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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:
Summary | What Did We Learn | What Was Left Out | What Research Shows | Supportive Programs and Prevention | References


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:

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.


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.

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

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


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

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:

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:

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.


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* 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.


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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