in Our World
Understanding the Health of U.S. Youth in Comparison to Youth in
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:
- What important information did we learn about common adolescent health
characteristics, and about U.S. adolescents specifically, that we didn't
- 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
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
less likely to feel happy in all countries as students age. U.S. boys rank
among countries for not feeling happy (at 9 percent), and girls rank eleventh
percent) with proportions ranging across countries from 5 percent to 42 percent
boys and 9 percent to 47 percent of girls. At the same time, U.S. students
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
stomachache, backache, headache, difficulty sleeping, feeling tired in
the morning and feeling low at least once a week. More than 40 percent of
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
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
- 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
all countries for frequency of exercise. Of those who exercise, U.S. students
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
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
drinks, sweets and potato chips, particularly among younger students
- 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:
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
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
ranks fourth for the proportion living with step-parents (13 percent).
one-third of U.S. students have difficulty talking to their mothers about
things that really bother them, with increasing difficulties as they
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
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
that really bother them than boys, and more students of both genders report
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
- 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.
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
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.
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
from teachers or other students, and perceive high expectations from teachers
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,
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
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.
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
students in their class (ranking fourth among countries). However, U.S.
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
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
necessary preparation for civic responsibilities, including voting.6,7 Research
also indicates that students who feel unconnected to school are more
substances, engage in violence, and become pregnant.8,9
Alcohol and Smoking
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 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
- 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
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
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
- Across countries, experimental smoking increases with age, so that 60-70
percent of all 15-year-olds report having smoked at least once. Countries
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
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
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
- 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
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
the proportion of students who report have been drunk by age 15. Those
proportions of young students having been drunk at age 11 had high proportions
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.
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
all firearm fatalities to children
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
students rank eighth from highest among HBSC countries for students
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
or more students
always feel safe at school.
- In questions about weapon-carrying, other HBSC countries felt that the
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
- 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
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
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
reporting moderate or frequent involvement as either bullies or
- 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
are no more
likely to be involved in bullying others at school than in other countries.
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
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:
youth are more likely to have very frequent episodes (at least once a
stomachache, backaches, headaches and difficulty sleeping than students
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.
symptoms may be partially associated with our students' general fitness
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
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,
mothers and fathers, appears to be more difficult for our students, with
difficulty reported in communicating with fathers than mothers and particularly
boys. U.S. students find it easy to make new friends, while they are among
likely to find students in their classrooms to be kind and helpful. U.S.
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
and rank tenth
in feeling that students are treated too severely or strictly at their
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
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
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
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
among students who are bullied at school at least sometimes. However, we
at all ages and seventh at age 13 among all countries for students who
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
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
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
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
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
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
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
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
to specific interventions to reduce unhealthy behavior.36 Adolescent
health behaviors measured between ages 11 and 15 years reflect not only genetic,
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
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
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
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.
* 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
- Roeser R., Eccles J.S. Adolescents' perceptions of middle school: Relation
to longitudinal changes in academic and psychologial adjustment. Journal of
Research on Adolescence. 1998;8:123-158.
- Eccles JS, Wigfield A, Midgley C, Reuman D, MacIver D, and
Feldlaufer H. Negative effects of traditional middle schools on students'
School Journal. 1993;93:553-574.
- Simons-Morton BG, Crump AD, Haynie DL, Saylor KE. Student-school
bonding and adolescent problem behavior. Health Education Research. 2001;14:99-107.
- Blum RW, McNeely CA, Rinehart PM.
Improving the odds: The untapped power of schools to improve the health of
teens. Minneapolis, MN: Center for
Health and Development, University of Minnesota; 2002.
- Samdal O, Dur W. The school environment
and health of adolescents. In: Currie C, Hurrelman K, Settertobulte W, Smith
R, Todd J, Health and Health
Behaviour Among Young People. WHO Policy Series: Health Policy for Children
and Adolescents Issue 1. Copenhagen, Denmark: World Health Organization
Regional Office for Europe, 2000.
- Center for Civic Education. NAEP
1999 Civics Report Card to the Nation. Available at http://www.civiced.org:
Last accessed January, 2003.
- U.S. Department of Education. We
the People...The Citizen and the Constitution. Program description available
- Resnick MD, Bearman PS, Blum RW,
et al. Protecting adolescents from harm: Findings from the National Longitudinal
Study on Adolescent Health.
- McNeely CA, Nonnemaker JM, Blum
RW. Promoting school connectedness: Evidence from the National Longitudinal
Study of Adolescent Health. J School
- McGinnis JM, Foege WH. Actual
causes of death in the United States. JAMA. 1993;270:2207-2212.
- Pickett W, Schmid H, Boyce WF,
Simpson K, Scheidt PC, Mazur J, Molcho, M, King MA, Godeau E, Overpeck MD,
Aszmann A, Szabo M, Harely. Multiple
behavior and injury: An international analysis of young people. Arch Pediatr
Adolesc Med 2002;156:786-793.
- World Report on Violence and
Health. Geneva, Switzerland: World Health Organization: 2002. Available at:
Last accessed on Oct. 3, 2002.
- Centers for Disease Control
and Prevention. Rates of homicide, suicide and firearm-related deaths among
children—26 industrialized countries.
Morbidity and Mortality Weekly Report 1997;46:101-105.
- Gaughan E, Cerio JD, Myers RA.
Lethal Violence in Schools: A National Study. Alfred, NY, Alfred University,
- Nansel TR, Overpeck MD, Ruan
WJ, Haynie DL, Scheidt PC. Relationships between bullying and violence among
US youth. Arch Pediatr Adoesc Med (in press)
- Nansel TR, Overpeck M, Pilla
RS, Ruan WJ, Simons-Morton BG. Bullying behaviors among the U.S. youth: Prevalence
and association with psychosical
- Schmidley AD. U.S. Census Bureau,
Current Population Reports, Series P23-206. Profile of the Foreign-Born Population
in the United States.
U.S. Government Printing Office, 2001.
- Research Forum on Children,
Families and the New Federalism. Lack of appropriate research leads to gaps
in knowledge about children in immigrant
- Harris KM. The health status
and risk behaviors of adolescents in immigrant families. In: Hernandez DJ
(Ed), National Research Council and
Medicine. Children of Immigrants: Health, Adjustment, and Public Assistance.
Washington, DC: National Academy Press, 1999, pages 286-315.
- Yu SM, Huang ZJ, Schwalberg
RH, Overpeck M, Kogan MD. Acculturation and the health and well-being of
U.S. immigrant adolescents. J Adolescent Health
- Guttmacher S, Weitzman BC, Kapadia
F, Weinberg SL. Classroom-based surveys of adolescent risk-taking behaviors:
Reducing the bias of absenteeism.
Public Health 2002;92:235-7.
- Grunbaum JA, Kann L, Kinchen
SA, Ross JG, Gowda VR, Collins JL, Kolbe LJ. Youth risk behavior surveillance:
National Alternative High School
Behavior Survey, United States, 1998. J School Health 2000;70:5-17.
- Kann L, Brener ND, Warren CD.
Et al. An assessment of the effect of data collection setting on the prevalence
of health risk behaviors among
J Adolescent Health 2002;31:327-335.
- U.S. Department of Health and
Human Services. Youth violence: A report of the Surgeon General. Rockville,
MD: U.S. Department of Health and
Services;2001, pages 42-52.
- Dahlberg LL, Potter LB. Youth
violence: Developmental pathways and prevention challenges. Am J Prev Med
- National Research Council and
Institute of Medicine, Committee on National Statistics,. Longitudinal Surveys
of Children. Washington, D.C.,
- Millstein SG, Ozer EJ, Ozer
EM, Brindis CD, Knopf DK, Irwin, CE, Jr. Research Priorities in Adolescent
Health: Ana analysis and Synthesis
of Research Recommendations.
San Francisco, CA: University of California, San Francisco. National Adolescent
Health Information Center, 1999.
- Currie C., et al (ed.). Health
and Health Behaviour Among Young People. WHO Policy Series: Health Policy
for Children and Adolescents, Issue
- Spoth, R., Redmond, C., Hockaday,
C. and Yoo, S. Protective factors and young adolescent tendency to abstain
from alcohol use: A model
of intervention study data. American Journal of Community Psychology. 1996;24:749-770.
- Bearman, P., Brückner, H., Brown, B.B., Theobald, W., & Philliber,
S. Peer Potential: Making the Most of How Teens Influence Each Other. Washington
DC: National Campaign to Prevent Teen Pregnancy. 1999.
- Group for the Advancement of
Psychiatry. Violent behavior in children and youth: Preventive intervention
from a psychiatric perspective.
of the American Academy of Child and Adolescent Psychiatry. 1999;38: 235-241.
- Kandel DB. Homophily, selection,
and socialization in adolescent friendships. American Journal of Sociology.
- Keenan K, Loeber et al. The
influence of deviant peers on the development of boys' disruptive and delinquent
behavior: A temporal analysis.
and Psychopathology. 1995;7:715-726.
- Haynie DL. Delinquent peers
revisited: Does network structure matter? American Journal of Sociology.
- Demographic and Behavioral Sciences
Branch. Research on Today's Issues: Strong school, family ties protect teens
from violence, drugs, suicide
early sex. Bethesda, MD: National Institute of Child Health and Human Development;
1998;Briefing Papers, Issue No. 8.
- National Research Council and
Institute of Medicine Committee on Integrating the Science of Early Childhood
Development. From Neurons to
The Science of Early Childhood Development. Washington, D.C., National
Academy Press, 2000.
- National Research Council and
Institute for Medicine (2002). Community Programs to Promote Youth Development.
Committee on Community-Level
for Youth. J Eccles and JA Gootman, eds. Board on Children, Youth and Families,
Division of Behavioral and Social Sciences and Education. Washington DC:
National Academy Press.
- National Institute on Drug Abuse
and University of Michigan Institute for Social Research. Monitoring the
Future Study. Available at: URL http://www.drugabuse.gov/related-topics/trends-statistics/monitoring-future and http://www.monitoringthefuture.org.
- 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 http://nap.edu.
- Healthy People 2010. Critical
Objectives for Adolescents and Young Adults. List available at http://nahic.ucsf.edu/.
- National Institute of Child
Health and Human Development. From Cells to Selves: Strategic Plan 2000.
Available at: https://www.nichd.nih.gov/publications/pubs/documents/strategicplan.pdf
- Health Resources and Services
Administration, Maternal and Child Health
Bureau. Program goal descriptions available at: http://www.mchb.hrsa.gov.
* 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
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