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Association between violent behaviors and substance use among Mexican-American and non-Hispanic white high school students
JOURNAL OF ADOLESCENT HEALTH 1998;23:153–159
ORIGINAL ARTICLE
Association Between Violent Behaviors and Substance Use Among Mexican-American and Non-Hispanic White High School Students JO ANNE GRUNBAUM, Ed.D.,* KAREN BASEN-ENGQUIST, Ph.D., AND DILIP PANDEY, M.B.B.S., Ph.D.
Purpose: To determine the prevalence of violent behaviors among Mexican-American and non-Hispanic white high school students and to explore the associations between violent behaviors and alcohol and illicit drug use. Methods: The Youth Risk Behavior Survey was administered to 1786 high school students in a biethnic community in Southeast Texas; 65% were Mexican-American, 26% were non-Hispanic white, and 9% were of another ethnicity. Results: There were no significant ethnic differences in prevalence of drinking alcohol, illicit drug use, fighting, carrying a weapon, or planning or attempting suicide. After adjustment for age, carrying a weapon and fighting were significantly associated with alcohol and illicit drug use, with few exceptions, among the four gender- and ethnic-specific subgroups. However, the relationship between suicide (plans and attempts) and substance use among the four subgroups was less consistent and of much lower magnitude than for carrying a weapon and fighting. Conclusions: A substantial percentage of adolescents engage in violent behaviors, and fighting and weapon carrying are associated with substance use among both gender and ethnic groups. A systematic and integrated approach to changing the environment and norms of communities is needed to affect change and reduce the morbidity and mortality associated with violent behaviors. © Society for Adolescent Medicine, 1998 From the Department of Behavioral Sciences, School of Public Health (J.A.G.)The Department of Behavioral Science, M.D. Anderson Cancer Center (K.B.)and the Department of Epidemiology, School of Public Health (D.P.), University of Texas-Houston, Houston, Texas, USA. Address reprint requests to: Jo Anne Grunbaum, Ed.D., Centers for Disease Control and Prevention, Division of Adolescent and School Health, 4770 Buford Highway, N.E., Mailstop K33, Atlanta, GA 30341. Manuscript accepted October 23, 1997.
KEY WORDS: Violence Adolescents Mexican-American Substance use Suicide
Violence among adolescents and young adults in the United States is a major public health problem responsible for substantial morbidity and mortality (1–3). Homicide is the second leading cause of death among adolescents and young adults (4–10), with homicide rates substantially higher among minority compared to white youth (11). However, the disparity in rates of violence between white adolescents and minority youth may be related to other factors (4,12–15). Morbidity associated with violence far exceeds the number of fatalities; however, data for nonfatal injuries are less accurately recorded (16,17). Morbidity owing to violent behaviors is disproportionately higher among African-Americans and Hispanics (12). Suicide is the third leading cause of death among adolescents (4,10,16,18), and in 1995 a nationwide survey of high school students demonstrated that Hispanic students were significantly more likely than white students to have attempted suicide (19). Behaviors that contribute to violent behaviors include carrying a weapon, fighting, use of alcohol, and use of illicit drugs (3,20 –23). Among homicide victims 15–24 years of age, at least 40% have measurable blood alcohol levels and 25% have a blood alcohol concentration of $0.10% (16). Although some data exist on the prevalence of risk behaviors among minority youth, little is known
© Society for Adolescent Medicine, 1998 Published by Elsevier Science Inc., 655 Avenue of the Americas, New York, NY 10010
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about violent behaviors among Mexican-American adolescents. In addition, no study has explored the association between violent behaviors and alcohol and drug use among Mexican-American youth. This study used the Youth Risk Behavior Survey (YRBS) to determine the prevalence of violent behaviors among Mexican-American and non-Hispanic white high school students in a biethnic community in Southeast Texas and to assess the association between violent behaviors and substance use. This study will help identify ethnic differences that may need to be considered when planning communityspecific public health interventions aimed at decreasing the prevalence of violence (5,14,15).
were anonymous, their participation was voluntary, and no names or codes were used that could identify an individual student; they were instructed not to write their name on any material, to place the completed answer sheet in an envelope, and to seal the envelope prior to turning it in. Teachers were instructed to stay in the front of the room. A total of 2139 students were enrolled and were considered eligible participants. Of those eligible, 1786 (84%) completed the survey, 92 (4%) refused to participate, 25 (1%) never received a consent form prior to survey administration, 177 (8%) were absent, and 59 (3%) did not participate, for unknown reasons.
Methods
Instruments
Sample
The YRBS was developed by the Centers for Disease Control and Prevention to assess the prevalence and age of initiation of health risk behaviors that contribute substantially to morbidity, mortality, and social problems among adolescents in the United States (24). The six risk categories addressed include tobacco use, drug and alcohol use, sexual activities, dietary patterns and disorders, physical activity, and behaviors that result in intentional or unintentional injuries. The YRBS has been used to collect data at the national, state, and local levels. At the national level, oversampling of African-American and Hispanic youth provide estimates of risk behaviors for those groups. A test-retest reliability study of the YRBS demonstrated that in general, students reported health risk behaviors reliably over time (25). A Kappa statistic was computed for each item, and over 70% of the items had substantial or higher reliability.
During Spring 1992, the YRBS was administered to students attending three high schools in a school district in Southeast Texas. To ensure adequate representation of non-Hispanic white adolescents, the five public high schools in the district were stratified based on percent enrollment of non-Hispanic white students: 4% at two schools, 26% at one school, and 43% at two schools. One school within each stratum was chosen. The target sample size within each school was 700 students, thus providing adequate representation of non-Hispanic white students. Rosters for second-period classes were provided by the district, and special education classes and those classes with ,10 students were eliminated prior to class selection. Classes were selected randomly from among all remaining second-period classes until the target number of students was reached. A total of 96 classes, ranging from 31 to 34 per school, were selected to participate. The study was approved by the University of Texas-Houston Committee for the Protection of Human Subjects. Written information explaining the survey was provided to all teachers whose classrooms were chosen, and all teachers agreed to participate. One week prior to survey administration, teachers distributed consent forms to each student in the class to take to his or her parents. Parents were to notify the teacher if they did not want their child to participate (passive consent). The research assistant was on-site at each school the day prior to and the day of data collection to assist teachers and collect the surveys. Several measures were implemented to ensure student privacy and promote validity of the responses. Students were told that their responses
Statistical Analysis Prior to data analysis, each answer form was visually inspected for patterned responses, such as choosing the same answer for all questions. Based on this inspection, one answer form was excluded resulting in 1785 respondents included in our analyses. Data analyses were performed using SPSS/PC. Chi-square tests were used to identify differences in prevalence between ethnic groups for both substance use behaviors and violence-related behaviors and to describe ethnic differences in type of weapon carried and the person with whom students fought. Use of alcohol, marijuana, cocaine, and steroids was used as
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Table 1. Prevalence of alcohol, substance use, and violent behaviors by gender and ethnicity among MexicanAmerican and non-Hispanic white high school students, 1992 Male Behaviors
Female
Non-Hispanic White [n (%)]
Mexican-American [n (%)]
Non-Hispanic White [n (%)]
Mexican-American [n (%)]
132* (64.7)
308 (55.9)
124 (53.4)
278 (48.8)
Alcohol At least 1 drink in past 30 days $5 drinks at least once (prior month) Substance use Smoked marijuana at least once (prior month) Used cocaine at least once (prior month) Used steroids at least once (in lifetime) Violent behaviors Carried a weapon in past 30 days Fought in past 12 months Injured in fight in past 12 months Planned suicide in past 12 months Attempted suicide in past 12 months
x2 5 4.75 100** (47.8)
x2 5 1.44 206 (36.3)
69 (29.6)
x2 5 8.48 42 (19.5)
135 (23.7)
35 (14.6)
x2 5 1.57 11 (5.2)
43 (7.6)
11 (4.6)
34 (5.9)
3 (1.3)
243 (42.9)
9 (3.8)
294 (51.7)
67 (28.0)
31 (5.5)
3 (1.3)
13 (2.3) x2 5 0.85
76 (14.2)
52 (22.9)
x2 5 0.23 13 (6.3)
197 (34.1) x2 5 2.88
x2 5 4.06 32 (15.6)
37 (6.4) x2 5 2.18
x2 5 1.12 20* (9.5)
13 (2.2) x2 5 0.85
x2 5 0.14 101 (47.4)
22 (3.8) x2 5 0.29
x2 5 0.00 94 (44.3)
85 (14.8) x2 5 0.00
x2 5 1.36 13 (6.0)
155 (27.0) x2 5 0.58
131 (24.4) x2 5 0.21
37 (6.9) x2 5 0.06
26 (11.2)
81 (14.9) x2 5 1.91
p value denotes ethnic comparison within gender by Chi-square test. * p , 0.05; ** p , 0.01.
indicator variables with no use of a given substance as the referent group. Logistic regression analyses were performed to examine age-adjusted cross-sectional associations between gender- and ethnic-specific substance use on the four violence-related behaviors: carried a weapon in the past 30 days, fought in the past 12 months, planned suicide in the past 12 months, and attempted suicide in the past 12 months. The 95% confidence intervals of the ageadjusted odds ratios were calculated using the standard error of the estimates.
ethnic groups; however, there was a significant difference for females, with a larger percentage of Mexican-American females, age $17 years, as compared to non-Hispanic white females. For all sex and ethnic groups, over 90% of the students were $15 years old. Over 30% of all students were in the ninth grade, and the percentage of students per grade decreased as grade level increased for males of both ethnic groups and for non-Hispanic white females.
Results
Non-Hispanic white males were significantly more likely than Mexican-American males to have had at least one drink of alcohol within the prior month (64.7% vs. 55.9%) and to have drunk five or more drinks at one time (heavy drinking) on at least one occasion during the prior month (47.8% vs. 36.3%). Although the same trend was true for females, the results were not statistically significant (Table 1). Mexican-American adolescents, both males and females, were more likely than non-Hispanic white youth to have smoked marijuana at least once in the prior month, and Mexican-American males were
Demographic Characteristics The ethnic distribution of respondents was reflective of the ethnic distribution of students within the school district. Sixty-five percent of the respondents were Mexican-American, 26% were non-Hispanic white, and the remaining 9% were of other or unknown ethnicity. Subsequent analyses were restricted to those 1617 respondents who were either Mexican-American or non-Hispanic white. The age distribution for males was similar in both
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Table 2. Prevalence of type of weapon carried among students who reported having carried a weapon during past 30 days (%) Male
Female
Weapon
Non-Hispanic White (n 5 93)
Mexican-American (n 5 234)
Non-Hispanic White (n 5 9)
Mexican-American (n 5 36)
Gun Knife or razor Club/pipe/other
22.6 54.8 22.6
26.9 47.9 25.2
— 55.6 44.4
8.3 80.6 11.1
more likely than non-Hispanic white males to have used some form of cocaine in the past month, but none of the differences was statistically significant (Table 1). Among females, there were no significant differences between ethnic groups for use of cocaine in the past month. Use of anabolic steroids was three times more prevalent among males than females. However, there were no significant differences in use of steroids between Mexican-American and non-Hispanic white youth within gender groups. Carried Weapon in Past Month Over 40% of males had carried a weapon at least once in the past 30 days, while ,10% of females reported having carried a weapon (Table 1). Among students who reported having carried a weapon in the past 30 days, the type of weapon carried most often was a knife or razor (Table 2). Among males and Mexican-American females, the next most frequently carried weapon was either a gun or a club/ pipe or other type of weapon, while no non-Hispanic white females indicated having carried a gun. There were no significant ethnic differences in prevalence of carrying a weapon or type of weapon carried. Among Mexican-American males and females, drinking alcohol, smoking marijuana, using cocaine, and using steroids were significantly associated with an increased risk of carrying a weapon (Table 3). Use of cocaine and use of steroids were associated with increased risk of carrying a weapon among nonHispanic white males and females (Table 3). Fighting Patterns Nearly 50% of males and approximately 30% of females reported having been in a physical fight at least once in the past 12 months (Table 1). NonHispanic white males were significantly more likely to have sustained an injury in a fight during the past year which had to be treated by medical personnel,
as compared to Mexican-American males. Less than 3% of females were injured in a fight in the past year. Among males who had fought in the past year, approximately one third of the fights were with a friend, while 12% were with a relative, and slightly more than 20% were with a stranger; there were no significant differences between the two ethnic groups. However, among females who reported having been in a fight in the past year, there were significant differences between ethnic groups. Fifty percent of non-Hispanic white females had fought with a relative, as compared to 33% for MexicanAmerican females. Mexican-American females were four times more likely to have fought with a stranger than were non-Hispanic white females. For all sex and ethnic groups, both smoking marijuana and using cocaine were significantly associated with an increased risk of fighting [odds ratio (OR) 5 2.71–13.5)] (Table 3). Heavy drinking was associated with a threefold increased risk of fighting only among Mexican-American youth (OR 5 3.37, male; OR 5 3.71, female). Drinking alcohol and use of steroids were each associated with an increased risk of fighting among Mexican-Americans and nonHispanic white males (Table 3).
Planned Suicide Approximately 15% of males and over 20% of females reported having planned suicide within the past year. There were no significant differences between ethnic groups within gender categories in prevalence of having planned suicide (Table 1). There was a twofold increase in the risk for planning suicide among Mexican-American males and all females who had drunk alcohol (Table 3). Heavy drinking was associated with an increased risk for planning suicide only among Mexican-American females. Smoking marijuana was associated with an increased risk of planning suicide among non-Hispanic white males (OR 5 3.26), non-Hispanic white
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Table 3. Age-adjusted odds ratios (95% confidence intervals) of violent behaviors according to alcohol and substance use behaviors among Mexican-American and non-Hispanic white high school students, 1992 Male
Carried weapon in past 30 days Drank alcohol (prior month) Heaving drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime) Fought in past 12 months Drank alcohol (prior month) Heavy drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime) Planned suicide in the past 12 months Drank alcohol (prior month) Heavy drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime) Attempted suicide in the past 12 months Drank alcohol (prior month) Heavy drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime)
Female
Non-Hispanic White
Mexican-American
Non-Hispanic White
Mexican-American
1.7 (0.91–3.14) 1.85 (1.03–3.3) 1.74 (0.86 –3.5) * 6.73 (1.41–32.03)
2.20 (1.53–3.16) 2.92 (2.02– 4.22) 2.68 (1.78 – 4.03) 2.55 (1.32– 4.9) 3.77 (1.68 – 8.44)
2.4 (0.46 –12.45) 3.75 (0.85–16.59) 3.19 (0.73–13.98) 8.7 (1.34 –56.59) 46.48 (1.92–1123.96)
3.60 (1.64 –7.86) 4.88 (2.4 –9.91) 5.65 (2.72–11.74) 13.98 (5.2–37.56) 8.15 (2.18 –30.45)
2.05 (1.11–3.67) 1.67 (0.95–2.94) 2.71 (1.29 –5.69) 13.5 (1.64 –110.82) 14.28 (1.79 –113.72)
3.01 (2.09 – 4.34) 3.37 (2.31– 4.92) 3.01 (1.97– 4.61) 4.0 (1.86 – 8.58) 4.36 (1.74 –10.89)
1.38 (0.76 –2.49) 1.14 (0.61–2.14) 4.3 (2.03–9.11) 7.08 (1.8 –27.92) 4.91 (0.42–58.0)
3.02 (2.09 – 4.36) 3.71 (2.5–5.52) 2.97 (1.84 – 4.8) 3.62 (1.41–9.3) 3.53 (1.01–12.35)
1.0 (0.42–2.38) 0.74 (0.33–1.69) 3.26 (1.4 –7.56) 6.01 (1.58 –22.91) 1.15 (0.24 –5.64)
1.81 (1.05–3.1) 1.53 (0.93–2.54) 1.52 (0.88 –2.64) 1.3 (0.54 –3.13) 1.49 (0.57–3.95)
2.03 (1.03–3.98) 0.95 (0.46 –1.97) 2.41 (1.06 –5.48) 2.26 (0.58 – 8.77) 1.69 (0.14 –19.94)
1.87 (1.24 –2.82) 2.68 (1.74 – 4.12) 2.8 (1.68 – 4.66) 2.05 (0.85– 4.96) 5.24 (1.49 –18.49)
2.59 (0.54 –12.47) 1.63 (0.44 – 6.0) 8.69 (2.36 –31.76) 21.12 (4.26 –104.69) 1.51 (0.17–12.95)
1.57 (0.74 –3.33) 1.79 (0.88 –3.62) 1.56 (0.73–3.32) 3.6 (1.43–9.11) 4.61 (1.76 –12.04)
2.65 (1.0 –7.06) 1.9 (0.79 – 4.59) 4.02 (1.59 –10.17) 4.28 (0.97–18.8) †
1.9 (1.16 –3.12) 3.0 (1.81– 4.98) 3.21 (1.8 –5.72) 2.08 (0.77–5.66) 7.77 (2.06 –29.36)
* All non-Hispanic white males who used cocaine also carried a weapon. † No non-Hispanic white females used steroids and attempted suicide.
females (OR 5 2.41), and Mexican-American females (OR 5 2.8). Use of cocaine was associated with an increased risk of planning suicide only among nonHispanic white males.
Attempted Suicide The prevalence of attempted suicide was two times greater among females than males, with 6% of males
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and 11–15% of females reporting having attempted suicide in the past year (Table 1). The risk of attempting suicide was increased twofold among MexicanAmerican females who had drunk alcohol in the past month, as compared to nondrinkers (Table 3). Heavy drinking was associated with increased risk of attempted suicide only among Mexican-American females (OR 5 3.0). Smoking marijuana was associated with an increased risk of attempted suicide among non-Hispanic white males (OR 5 8.69), non-Hispanic white females (OR 5 4.02), and Mexican-American females (OR 5 3.21). Use of cocaine was associated with attempted suicides among males, while use of steroids was associated with increased risk of attempted suicides among Mexican-American youth. No non-Hispanic white females used steroids and attempted suicide.
Discussion The results of this study on ethnic differences in prevalence of alcohol, marijuana, cocaine, and steroid use are generally consistent with other studies (26 –28). Mexican-American youth were more likely to have smoked marijuana in the past month, with the trend in the same direction as reported by a national study of high school students (19). Prevalence of cocaine use was higher among non-Hispanic white youth as compared to national data, while female use of steroids was lower as compared to national data (19). Unique to this study are the data on violencerelated behaviors for Mexican-American and nonHispanic white youth. These data demonstrate small ethnic differences in the prevalence of fighting, planning suicide, or attempting suicide, with the results similar in magnitude and direction to the results of a national study (19). Disparate from the national sample, however, are the differences among males in prevalence of carrying a weapon and in being injured in a fight. In this study, a larger percentage of Mexican-American males reported carrying a weapon as compared to non-Hispanic white males, while nationally, non-Hispanic white males were more likely to have carried a weapon than MexicanAmerican youth (19). In addition, in this study, non-Hispanic white males were twice as likely to report having been injured in a fight as compared to Mexican-American males. Nationally, Mexican-American youth were more likely to have been injured in a fight than non-Hispanic white youth (19). Among youth who reported having carried a weapon in the past 30 days, choice of weapon was
JOURNAL OF ADOLESCENT HEALTH Vol. 23, No. 2
very similar between ethnic groups among males, with one half choosing a knife or razor and one quarter carrying a gun. These results are similar to those reported by Valois and colleagues for white males (29). Type of weapon carried was very different between non-Hispanic white and Mexican-American females, but, owing to the small number of females who reported having ever carried a weapon, the differences are not statistically significant and may not be generalizable. There were no ethnic differences in the relationship to the opponent in the last fight among males; this was similar to results reported by Valois and colleagues for white males (29). However, among females, there were significant differences in the choice of opponent with the pattern for non-Hispanic white females disparate from that reported by others (29). A major contribution of this study is the information on the association between violent behaviors and substance use by gender and ethnic group. After adjustment for age, carrying a weapon and fighting are significantly associated with alcohol and substance use, with few exceptions, among all four gender and ethnic groups. Orpinas and colleagues reported similar results among high school males (8). The relationships between suicide (plan and attempts) and substance use among the subgroups is less consistent and of much lower magnitude than for carrying a weapon and fighting. An advantage of this study is that respondents live in the same geographic community and attend the same high schools. Therefore, they are subject to similar influences, a factor not accounted for by national studies. Although there were some ethnic differences in substance use associated with fighting and carrying a weapon between Mexican-American and non-Hispanic white youth, the differences should not affect community intervention programs aimed at decreasing violence among adolescents. It is clear that use of alcohol and other illegal substances increases substantially the risk of fighting and carrying a weapon. Thus, intervention programs to decrease violence need to address the issues of alcohol and illicit drug use, regardless of ethnicity of the audience. Factors associated with suicide planning and suicide attempts are less clear. Drinking alcohol, smoking marijuana, and using steroids all increased the risk of suicide plans and attempts among MexicanAmerican females, with inconsistent associations among the other subgroups. It is possible that substance use plays a minor role in suicide plans and attempts, while mental health disorders, such as depression, are more powerful risk factors. Interven-
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tions to decrease suicide among adolescents may need to focus more on mental health disorders, although substance use is an important risk factor for Mexican-American females. Although a substantial percentage of youth drink alcohol, use illicit drugs, and engage in violent behaviors, many do not. Thus, future research needs to explore protective factors for violent behaviors and substance use and determine why many of the youth exposed to violent acts and who live in the same communities do not engage in violent behavior. What are the factors that make them resilient? In addition, future research needs to explore the impact of psychological factors such as meaning of risk activities or sensation seeking on substance use and violent behaviors. It is clear from the results of this study that a substantial percentage of adolescents engage in violent behaviors which are associated with substance use, more strongly for fighting and weapon carrying than for suicide, among both gender and ethnic groups. Violence prevention needs primary prevention and must be comprehensive in scope, addressing both the violent behaviors and use of alcohol and illicit drugs.
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10. Sells CW, Blum RW. Morbidity and mortality among US adolescents: An overview of data and trends. Am J Public Health 1996;86:513–9. 11. Singh GK, Yu SM. Trends and differentials in adolescent and young adult mortality in the United States, 1950 through 1993. Am J Public Health 1996;86:560 – 4. 12. Houk VN, Warren RC. Foreword to the proceedings. Public Health Rep 1991;106:226. 13. Spivak H, Hausman AJ, Prothrow-Stith D. Practitioners’ forum: Public health and the primary prevention of adolescent violence—the Violence Prevention Project. Violence Victims 1989;4:203–12. 14. Rosenberg ML. Charge to the participants: From analysis to action. Public Health Rep 1991;106:233– 6. 15. DuRant RH, Cadenhead C, Pendergrast RA, et al. Factors associated with the use of violence among urban black adolescents. Am J Public Health 1994;84:612–7. 16. Runyan CW, Gerken EA. Epidemiology and prevention of adolescent injury. JAMA 1989;262:2273–9. 17. Hammond WR, Yung B. Psychology’s role in the public health response to assaultive violence among young African-American men. Am Psychol 1993;48:142–54. 18. Koop CE, Lundberg GD. Violence in America: A public health emergency. JAMA 1992;267:3075– 6. 19. The Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 1995. MMWR 1996;45: 1– 84.
This research was funded by Grant R48/CCR602176, from the Centers for Disease Control and Prevention.
20. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Dept. of Health and Human Services, 1990. DHHS Pub. no. PHS 91-50212.
References
21. Black MM, Ricardo IB. Drug use, drug trafficking, and weapon carrying among low-income, African-American, early adolescent boys. Pediatrics 1994;93:1065–72.
1. Hammett M, Powell KE, O’Carroll PW, Clanton ST. Homicide surveillance—United States, 1979 –1988. MMWR 1992; 41:1–34. 2. Rosenberg ML, O’Carroll PW, Powell KE. Let’s be clear: Violence is a public health problem. JAMA 1992;267:3071–2. 3. McGinnis JM. The year 2000 initiative: Implications for comprehensive school health. Prevent Med 1993;22:493– 8. 4. Blum R. Contemporary threats to adolescent health in the United States. JAMA 1987;257:3390 –5. 5. Fingerhut LA, Ingram DD, Feldman JJ. Firearm and nonfirearm homicide among persons 15 through 19 years of age. JAMA 1992;267:3048 –53. 6. Hausman AJ, Spivak H, Prothrow-Stith D. Adolescents’ knowledge and attitudes about and experience with violence. J Adolesc Health 1994;15:400 – 6. 7. Leenaars AA, Lester D. Suicide and homicide rates in Canada and the United States. Suicide Life-Threat Behav 1994;24:184–91. 8. Orpinas PK, Basen-Engquist K, Grunbaum JA, Parcel GS. The co-morbidity of violence-related behaviors with health-risk behaviors in a population of high school students. J Adolesc Health 1995;16:216 –25. 9. Roper WL. The prevention of minority youth violence must begin despite risks of imperfect understanding. Public Health Rep 1991;106:229 –31.
22. Valois RF, Vincent ML, McKeown RE, et al. Adolescent risk behaviors and the potential for violence: A look at what’s coming to campus. Coll Health 1993;41:141–7. 23. Kingery PM, Pruitt BE, Hurley RS. Violence and illegal drug use among adolescents: Evidence from the U.S. National Adolescent Student Health Survey. Int J Addict 1992;27:1445– 64. 24. Kolbe, LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Educ 1990;21:44 – 8. 25. Brener ND, Collins JL, Kann L, et al. Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol 1995; 141:575– 80. 26. Bachman JG, Wallace JM, O’Malley PM, et al. Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976 – 89. Am J Public Health 1991;81:372–7. 27. Chavez EL, Swaim RC. An epidemiological comparison of Mexican-American and white non-Hispanic 8th- and 12th-grade students’ substance use. Am J Public Health 1992;82:445–7. 28. Welte JW, Barnes GM. Alcohol use among adolescent minority groups. J Stud Alcohol 1987;48:329 –36. 29. Valois RF, McKeown RE, Garrison CZ, Vincent ML. Correlates of aggressive and violent behaviors among public high school adolescents. J Adolesc Health 1995;16:26 –34.
ORIGINAL ARTICLE
Association Between Violent Behaviors and Substance Use Among Mexican-American and Non-Hispanic White High School Students JO ANNE GRUNBAUM, Ed.D.,* KAREN BASEN-ENGQUIST, Ph.D., AND DILIP PANDEY, M.B.B.S., Ph.D.
Purpose: To determine the prevalence of violent behaviors among Mexican-American and non-Hispanic white high school students and to explore the associations between violent behaviors and alcohol and illicit drug use. Methods: The Youth Risk Behavior Survey was administered to 1786 high school students in a biethnic community in Southeast Texas; 65% were Mexican-American, 26% were non-Hispanic white, and 9% were of another ethnicity. Results: There were no significant ethnic differences in prevalence of drinking alcohol, illicit drug use, fighting, carrying a weapon, or planning or attempting suicide. After adjustment for age, carrying a weapon and fighting were significantly associated with alcohol and illicit drug use, with few exceptions, among the four gender- and ethnic-specific subgroups. However, the relationship between suicide (plans and attempts) and substance use among the four subgroups was less consistent and of much lower magnitude than for carrying a weapon and fighting. Conclusions: A substantial percentage of adolescents engage in violent behaviors, and fighting and weapon carrying are associated with substance use among both gender and ethnic groups. A systematic and integrated approach to changing the environment and norms of communities is needed to affect change and reduce the morbidity and mortality associated with violent behaviors. © Society for Adolescent Medicine, 1998 From the Department of Behavioral Sciences, School of Public Health (J.A.G.)The Department of Behavioral Science, M.D. Anderson Cancer Center (K.B.)and the Department of Epidemiology, School of Public Health (D.P.), University of Texas-Houston, Houston, Texas, USA. Address reprint requests to: Jo Anne Grunbaum, Ed.D., Centers for Disease Control and Prevention, Division of Adolescent and School Health, 4770 Buford Highway, N.E., Mailstop K33, Atlanta, GA 30341. Manuscript accepted October 23, 1997.
KEY WORDS: Violence Adolescents Mexican-American Substance use Suicide
Violence among adolescents and young adults in the United States is a major public health problem responsible for substantial morbidity and mortality (1–3). Homicide is the second leading cause of death among adolescents and young adults (4–10), with homicide rates substantially higher among minority compared to white youth (11). However, the disparity in rates of violence between white adolescents and minority youth may be related to other factors (4,12–15). Morbidity associated with violence far exceeds the number of fatalities; however, data for nonfatal injuries are less accurately recorded (16,17). Morbidity owing to violent behaviors is disproportionately higher among African-Americans and Hispanics (12). Suicide is the third leading cause of death among adolescents (4,10,16,18), and in 1995 a nationwide survey of high school students demonstrated that Hispanic students were significantly more likely than white students to have attempted suicide (19). Behaviors that contribute to violent behaviors include carrying a weapon, fighting, use of alcohol, and use of illicit drugs (3,20 –23). Among homicide victims 15–24 years of age, at least 40% have measurable blood alcohol levels and 25% have a blood alcohol concentration of $0.10% (16). Although some data exist on the prevalence of risk behaviors among minority youth, little is known
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about violent behaviors among Mexican-American adolescents. In addition, no study has explored the association between violent behaviors and alcohol and drug use among Mexican-American youth. This study used the Youth Risk Behavior Survey (YRBS) to determine the prevalence of violent behaviors among Mexican-American and non-Hispanic white high school students in a biethnic community in Southeast Texas and to assess the association between violent behaviors and substance use. This study will help identify ethnic differences that may need to be considered when planning communityspecific public health interventions aimed at decreasing the prevalence of violence (5,14,15).
were anonymous, their participation was voluntary, and no names or codes were used that could identify an individual student; they were instructed not to write their name on any material, to place the completed answer sheet in an envelope, and to seal the envelope prior to turning it in. Teachers were instructed to stay in the front of the room. A total of 2139 students were enrolled and were considered eligible participants. Of those eligible, 1786 (84%) completed the survey, 92 (4%) refused to participate, 25 (1%) never received a consent form prior to survey administration, 177 (8%) were absent, and 59 (3%) did not participate, for unknown reasons.
Methods
Instruments
Sample
The YRBS was developed by the Centers for Disease Control and Prevention to assess the prevalence and age of initiation of health risk behaviors that contribute substantially to morbidity, mortality, and social problems among adolescents in the United States (24). The six risk categories addressed include tobacco use, drug and alcohol use, sexual activities, dietary patterns and disorders, physical activity, and behaviors that result in intentional or unintentional injuries. The YRBS has been used to collect data at the national, state, and local levels. At the national level, oversampling of African-American and Hispanic youth provide estimates of risk behaviors for those groups. A test-retest reliability study of the YRBS demonstrated that in general, students reported health risk behaviors reliably over time (25). A Kappa statistic was computed for each item, and over 70% of the items had substantial or higher reliability.
During Spring 1992, the YRBS was administered to students attending three high schools in a school district in Southeast Texas. To ensure adequate representation of non-Hispanic white adolescents, the five public high schools in the district were stratified based on percent enrollment of non-Hispanic white students: 4% at two schools, 26% at one school, and 43% at two schools. One school within each stratum was chosen. The target sample size within each school was 700 students, thus providing adequate representation of non-Hispanic white students. Rosters for second-period classes were provided by the district, and special education classes and those classes with ,10 students were eliminated prior to class selection. Classes were selected randomly from among all remaining second-period classes until the target number of students was reached. A total of 96 classes, ranging from 31 to 34 per school, were selected to participate. The study was approved by the University of Texas-Houston Committee for the Protection of Human Subjects. Written information explaining the survey was provided to all teachers whose classrooms were chosen, and all teachers agreed to participate. One week prior to survey administration, teachers distributed consent forms to each student in the class to take to his or her parents. Parents were to notify the teacher if they did not want their child to participate (passive consent). The research assistant was on-site at each school the day prior to and the day of data collection to assist teachers and collect the surveys. Several measures were implemented to ensure student privacy and promote validity of the responses. Students were told that their responses
Statistical Analysis Prior to data analysis, each answer form was visually inspected for patterned responses, such as choosing the same answer for all questions. Based on this inspection, one answer form was excluded resulting in 1785 respondents included in our analyses. Data analyses were performed using SPSS/PC. Chi-square tests were used to identify differences in prevalence between ethnic groups for both substance use behaviors and violence-related behaviors and to describe ethnic differences in type of weapon carried and the person with whom students fought. Use of alcohol, marijuana, cocaine, and steroids was used as
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Table 1. Prevalence of alcohol, substance use, and violent behaviors by gender and ethnicity among MexicanAmerican and non-Hispanic white high school students, 1992 Male Behaviors
Female
Non-Hispanic White [n (%)]
Mexican-American [n (%)]
Non-Hispanic White [n (%)]
Mexican-American [n (%)]
132* (64.7)
308 (55.9)
124 (53.4)
278 (48.8)
Alcohol At least 1 drink in past 30 days $5 drinks at least once (prior month) Substance use Smoked marijuana at least once (prior month) Used cocaine at least once (prior month) Used steroids at least once (in lifetime) Violent behaviors Carried a weapon in past 30 days Fought in past 12 months Injured in fight in past 12 months Planned suicide in past 12 months Attempted suicide in past 12 months
x2 5 4.75 100** (47.8)
x2 5 1.44 206 (36.3)
69 (29.6)
x2 5 8.48 42 (19.5)
135 (23.7)
35 (14.6)
x2 5 1.57 11 (5.2)
43 (7.6)
11 (4.6)
34 (5.9)
3 (1.3)
243 (42.9)
9 (3.8)
294 (51.7)
67 (28.0)
31 (5.5)
3 (1.3)
13 (2.3) x2 5 0.85
76 (14.2)
52 (22.9)
x2 5 0.23 13 (6.3)
197 (34.1) x2 5 2.88
x2 5 4.06 32 (15.6)
37 (6.4) x2 5 2.18
x2 5 1.12 20* (9.5)
13 (2.2) x2 5 0.85
x2 5 0.14 101 (47.4)
22 (3.8) x2 5 0.29
x2 5 0.00 94 (44.3)
85 (14.8) x2 5 0.00
x2 5 1.36 13 (6.0)
155 (27.0) x2 5 0.58
131 (24.4) x2 5 0.21
37 (6.9) x2 5 0.06
26 (11.2)
81 (14.9) x2 5 1.91
p value denotes ethnic comparison within gender by Chi-square test. * p , 0.05; ** p , 0.01.
indicator variables with no use of a given substance as the referent group. Logistic regression analyses were performed to examine age-adjusted cross-sectional associations between gender- and ethnic-specific substance use on the four violence-related behaviors: carried a weapon in the past 30 days, fought in the past 12 months, planned suicide in the past 12 months, and attempted suicide in the past 12 months. The 95% confidence intervals of the ageadjusted odds ratios were calculated using the standard error of the estimates.
ethnic groups; however, there was a significant difference for females, with a larger percentage of Mexican-American females, age $17 years, as compared to non-Hispanic white females. For all sex and ethnic groups, over 90% of the students were $15 years old. Over 30% of all students were in the ninth grade, and the percentage of students per grade decreased as grade level increased for males of both ethnic groups and for non-Hispanic white females.
Results
Non-Hispanic white males were significantly more likely than Mexican-American males to have had at least one drink of alcohol within the prior month (64.7% vs. 55.9%) and to have drunk five or more drinks at one time (heavy drinking) on at least one occasion during the prior month (47.8% vs. 36.3%). Although the same trend was true for females, the results were not statistically significant (Table 1). Mexican-American adolescents, both males and females, were more likely than non-Hispanic white youth to have smoked marijuana at least once in the prior month, and Mexican-American males were
Demographic Characteristics The ethnic distribution of respondents was reflective of the ethnic distribution of students within the school district. Sixty-five percent of the respondents were Mexican-American, 26% were non-Hispanic white, and the remaining 9% were of other or unknown ethnicity. Subsequent analyses were restricted to those 1617 respondents who were either Mexican-American or non-Hispanic white. The age distribution for males was similar in both
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Table 2. Prevalence of type of weapon carried among students who reported having carried a weapon during past 30 days (%) Male
Female
Weapon
Non-Hispanic White (n 5 93)
Mexican-American (n 5 234)
Non-Hispanic White (n 5 9)
Mexican-American (n 5 36)
Gun Knife or razor Club/pipe/other
22.6 54.8 22.6
26.9 47.9 25.2
— 55.6 44.4
8.3 80.6 11.1
more likely than non-Hispanic white males to have used some form of cocaine in the past month, but none of the differences was statistically significant (Table 1). Among females, there were no significant differences between ethnic groups for use of cocaine in the past month. Use of anabolic steroids was three times more prevalent among males than females. However, there were no significant differences in use of steroids between Mexican-American and non-Hispanic white youth within gender groups. Carried Weapon in Past Month Over 40% of males had carried a weapon at least once in the past 30 days, while ,10% of females reported having carried a weapon (Table 1). Among students who reported having carried a weapon in the past 30 days, the type of weapon carried most often was a knife or razor (Table 2). Among males and Mexican-American females, the next most frequently carried weapon was either a gun or a club/ pipe or other type of weapon, while no non-Hispanic white females indicated having carried a gun. There were no significant ethnic differences in prevalence of carrying a weapon or type of weapon carried. Among Mexican-American males and females, drinking alcohol, smoking marijuana, using cocaine, and using steroids were significantly associated with an increased risk of carrying a weapon (Table 3). Use of cocaine and use of steroids were associated with increased risk of carrying a weapon among nonHispanic white males and females (Table 3). Fighting Patterns Nearly 50% of males and approximately 30% of females reported having been in a physical fight at least once in the past 12 months (Table 1). NonHispanic white males were significantly more likely to have sustained an injury in a fight during the past year which had to be treated by medical personnel,
as compared to Mexican-American males. Less than 3% of females were injured in a fight in the past year. Among males who had fought in the past year, approximately one third of the fights were with a friend, while 12% were with a relative, and slightly more than 20% were with a stranger; there were no significant differences between the two ethnic groups. However, among females who reported having been in a fight in the past year, there were significant differences between ethnic groups. Fifty percent of non-Hispanic white females had fought with a relative, as compared to 33% for MexicanAmerican females. Mexican-American females were four times more likely to have fought with a stranger than were non-Hispanic white females. For all sex and ethnic groups, both smoking marijuana and using cocaine were significantly associated with an increased risk of fighting [odds ratio (OR) 5 2.71–13.5)] (Table 3). Heavy drinking was associated with a threefold increased risk of fighting only among Mexican-American youth (OR 5 3.37, male; OR 5 3.71, female). Drinking alcohol and use of steroids were each associated with an increased risk of fighting among Mexican-Americans and nonHispanic white males (Table 3).
Planned Suicide Approximately 15% of males and over 20% of females reported having planned suicide within the past year. There were no significant differences between ethnic groups within gender categories in prevalence of having planned suicide (Table 1). There was a twofold increase in the risk for planning suicide among Mexican-American males and all females who had drunk alcohol (Table 3). Heavy drinking was associated with an increased risk for planning suicide only among Mexican-American females. Smoking marijuana was associated with an increased risk of planning suicide among non-Hispanic white males (OR 5 3.26), non-Hispanic white
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Table 3. Age-adjusted odds ratios (95% confidence intervals) of violent behaviors according to alcohol and substance use behaviors among Mexican-American and non-Hispanic white high school students, 1992 Male
Carried weapon in past 30 days Drank alcohol (prior month) Heaving drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime) Fought in past 12 months Drank alcohol (prior month) Heavy drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime) Planned suicide in the past 12 months Drank alcohol (prior month) Heavy drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime) Attempted suicide in the past 12 months Drank alcohol (prior month) Heavy drinking (prior month) Smoked marijuana (prior month) Used cocaine (prior month) Used steroids (in lifetime)
Female
Non-Hispanic White
Mexican-American
Non-Hispanic White
Mexican-American
1.7 (0.91–3.14) 1.85 (1.03–3.3) 1.74 (0.86 –3.5) * 6.73 (1.41–32.03)
2.20 (1.53–3.16) 2.92 (2.02– 4.22) 2.68 (1.78 – 4.03) 2.55 (1.32– 4.9) 3.77 (1.68 – 8.44)
2.4 (0.46 –12.45) 3.75 (0.85–16.59) 3.19 (0.73–13.98) 8.7 (1.34 –56.59) 46.48 (1.92–1123.96)
3.60 (1.64 –7.86) 4.88 (2.4 –9.91) 5.65 (2.72–11.74) 13.98 (5.2–37.56) 8.15 (2.18 –30.45)
2.05 (1.11–3.67) 1.67 (0.95–2.94) 2.71 (1.29 –5.69) 13.5 (1.64 –110.82) 14.28 (1.79 –113.72)
3.01 (2.09 – 4.34) 3.37 (2.31– 4.92) 3.01 (1.97– 4.61) 4.0 (1.86 – 8.58) 4.36 (1.74 –10.89)
1.38 (0.76 –2.49) 1.14 (0.61–2.14) 4.3 (2.03–9.11) 7.08 (1.8 –27.92) 4.91 (0.42–58.0)
3.02 (2.09 – 4.36) 3.71 (2.5–5.52) 2.97 (1.84 – 4.8) 3.62 (1.41–9.3) 3.53 (1.01–12.35)
1.0 (0.42–2.38) 0.74 (0.33–1.69) 3.26 (1.4 –7.56) 6.01 (1.58 –22.91) 1.15 (0.24 –5.64)
1.81 (1.05–3.1) 1.53 (0.93–2.54) 1.52 (0.88 –2.64) 1.3 (0.54 –3.13) 1.49 (0.57–3.95)
2.03 (1.03–3.98) 0.95 (0.46 –1.97) 2.41 (1.06 –5.48) 2.26 (0.58 – 8.77) 1.69 (0.14 –19.94)
1.87 (1.24 –2.82) 2.68 (1.74 – 4.12) 2.8 (1.68 – 4.66) 2.05 (0.85– 4.96) 5.24 (1.49 –18.49)
2.59 (0.54 –12.47) 1.63 (0.44 – 6.0) 8.69 (2.36 –31.76) 21.12 (4.26 –104.69) 1.51 (0.17–12.95)
1.57 (0.74 –3.33) 1.79 (0.88 –3.62) 1.56 (0.73–3.32) 3.6 (1.43–9.11) 4.61 (1.76 –12.04)
2.65 (1.0 –7.06) 1.9 (0.79 – 4.59) 4.02 (1.59 –10.17) 4.28 (0.97–18.8) †
1.9 (1.16 –3.12) 3.0 (1.81– 4.98) 3.21 (1.8 –5.72) 2.08 (0.77–5.66) 7.77 (2.06 –29.36)
* All non-Hispanic white males who used cocaine also carried a weapon. † No non-Hispanic white females used steroids and attempted suicide.
females (OR 5 2.41), and Mexican-American females (OR 5 2.8). Use of cocaine was associated with an increased risk of planning suicide only among nonHispanic white males.
Attempted Suicide The prevalence of attempted suicide was two times greater among females than males, with 6% of males
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and 11–15% of females reporting having attempted suicide in the past year (Table 1). The risk of attempting suicide was increased twofold among MexicanAmerican females who had drunk alcohol in the past month, as compared to nondrinkers (Table 3). Heavy drinking was associated with increased risk of attempted suicide only among Mexican-American females (OR 5 3.0). Smoking marijuana was associated with an increased risk of attempted suicide among non-Hispanic white males (OR 5 8.69), non-Hispanic white females (OR 5 4.02), and Mexican-American females (OR 5 3.21). Use of cocaine was associated with attempted suicides among males, while use of steroids was associated with increased risk of attempted suicides among Mexican-American youth. No non-Hispanic white females used steroids and attempted suicide.
Discussion The results of this study on ethnic differences in prevalence of alcohol, marijuana, cocaine, and steroid use are generally consistent with other studies (26 –28). Mexican-American youth were more likely to have smoked marijuana in the past month, with the trend in the same direction as reported by a national study of high school students (19). Prevalence of cocaine use was higher among non-Hispanic white youth as compared to national data, while female use of steroids was lower as compared to national data (19). Unique to this study are the data on violencerelated behaviors for Mexican-American and nonHispanic white youth. These data demonstrate small ethnic differences in the prevalence of fighting, planning suicide, or attempting suicide, with the results similar in magnitude and direction to the results of a national study (19). Disparate from the national sample, however, are the differences among males in prevalence of carrying a weapon and in being injured in a fight. In this study, a larger percentage of Mexican-American males reported carrying a weapon as compared to non-Hispanic white males, while nationally, non-Hispanic white males were more likely to have carried a weapon than MexicanAmerican youth (19). In addition, in this study, non-Hispanic white males were twice as likely to report having been injured in a fight as compared to Mexican-American males. Nationally, Mexican-American youth were more likely to have been injured in a fight than non-Hispanic white youth (19). Among youth who reported having carried a weapon in the past 30 days, choice of weapon was
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very similar between ethnic groups among males, with one half choosing a knife or razor and one quarter carrying a gun. These results are similar to those reported by Valois and colleagues for white males (29). Type of weapon carried was very different between non-Hispanic white and Mexican-American females, but, owing to the small number of females who reported having ever carried a weapon, the differences are not statistically significant and may not be generalizable. There were no ethnic differences in the relationship to the opponent in the last fight among males; this was similar to results reported by Valois and colleagues for white males (29). However, among females, there were significant differences in the choice of opponent with the pattern for non-Hispanic white females disparate from that reported by others (29). A major contribution of this study is the information on the association between violent behaviors and substance use by gender and ethnic group. After adjustment for age, carrying a weapon and fighting are significantly associated with alcohol and substance use, with few exceptions, among all four gender and ethnic groups. Orpinas and colleagues reported similar results among high school males (8). The relationships between suicide (plan and attempts) and substance use among the subgroups is less consistent and of much lower magnitude than for carrying a weapon and fighting. An advantage of this study is that respondents live in the same geographic community and attend the same high schools. Therefore, they are subject to similar influences, a factor not accounted for by national studies. Although there were some ethnic differences in substance use associated with fighting and carrying a weapon between Mexican-American and non-Hispanic white youth, the differences should not affect community intervention programs aimed at decreasing violence among adolescents. It is clear that use of alcohol and other illegal substances increases substantially the risk of fighting and carrying a weapon. Thus, intervention programs to decrease violence need to address the issues of alcohol and illicit drug use, regardless of ethnicity of the audience. Factors associated with suicide planning and suicide attempts are less clear. Drinking alcohol, smoking marijuana, and using steroids all increased the risk of suicide plans and attempts among MexicanAmerican females, with inconsistent associations among the other subgroups. It is possible that substance use plays a minor role in suicide plans and attempts, while mental health disorders, such as depression, are more powerful risk factors. Interven-
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tions to decrease suicide among adolescents may need to focus more on mental health disorders, although substance use is an important risk factor for Mexican-American females. Although a substantial percentage of youth drink alcohol, use illicit drugs, and engage in violent behaviors, many do not. Thus, future research needs to explore protective factors for violent behaviors and substance use and determine why many of the youth exposed to violent acts and who live in the same communities do not engage in violent behavior. What are the factors that make them resilient? In addition, future research needs to explore the impact of psychological factors such as meaning of risk activities or sensation seeking on substance use and violent behaviors. It is clear from the results of this study that a substantial percentage of adolescents engage in violent behaviors which are associated with substance use, more strongly for fighting and weapon carrying than for suicide, among both gender and ethnic groups. Violence prevention needs primary prevention and must be comprehensive in scope, addressing both the violent behaviors and use of alcohol and illicit drugs.
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10. Sells CW, Blum RW. Morbidity and mortality among US adolescents: An overview of data and trends. Am J Public Health 1996;86:513–9. 11. Singh GK, Yu SM. Trends and differentials in adolescent and young adult mortality in the United States, 1950 through 1993. Am J Public Health 1996;86:560 – 4. 12. Houk VN, Warren RC. Foreword to the proceedings. Public Health Rep 1991;106:226. 13. Spivak H, Hausman AJ, Prothrow-Stith D. Practitioners’ forum: Public health and the primary prevention of adolescent violence—the Violence Prevention Project. Violence Victims 1989;4:203–12. 14. Rosenberg ML. Charge to the participants: From analysis to action. Public Health Rep 1991;106:233– 6. 15. DuRant RH, Cadenhead C, Pendergrast RA, et al. Factors associated with the use of violence among urban black adolescents. Am J Public Health 1994;84:612–7. 16. Runyan CW, Gerken EA. Epidemiology and prevention of adolescent injury. JAMA 1989;262:2273–9. 17. Hammond WR, Yung B. Psychology’s role in the public health response to assaultive violence among young African-American men. Am Psychol 1993;48:142–54. 18. Koop CE, Lundberg GD. Violence in America: A public health emergency. JAMA 1992;267:3075– 6. 19. The Centers for Disease Control and Prevention. Youth risk behavior surveillance—United States, 1995. MMWR 1996;45: 1– 84.
This research was funded by Grant R48/CCR602176, from the Centers for Disease Control and Prevention.
20. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. Washington, DC: U.S. Dept. of Health and Human Services, 1990. DHHS Pub. no. PHS 91-50212.
References
21. Black MM, Ricardo IB. Drug use, drug trafficking, and weapon carrying among low-income, African-American, early adolescent boys. Pediatrics 1994;93:1065–72.
1. Hammett M, Powell KE, O’Carroll PW, Clanton ST. Homicide surveillance—United States, 1979 –1988. MMWR 1992; 41:1–34. 2. Rosenberg ML, O’Carroll PW, Powell KE. Let’s be clear: Violence is a public health problem. JAMA 1992;267:3071–2. 3. McGinnis JM. The year 2000 initiative: Implications for comprehensive school health. Prevent Med 1993;22:493– 8. 4. Blum R. Contemporary threats to adolescent health in the United States. JAMA 1987;257:3390 –5. 5. Fingerhut LA, Ingram DD, Feldman JJ. Firearm and nonfirearm homicide among persons 15 through 19 years of age. JAMA 1992;267:3048 –53. 6. Hausman AJ, Spivak H, Prothrow-Stith D. Adolescents’ knowledge and attitudes about and experience with violence. J Adolesc Health 1994;15:400 – 6. 7. Leenaars AA, Lester D. Suicide and homicide rates in Canada and the United States. Suicide Life-Threat Behav 1994;24:184–91. 8. Orpinas PK, Basen-Engquist K, Grunbaum JA, Parcel GS. The co-morbidity of violence-related behaviors with health-risk behaviors in a population of high school students. J Adolesc Health 1995;16:216 –25. 9. Roper WL. The prevention of minority youth violence must begin despite risks of imperfect understanding. Public Health Rep 1991;106:229 –31.
22. Valois RF, Vincent ML, McKeown RE, et al. Adolescent risk behaviors and the potential for violence: A look at what’s coming to campus. Coll Health 1993;41:141–7. 23. Kingery PM, Pruitt BE, Hurley RS. Violence and illegal drug use among adolescents: Evidence from the U.S. National Adolescent Student Health Survey. Int J Addict 1992;27:1445– 64. 24. Kolbe, LJ. An epidemiological surveillance system to monitor the prevalence of youth behaviors that most affect health. Health Educ 1990;21:44 – 8. 25. Brener ND, Collins JL, Kann L, et al. Reliability of the Youth Risk Behavior Survey Questionnaire. Am J Epidemiol 1995; 141:575– 80. 26. Bachman JG, Wallace JM, O’Malley PM, et al. Racial/ethnic differences in smoking, drinking, and illicit drug use among American high school seniors, 1976 – 89. Am J Public Health 1991;81:372–7. 27. Chavez EL, Swaim RC. An epidemiological comparison of Mexican-American and white non-Hispanic 8th- and 12th-grade students’ substance use. Am J Public Health 1992;82:445–7. 28. Welte JW, Barnes GM. Alcohol use among adolescent minority groups. J Stud Alcohol 1987;48:329 –36. 29. Valois RF, McKeown RE, Garrison CZ, Vincent ML. Correlates of aggressive and violent behaviors among public high school adolescents. J Adolesc Health 1995;16:26 –34.