least likely to feel that they participate in making rules at school, ranking fifth from last. Only one-fifth of U.S. students agree or strongly agree that students in their school take part in making rules. This compares to a cross- country range of about two-thirds of Swiss students who feel they take part in rule-making to less than one in five in Finland, the Russian Federation, Czech Republic and Flemish Belgium. In addition to its probable effects on students' sense of school connectedness, educating students to be part of the rule-making process is necessary preparation for civic responsibilities, including voting.^6,7 Research also indicates that students who feel unconnected to school are more likely to abuse substances, engage in violence, and become pregnant.^8,9

Alcohol and Smoking Behavior

Alcohol and tobacco are among the top contributors to mortality and morbidity in the U.S.¹⁰ Associations of smoking and drinking with both behavioral and health-related conditions are shown in the HBSC international report, as well as other studies considering multi-risk taking behaviors and effects such as injuries.¹¹

A cross-country analysis described in the international report among all HBSC youth shows a number of associations between use of the two substances:
- Students who ever experimented with smoking are more likely to have Experience with drinking alcohol, including being drunk, as well as to dislike school and be truant from school, regardless of age or gender. Students who ever smoked experimentally report feeling less healthy, spend more time with friends after school and in the evening, and have more difficulties talking to their fathers, and for girls only, with their mothers.
- Overall, daily smokers are also more likely to drink or get drunk more frequently. However, the strong association between smoking and drinking did not hold in each country. Even though daily smokers are more likely to drink, drinkers are not necessarily more likely to smoke in all countries. Still, there are strong associations between being really drunk at least twice and daily smoking.
- Daily smokers are more likely to be truant more often and to dislike school. Older students who drink frequently are more likely to spend time with friends after school 4-5 days a week and in the evening and are more like to be truant from school and dislike school. Besides the associations with time spent with friends and school problems, older girls who smoke also report feeling less healthy.
Across countries, experimental smoking increases with age, so that 60-70 percent of all 15-year-olds report having smoked at least once. Countries with fewer students experimenting at age 11 have fewer students experimenting at age 15 as well. Boys are generally more likely to smoke experimentally than girls, although there are variations in the gender patterns among countries.
Daily smoking increases substantially with age, with prevalence varying widely among countries. About half of the countries show more females smoking daily than males. By age 15, proportions of girls smoking daily ranged from a high of 56 percent in Greenland to 6-8 percent in Lithuania, Israel, and Estonia, with 12 percent for U.S. girls. For boys, 45 percent smoked daily in Greenland compared to only 13 percent in Portugal and the U.S. By age 15, U.S. students are among the lowest ranking countries for daily smoking, at fifth lowest for both genders combined.
At age 15 years, boys in all countries are more likely to drink alcoholic beverages than girls. Some countries varied their relative rankings as students became older, with smaller gender differences among younger students, including students in the U.S. U.S. students rank seventh highest among all countries in the percentage of 11-year-olds who drink at least weekly, and U.S. 13-year-olds rank 11th for weekly drinking. By age 15, the U.S. ranking falls to the lowest third of countries.
In nearly all countries, 15-year-old boys are more likely than girls to have been drunk on two or more occasions. Generally, countries with high proportions of students who drink at least weekly are also more likely to have students who have been drunk on two or more occasions. The age trends for drunkenness within countries are consistent with the proportion of students who report have been drunk by age 15. Those with high proportions of young students having been drunk at age 11 had high proportions at age 15; and conversely, those with fewer students at age 11 had lower proportions at age 15. U.S. students were among the lowest third of countries for drunkenness, with 28 percent of girls and 34 percent of boys having been drunk at least twice by age 15.

Violence

Since U.S. youth homicide rates are the highest among industrialized countries and suicide rates are among the highest, our concern for violent behavior is strong.¹² U.S. homicides and suicides are most likely to involve firearms, accounting for more than 80 percent of all firearm fatalities to children and youth under age 15 in a study combining manner of death in 26 industrialized countries.¹³ Shootings at school have heightened our awareness of school safety.¹⁴

U.S. students rank eighth from highest among HBSC countries for students who never or rarely feel safe at school (30 percent). Fewer than two out of five U.S. students always feel safe. However, in only five countries did 50 percent or more students always feel safe at school.
In questions about weapon-carrying, other HBSC countries felt that the prevalence of carrying guns was so small that estimates would not be reliable. Therefore, weapon- carrying questions did not ask specifically about firearms. Other countries also did not expect that asking about carrying weapons at school would yield reliable estimates due to low prevalence, so the question is not specific to school safety concerns. Among the few countries asking about fighting or weapon-carrying (gun, knife or club) for self protection, U.S. students are no more likely to fight or carry weapons. As in other countries, U.S. students are more likely to fight with friends, family members or acquaintances than with strangers.
Analysis of the U.S. HBSC data on student in grades 6-10 shows strong associations between involvement in frequent bullying with violent behavior, including weapon- carrying and having four or more fights a year.¹⁵ Those who report bullying or being bullied at least once a week are more likely than other U.S. students to report carrying a weapon for protection either at school or away. The likelihood of weapon- carrying was particularly high when students either bullied others or were bullied away from school grounds. Bullies (including bullies who are also victims of bullying by others) are most likely to carry weapons for self-defense.
Another study using only the U.S. HBSC data shows the significantly poorer psychosocial adjustment of students who are bullies, bullied, or both a bully and a target of bullying at least once a week or more.¹⁶ The U.S. study asked about bullying both at school and away from school, with almost 30 percent of students reporting moderate or frequent involvement as either bullies or victims.
The international HBSC study asked only about bullying that occurred at school but not other locations. Overall, U.S. youth at all ages (11, 13 and 15 years) are no more likely to be involved in bullying others at school than in other countries. Our students rank in about the middle among students who are bullied at school at least sometimes. However we rank ninth at all ages and seventh at age 13 among all countries for students who are bullied frequently (at least once a week or more often) at school. Our students are also among the higher ranking countries for students who report that they bully others at school frequently. More than one out of twenty U.S. students at all ages report bullying others or being bullied at least once a week or more often at school. Proportions are higher at ages 11 and 13 than at age 15.

The many comparisons in this and the international report show a number of commonalities across countries, including consistent gender differences. The differences summarized above 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 most important differences are highlighted below:

U.S. youth are more likely to have very frequent episodes (at least once a week) of stomachache, backaches, headaches and difficulty sleeping than students in almost all other HBSC countries. U.S. students are also more likely to feel tired in the morning or feel low compared to students in other countries. These health-related symptoms may be partially associated with our students' general fitness levels related to diet and exercise since we are also more likely to eat items such as french fries or to drink sodas with sugar, while generally exercising less frequently. They may also stem from other activities and school schedules not measured or analyzed in the HBSC.
Research cited in each of the chapters shows that appropriate supportive networks are critical for positive development of health and healthy behaviors. The ability of U.S parents to provide support may be relatively limited by the high proportions of students living with single and step-parents. Communication with parents, both mothers and fathers, appears to be more difficult for our students, with far greater difficulty reported in communicating with fathers than mothers and particularly for boys. U.S. students find it easy to make new friends, while they are among the least likely to find students in their classrooms to be kind and helpful. U.S. students rank second in reports of feeling a lot of pressure from school at the same time that their perceptions of their own performance is very high compared to other students in their classes. Our students are no more likely than students in other countries to feel that either teachers or parents expect too much of them at school; and rank tenth in feeling that students are treated too severely or strictly at their school. The proportion of U.S. students who are enthusiastic about school (like it a lot) is among the best of countries, even though about four out of five U.S. students like school only a little, not very much, or not at all. Across all countries girls like school and consider rules to be fair more often than boys. However, U.S. students are among the least likely to feel that they participate in making rules at school.
Findings on student substance use (smoking and drinking) are generally positive, but with somewhat mixed results. Our 15-year-old youth are generally less likely to smoke than students in almost all other countries and rank in about the middle range for drinking alcohol at least once a week. The latter is consistent with our ranking for students who have been drunk at least twice.
U.S. students rank relatively high for never or rarely feeling safe at school. Fewer than two out of five U.S. students always feel safe. Our students rank in about the middle among students who are bullied at school at least sometimes. However, we rank ninth at all ages and seventh at age 13 among all countries for students who are bullied frequently (at least once a week or more often) at school. The U.S. is also among the higher-ranking countries for students who report that they bully others frequently. Among the few countries asking about fighting or weapon-carrying (gun, knife or club) for self protection, U.S. students are no more likely to fight or carry weapons. As in other countries, U.S. students are more likely to fight with friends, family members or acquaintances than with strangers.

What was left out?

The international study did not address issues related to race, ethnicity or immigration. Historical immigration patterns and the extent of diversity are quite different in the U.S. compared to most European countries. Nearly 14 million children under 18 years of age in the U.S. are immigrants or have immigrant parents in 2000, with almost one in six children living with a foreign-born householder.¹⁷ Other U.S. studies among adolescents and other ages have shown differences in health-related attributes and behaviors by race and ethnicity but little research has been completed on effects of acculturation among immigrant youth within the context of family, peer, and school relations.¹⁸ One Add Health study shows that 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.¹⁹ Both published²⁰ and preliminary analysis of the U.S. HBSC data on youth living in homes where the primary language spoken is other than English shows that they are at an elevated risk for psychosocial and parental risk factors 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 health-related behaviors.

The potential exclusion of higher-risk teens from school-based surveys, as discussed in the previous chapter, indicates that generalization of results from these nationally representative samples can be made only for the more normative populations of teens.^21,22 Comparisons across countries of the highest risk youth with chronic illnesses, disabilities, or instability in living arrangements, including homelessness, etc., can't be made in this study. Thus, the levels of risk and associations with family, school, and peer relationships reported here may be lower than those of the adolescent populations as a whole. Regional and language differences within countries cannot be compared either. This chartbook is only a snapshot of the majority of teens attending schools in the 27 European and North American countries represented by the HBSC.

Even though questions were tested across countries and language adjusted to measure the same concepts constructs, local culture may still affect teens' interpretations of the questions asked. Beyond the issues of higher prevalence of health-related behaviors reported by teens compared to parental reports in household surveys discussed in the previous chapter,²³ some new questions have been raised. We know very little about the way that adolescents think about their health and whether their perceptions parallel that of adults. Particularly pertinent are the somatic symptoms of stomachache, backache, headache, and feeling tired or the depressive affect questions such as feeling low, lonely, or unhappy. Adolescent assessment of whether or not they feel healthy may also change with their development. 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 and health problems. This may be an important research question for assessing the functional health status of our teens.

What the research shows:

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 cross-national comparisons to demonstrate common factors and highlight differences associated with cultural influences. As with all cross-sectional studies—or studies based on questions asked at one point in time—associations found among the many factors included in this report cannot be used to infer cause and effect. Comparisons of multiple dimensions across health and health-related behaviors provide highlights of the individual and social dimensions of our adolescents' lives. In-depth studies that follow students and their families from the prenatal stage are needed to understand interactions at each developmental phase and the progression of influences on current health-related behaviors. Research specific to limited behaviors has demonstrated that risk and protective factors vary in predictive power depending on when in the course of development they occur. As children move from infancy to early adulthood, some risk factors will become more important. For example, substance use as a risk factor or predictor of violence is much stronger at age 9 than it is at age 14.^24,25 These developmental pathways present a challenge not only to understanding cause and effect but also to developing strategies for prevention.

Only two nationally representative U.S. studies currently follow the same adolescents over time: 1) the National Longitudinal Survey of Youth 1997 (NLSY97), which focuses on transitions into the labor market and adulthood, and 2) the National Adolescent Study of Health (Add Health), which focuses on forces that influence adolescents' behavior, particularly in the context of families, peers, schools, neighborhoods and communities.²⁶ The Add Health study is beginning to inform us about the family, peer and school relationships which both influence and are influenced by individual student health-related behaviors over time.

Both the cross-national analyses from the HBSC, based on extensive work in Europe, and the more in-depth longitudinal, multi-level research of the U.S. Add Health study cited in previous chapters show that feelings of support and connectedness to family, school, and peers are highly associated with positive health and behaviors. 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 makes a difference.⁴^,8,9,26 While the influence and educational role of the family may decrease as students move toward independence, the family's role throughout early life in shaping the health behavior of adolescents is critical and well-documented.²⁶ Similar thorough review and documentation of research demonstrating what we know about influences on health and health behavior in children during middle childhood or adolescents has not been completed, although a synthesis of research recommendations for adolescents was completed in 1999.²⁷

The HBSC study examined the association of students' health-related behaviors among all countries with the strength of their relationships and the lines of communication with their parents and their peers.²⁸ The Add Health study shows that the physical presence of a parent in the home at key times, as well as parental connectedness (e.g. feelings of warmth, love, and caring from parents), and parental expectations are associated with adolescent health behavior.⁸

Pro-social peer networks have been shown to have positive associations with health-related behaviors. Adolescents' affiliation with "pro-social" peers has been shown to be associated with abstinence from alcohol use, delayed initiation of sexual activity, and protective against violent behavior among youths.^29,30,31 The causal relationship between friends' risk behavior and adolescents' own behavior is important to consider in examining adolescent health behavior. Adolescents may choose friends who engage in similar types of behavior,³² or they may be influenced by the behavior of friends.³³ Research from the longitudinal Add Health study addresses the multifaceted nature of friendship networks as they affect the relationship between peer delinquency and an adolescent's own delinquency.³⁴ The same need for supportive school environments is demonstrated through the HBSC, Add Health and other research. Add Health studies emphasize that feeling that one belongs and is cared for at school is a crucial requirement for student health and well-being.⁹ The issues of supportive families, peer networks, and schools need to be addressed in areas of bullying, exclusionary social cliques, and gangs since students may be turning to more anti-social peer networks for the connectedness that the HBSC and other research studies show that they need. Findings that strong school and family ties protect teens from violence, substance use, suicide and early sex may also be found in a briefing paper prepared by NICHD.³⁵

Research shows us that it is even more difficult to measure effects of neighborhoods, communities and the larger cultural influences. These influences represent complex interactions of biological, social and physical environmental factors though the various developmental stages of children and youth, including prenatal influences and family genetics. The National Research Council and Institute of Medicine report (NRC/IOM), From Neurons to Neighborhoods, emphasizes the complexity of relating these multiple influences during early childhood development to specific interventions to reduce unhealthy behavior.³⁶ Adolescent health behaviors measured between ages 11 and 15 years reflect not only genetic, family and early and middle childhood exposures, but effects of puberty, maturation as well as direct interactions with peers, neighborhoods, and communities.

Over the past few decades, the amount of research on adolescent health has grown considerably. A review of recent research findings provides a synthesis of lessons learned and recommendations from research reports.²⁷ The review identifies broad-based trends in research priorities, describes gaps in the existing knowledge base, and suggests approaches for developing and implementing a national adolescent health research agenda. Research priorities are examined in four major content areas: adolescent physical, psychological and social development; social and environmental contexts; health- enhancing and health-risk behaviors; and physical and mental disorders. Cross-cutting themes identified as priorities for directions of future research include:

Applying a developmental perspective to adolescent health research.
Emphasizing "health" in adolescent health research.
Using multiple influence models for understanding and improving adolescent health and development.
Recognizing the diversity of the adolescent population.

Supportive Programs and Prevention

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. The Committee on Community-Level Programs for Youth of the NRC/IOM assessed programs that may serve as models to promote positive outcomes in youth by identifying community interventions with sufficiently strong evidence of effectiveness.³⁷ These programs are located in communities in which youth live: neighborhoods, block groups, towns and cities, as well as nongeographically defined communities based on family connections and shared interests or values. The Committee was not able to separate programs performed within schools since many of the best-regarded programs craft explicit links with both home and school, with some even taking place during normal school hours in the school building itself. Two of the focus areas of the HBSC, bullying behavior and substance use (smoking and alcohol), demonstrate how measuring individual health-related behaviors in only one venue, such as school, may lead our research and programs away from some of integrally linked venues where the behaviors and related psychosocial factors need to be addressed through community, family and professional partnerships to promote positive behaviors. An illustration is demonstrated by the two U.S. HBSC studies on bullying.^15,16 Part of the concern about bullying behavior is the involvement with physical violence. U.S. HBSC data analysis results show that weapon-carrying and fighting risks are higher for students involved in bullying away from school grounds than at school.¹⁵ The U.S. survey asked about bullying behavior both at school and away. Comparisons to the remaining HBSC countries which asked only about bullying 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 should 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,⁴ but probably not fully sufficient for fully successful interventions.³⁷ This may be demonstrated by U.S. efforts to reduce smoking. The HBSC data on smoking among U.S. youth 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.³⁸ U.S. ranking at age 15 years is low even though our students are equally as likely to experiment with smoking as students in other countries. The U.S. has devoted more than twenty-five years to applying basic public health principles to reduce smoking behavior among our youth. Evaluation of higher level interventions targeted to the general population (clean air ordinances, media messages) concludes that no single strategy has been successful on its own, and multiple approaches have the greatest chance of success.³⁹

The National Initiative to Improve Adolescent Health by the Year 2010 (NAIIC 2010) was created to support collaborative action at the community, State and national levels. It was created to elevate the national focus on the health and well-being of adolescents and young adults. The goal is to comprehensively address the 21 Critical Health Objectives identified in Healthy People 2010.⁴⁰ Targeted objectives are based on measurable health behaviors and symptoms that are currently collected through national data sources enabling monitoring of change across time. NAIIC 2010 is facilitated by joint efforts of the Health Resources and Services Administration's Maternal and Child Health Bureau/Office of Adolescent Health (HRSA/MCHB) and the Centers for Disease Control and Prevention's Division of Adolescent and School Health. Supporting partners include university-based research organizations, State maternal and child health programs and adolescent health coordinators, and many health professional associations.

Beyond the measurable objectives that are the focus of NAIIC 2010, programs need to address the underlying supportive network required to improve adolescent health demonstrated through the research and findings described in this chartbook. The two sponsoring agencies of the HBSC study are responsible for conduct of research on the causes and prevention of disease and health behaviors leading to poor adolescent (NICHD)⁴¹ and for promoting and improving the health of adoelscents through effectively targeted programs (HRSA/MCHB/OAH).⁴² Obviously, the HBSC focus on adolescents within the context of family, school, peer, neighborhood, community and larger cultural influences contributes to the efforts of those concerned about the future of our children and teens.

REFERENCES:

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