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Defining and understanding healthy lifestyles choices for adolescents
JOURNAL OF ADOLESCENT HEALTH 2004;35:26 –33
ORIGINAL ARTICLE
Defining and Understanding Healthy Lifestyles Choices for Adolescents KA HE, M.D., Sc.D., ELLEN KRAMER, Sc.D., ROBERT F. HOUSER, Ph.D., VIRGINIA R. CHOMITZ, PhD., AND KAREN A. HACKER, M.D., M.P.H.
Purpose: To: (a) establish criteria for defining positive health behaviors and lifestyle; and (b) identify characteristics of adolescents who practice a healthy lifestyle. Methods: Responses from a 1998 survey via questionnaire, of 1487 students, from a public high school, Cambridge, Massachusetts, were used to assess correlates of healthy lifestyle choices. Strict and broad assessments of healthy behaviors were defined for students: use of alcohol, tobacco, and illegal drugs; sexual behavior; attempted suicide. Whereas the “strict” criteria included only those adolescents who did not practice any of the behaviors in question, the broad criteria reflected experimentation and moderate risk-taking. The prevalence of positive behaviors was assessed by demographic and student characteristics. In addition, logistic regression models were created to predict determinants of teenagers’ healthy lifestyles using both strict and broad definitions. Results: Using strict criteria of healthy lifestyle, significant predictors were being female, born outside the United States, higher academic performance, and fewer stressful life events. Using a broad definition of a healthy lifestyle, significant predictors were being non-Caucasian, in the lower grade levels at the school, higher academic performance, and fewer stressful life events. In both models, peers’ approval of risky behaviors nega-
From the Department of Preventive Medicine, Northwestern University School of Medicine, Chicago, Illinois (K.H.); The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, Massachusetts (R.F.H.); and Cambridge Institute for Community Health, Cambridge, Massachusetts (E.K., V.R.C., K.A.H.). Address correspondence to: Dr. Ka He, Department of Preventive Medicine, Northwestern University School of Medicine, Suite 1102, 680 North Lake Shore Drive, Chicago, IL 60611. E-mail: [email protected] Manuscript accepted September 18, 2003. 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2003.09.004
tively influenced teens’ lifestyles, whereas parents’ disapproval of risky behaviors was a positive influence. Conclusions: These results reinforce the importance of school, peer, and parent support of positive behaviors. It is important for public health workers and families to understand and define healthy lifestyles choices for adolescents. © Society for Adolescent Medicine, 2004 KEY WORDS:
Adolescents Gender differences Healthy lifestyle Positive health behavior
Adolescence is a time of risk-taking and experimentation. By and large, the leading causes of morbidity and mortality in this age group are behaviorally mediated. A wealth of literature exists on the myriad of adolescent risky health behaviors that have been linked to disability and disease in later life [1– 4]. Historically, these studies have focused on negative choices teens have made and the resulting morbidity and mortality [5– 8]. As the field of youth development evolves, clinicians and researchers are now arguing that using a risk factor model burdens already at-risk children with the expectation of failure rather than identifying their strengths. An individual can bounce back from adversity and go on with his/her life [9], recognizing that not all people are devastated by bad events [10]. An increasing number of researchers and community activists argue that instead of focusing on youth problems, attention should focus on youth assets: the positive relationships, opportunities, skills, and values that help young people grow up healthy [11,12]. © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
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The characteristics of individuals who choose healthy lifestyles are extremely important to the overall understanding of positive health behaviors. A variety of protective factors has been associated with positive health behaviors and practices, including connectedness to family, school and peers, as well as higher self-esteem [13–15]. Additionally, recent studies have demonstrated the co-occurrence of health-promoting behaviors [16]. Understanding health behaviors of teens requires consideration of many personal and social environmental factors, including the family and school context as well as individual characteristics [8,17,18]. It may be possible to identify both youth who choose positive health behaviors and the correlates to such activities. Identifying characteristics of adolescents who make positive health choices could improve the ability of health professionals to target at-risk youth, develop innovative preventive strategies, support inherent strengths, and ultimately, modify negative health behaviors. To the best of our knowledge, there are no universal, objective definitions of positive health behaviors among teenagers. This is particularly true for behaviors like alcohol use and sexual activity. Previous studies have introduced a variety of definitions to describe adolescent health behaviors [16,19]. However, these definitions tend to classify behaviors in strict terms such as “never used alcohol,” and “never had sexual intercourse.” This approach fails to capture an important group of adolescents; teenagers who engage in modest risk-taking health behaviors that are considered experimental in nature. For example, many adolescents have tried alcohol and some drink in moderation. It is not clear that the best definition of healthy teen behavior related to alcohol use is complete abstinence. Does one-time experimentation with marijuana have negative effects on health? Should the teenager who briefly experiments with alcohol or marijuana be considered at-risk? In the present study, we developed two sets of definitions of positive health behaviors to identify adolescent healthy behaviors strictly and broadly. According to literature and previous studies [17,20 – 24], we postulated that gender, race, immigration status, grade in school, academic performance, whether the respondents had close friend(s), whether they received special educational services, whether their families received public assistance, parents’ education level, stress index (a summary measurement of stress), peer approval, and perception that their parents would be upset by their engagement in risky behaviors were all important
factors in influencing how teens make decision about health behaviors. The objectives of our study were to: (a) establish criteria for defining positive health behaviors and lifestyle; and (b) identify characteristics of adolescents practicing a healthy lifestyle.
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Methods Participants Cambridge, Massachusetts is an urban community of approximately 100,000 people outside of Boston, with one high school, Cambridge Rindge and Latin. The school population was 1936 (grades 9 –12) during the 1997–1998 academic year. Fifty-three percent of the students were female, whereas 36.7% were African-American, 14.4% Hispanic, 40.5% Caucasian, 8.3% Asian, and 0.2% were Native American [20]. The survey was administered to all consenting students in attendance at Cambridge Rindge and Latin high school on the day of survey administration. An “opt-out” form was sent home to parents before the survey. Parents wishing to exclude their child from the survey were advised to inform their child’s teacher. On the day of administration, only students who were absent or whose parents excluded them from the survey did not participate in the survey. Additionally, obvious cases of frivolous or invalid responds were excluded, as were questionnaires in which fewer than 75% of questions were answered. A total of 1487 students (77.9%) completed the survey and were included in this analysis. The study protocol was approved by the Institutional Review Board of the Cambridge Health Alliance.
Questionnaire The questionnaire used in this survey was based on the Youth Risk Behavior Surveillance System (YRBSS) questions from the Centers for Disease Control and Prevention (CDC), as well as Michigan Model Surveys, Monitoring the Future, and locally designed questions [25,26]. The questions covered information on demographics; family constellation; access to health care; stressful events such as a death in the family; violence; suicide; sexuality; use of alcohol, tobacco and illegal drugs; delinquency; and personal habits (for example, nutrition, physical activity). Surveys were available in Spanish, Portuguese, Chinese, and Haitian Creole. Before distributing the survey, teachers and staff gave the students directions on taking the survey and emphasized that
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participation was voluntary, anonymous, and confidential. Students were instructed that there were no right or wrong answers. Although they were encouraged to answer all of the survey questions, students were also told that they could skip particular questions if they did not want to answer them.
Defining Healthy Behavior Working with local community leaders, teachers, health professionals, and parents in both group and individual informant sessions, we developed two sets of definitions of positive health behaviors. The first set was based on a restrictive set of criteria called “strict.” The second set was based on broader criteria. The “broad” definitions reflected the mindset of some health professionals that experimentation and moderate risk-taking in adolescence is normal behavior. We selected and classified six health-related behaviors: suicidal attempts, sexual behavior, use of “hard drugs” (including psychedelics, cocaine, amphetamines, tranquilizers, barbiturates, heroin, narcotics, and glue), and use of marijuana, tobacco, and alcohol, based on determined “strict” and “broad” definitions of healthy behaviors. In the “strict” definition, we defined healthy behaviors as alcohol use: did not drink during the last 30 days; tobacco use: never smoked; “hard drug” use: never tried; marijuana use: never tried; sexual behavior: never had sexual intercourse; and suicidal behavior: no attempted suicide during the past 12 months. In contrast, we determined “broad” definitions as alcohol use: (a) did not consume 5 or more drinks in a row during the last 30 days, and (b) did not drink enough to feel drunk or high during the last 30 days; tobacco use: (a) did not use smokeless tobacco during the last 30 days, and (b) did not use cigars during the last 12 months, and (c) did not use cigarettes during the last 30 days; “hard drug” use: did not use any “hard drug” during the last 30 days; marijuana use: did not use marijuana during the last 30 days; sexual behavior: (a) had no more than one partner during the past 3 months, and (b) always used condoms to protect against sexual transmitted diseases or AIDS; and suicidal behavior: same as “strict” definition.
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explore relationships among the various health choices and between health choices and demographic characteristics of the participants. In addition, logistic regression was used to test models predicting possible determinants of teenagers’ healthy lifestyles based on their avoidance of risk behaviors. We made two binary-dependent “healthy lifestyle” variables according to strict or broad definitions of healthy behaviors by combining healthy choices on the six selected behaviors. Participants were divided into either the strict lifestyle group, which was composed of those who made healthy choices on all six behaviors based on the strict definition, or the broad group, which consisted of those who qualified under the broader definitions of healthy behavior. Independent variables measuring stress, social influence, and parental concern were created for use in the logistic regression. The stress score was an index from 0 –14 and included 14 stressful events, including failing grades, divorce or separation in family, moving, verbal, physical and sexual abuse, witnessing violence in the family, and being threatened with a knife or gun. A social influence measurement, “peers approval,” was created to measure teens’ perception of friends’ approval of substance use. It was based on six questions on substance use with four answer options. We coded “disapprove and stop being my friend” as “1,” “disapprove but still be my friend” as “2,” “they would not care” as “3,” and “they would approve” as “4.” Summarized scores ranged from 6 to 24. Similarly, student perception of parents’ potential level of upset was based on nine questions on substance use with four possible answers. We coded parents would be “not upset at all” as “1,” “a little upset” as “2,” “pretty upset” as “3,” and “very upset” as “4.” Summarized scores ranged from 9 to 36. Because marijuana is the most popular illegal drug in this cohort, we analyzed marijuana use separately from other drugs. We defined “hard drugs” as all illegal drugs except marijuana. All reported p values were two-tailed, and less than .05 was considered statistically significant. SPSS 9.0 package (SPSS Inc., Chicago, IL) was used for all analyses.
Data Analysis
Results
The outcomes of interest were binary results of healthy choices on all six selected behaviors at strict and broad levels. Chi-square analysis was used to
Of 1487 participants, 48.2% were female. The median age was 16 years (range 13–22). Participants were ethnically and racially diverse, including white
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Table 1. Proportions of Students (N ⫽ 1487) Making Healthy Choices on Each Health-related Behavior Under Strict and Broad Definitions Behaviors
Percentage of healthy choice based on strict definitiona
Percentage of healthy choice based on broad definitiona
Suicidal attempt Hard drug use Sexual behavior Marijuana use Alcohol use Tobacco use Those who exhibited all six behaviors
92.3 (n ⫽ 1348/1461) 80.0 (n ⫽ 1122/1402) 55.9 (n ⫽ 785/1405) 50.8 (n ⫽ 727/1432) 49.6 (n ⫽ 687/1386) 46.9 (n ⫽ 663/1413) 19.6 (n ⫽ 256/1306)
92.3 (n ⫽ 1348/1461) 92.3 (n ⫽ 1261/1366) 75.2 (n ⫽ 1060/1409) 69.4 (n ⫽ 983/1416) 61.5 (n ⫽ 885/1439) 65.6 (n ⫽ 893/1362) 37.6 (n ⫽ 496/1319)
a Strict and broad definitions of healthy choices on each health-related behavior are described in the Methods section of the text; the denominators not equal to 1487 are owing to missing data.
(34.6%), African-American (27.3%), Hispanic (12.2%), Asian-American/Pacific Islander (7.4%), biracial (5.9%), Native American (0.3%), and other (12.3%). About one-third (30.2%) of participants were born outside the United States. Approximately 17% of the students belonged to families who received public assistance. Nearly a half of the students’ mothers (45.8%) and fathers (49.3%) had completed college or graduate school. The differences between behaviors under the strict and broad definitions are shown in Table 1. Whereas 19.6% of adolescents made positive health choices for all six health-related behaviors under the strict definition, 37.6% did so under the broad definition. Healthy choices regarding sexual behavior showed the largest difference between the broad and strict definitions; 75% of participants met the criteria under the broad definition and 56% met the criteria under the strict definition of abstinence. Differences in the association of personal and social-environmental factors to positive health choices based on strict and broad definitions are presented in Table 2. Under both definition sets, there were significant associations with regard to gender, race, immigration status, grade in school, academic performance, stress index, peer approval, and parental upset of substance use, respectively. For special education service, there was significant difference when broad definitions were applied. In the multivariate analysis based on the strict definitions, the significant predictors of healthy behaviors were gender, immigration status, stress index, academic performance, peer approval, and parental upset at risky health behaviors (Table 3). Females were 52% more likely to make healthy choices than males. Immigrants were 58% more likely than U.S.-born teens to make healthy choices. With each additional stressful life event, there was about 24% decrease in the likelihood of making
healthy choices. Positive health behaviors were also associated with improved academic achievement. If teenagers’ average grades increased by one ordinal level, for example, from C to B, the probability of making healthy choices would be expected to increase 35%. Teenagers with friends who approved of substance use were 9% less likely to make healthy choices. In contrast, teens who reported that their parents would be upset to learn of their children’s involvement in substance use were 11% more likely to make healthy choices. Under the broad definitions, the significant predictors of healthy behaviors were grade level, stress index, Caucasian or not, academic performance, peer approval and parental upset. There was a 55% increase in the likelihood of making healthy choices if teenagers’ grade point average improved by one ordinal level. In addition, participants who perceived that their parents would be upset to learn about their children’s substance use were 8% more likely to make healthy choices. Nevertheless, with each increasing year in school, teens were 15% less likely to make healthy choices, and they were 21% less likely to make healthy choices by one additional stressful event. Caucasian teens were 30% less likely to make healthy choices than non-Caucasian teens.
Discussion This study examined personal and social-environmental factors that influence adolescents’ health choices. Teenagers’ health choices and behaviors were investigated by using two different definitions, one strict and another broad, and employing them in two sets of analyses. The broad definition identified students with modest risk-taking behaviors and thus included more participants in the healthy groups. However,
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Table 2 . Proportions of Students (N ⫽ 1487) Who Had Healthy Choices in All Six Selected Health-related Behaviors Under Strict and Broad Definitions According to Selected Predictors Strict definitionsa Personal and socialenvironmental factors Gender Male Female Race Caucasian Non–Caucasian Immigration status Born in the US Immigrant Having close friend(s) Yes No Special education service Yes No Family receiving public assistance Yes No School grade in year Freshman Sophomore Junior Senior Academic performance A B C D F Mother’s education levels College or above Some college High school or below Father’s education levels College or above Some college High school or below Stress indexc ⱖ median score ⬍ median score Peers’ approval of substance usec ⱖ median score ⬍ median score Parents’ upset substance usec ⱖ median score ⬍ median score
Broad definitionsa
Those with healthy behaviors %b
p value
Those with healthy behaviors %b
p value
16.2 (n ⫽ 105/650) 23.2 (n ⫽ 151/650)
*
33.4 (n ⫽ 217/650) 41.9 (n ⫽ 277/661)
*
15.3 (n ⫽ 72/472) 22.2 (n ⫽ 180/811)
*
33.2 (n ⫽ 158/476) 39.8 (n ⫽ 326/819)
*
15.8 (n ⫽ 148/937) 29.5 (n ⫽ 108/366)
**
33.9 (n ⫽ 321/947) 47.0 (n ⫽ 174/370)
**
19.6 (n ⫽ 245/1249) 18.2 (n ⫽ 10/55)
NS
37.5 (n ⫽ 472/1259) 39.5 (n ⫽ 23/58)
NS
14.7 (n ⫽ 17/116) 19.6 (n ⫽ 214/1093)
NS
28.2 (n ⫽ 33/117) 38.3 (n ⫽ 422/1103)
*
17.4 (n ⫽ 35/201) 19.3 (n ⫽ 201/1042)
NS
37.3 (n ⫽ 75/201) 37.3 (n ⫽ 395/1058)
NS
22.2 (n ⫽ 80/361) 24.9 (n ⫽ 83/333) 17.8 (n ⫽ 57/320) 12.3 (n ⫽ 35/284) 31.7 (n ⫽ 84/265) 18.3 (n ⫽ 96/524) 14.4 (n ⫽ 52/360) 10.3 (n ⫽ 10/97) 6.7 (n ⫽ 1/15)
*
45.5 (n ⫽ 167/367) 39.4 (n ⫽ 134/340) 35.4 (n ⫽ 113/319) 28.3 (n ⫽ 80/283)
**
**
52.8 (n ⫽ 140/265) 39.2 (n ⫽ 207/528) 31.0 (n ⫽ 112/361) 20.8 (n ⫽ 21/101) 11.8 (n ⫽ 2/17)
**
18.6 (n ⫽ 99/532) 18.0 (n ⫽ 78/434) 24.3 (n ⫽ 44/181)
NS
38.0 (n ⫽ 206/542) 36.7 (n ⫽ 160/436) 39.7 (n ⫽ 71/179)
NS
22.1 (n ⫽ 113/512) 16.6 (n ⫽ 55/332) 22.7 (n ⫽ 39/172)
NS
41.5 (n ⫽ 214/516) 34.5 (n ⫽ 115/333) 38.5 (n ⫽ 67/174)
NS
11.7 (n ⫽ 91/781) 25.5 (n ⫽ 154/603)
**
26.5 (n ⫽ 207/781) 45.6 (n ⫽ 275/603)
**
9.8 (n ⫽ 69/701) 26.5 (n ⫽ 178/671)
**
21.5 (n ⫽ 151/701) 49.6 (n ⫽ 333/671)
**
26.7 (n ⫽ 188/703) 9.9 (n ⫽ 66/668)
**
47.1 (n ⫽ 331/703) 23.7 (n ⫽ 158/668)
**
* p ⬍ .05, ** p ⬍ .01, NS ⫽ nonsignificant. Strict and broad definitions of health choices on each health-related behavior are described in the Methods section of the text. b Total numbers not equal to 1487 are owing to missing data. c See Methods for definitions. Median scores of stress index, peers’ approval of substance use and parents’ upset substance use are 2, 16, and 15, respectively. a
even under the broad definitions, only 37.6% of participants made healthy choices for all six behaviors.
Our results highlight certain subgroups that were more likely to be practicing healthy behaviors: immigrants, females, and academic achievers. Immi-
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Table 3. Significant Variables for Teens Who Had Healthy Lifestyle Choices in All Six Selected Health Behaviors Under Strict and Broad Definitions
However, they were 50% more likely than male students to have attempted suicide during the last 12 months. This is consistent with other research, which has shown males to be at higher risk for substance abuse, violence, and early sexual activity [15,17,28], and females have been shown to have higher levels of depression and more suicide attempts [17,29]. Perhaps where males tend to act out their feelings with behaviors, females are more likely to express their stress through self-harming behaviors. The gender differences demonstrated here certainly merit further investigation. Multivariate analysis based on both strict and broad definitions showed that teenagers with higher academic achievement were significantly more likely to choose healthy behaviors. Academic success has been correlated with a greater likelihood of abstinence, less depression, and lower drug and alcohol use [30,31]. Consistent with previous studies [15,32], teenagers in higher-grade levels were less likely to make healthy choices about substance use and sexual behavior. The correlation between age/grade level and riskier behavior has been demonstrated elsewhere [17]. In addition, students receiving special education reported more frequent sexual intercourse than non-special-education students. We think this may be attributed to the fact that students receiving special education were older than other students in the study, owing, in part, to lower rates of grade advancement. However, the relationship between special education and risk-taking behavior for teens merits further research. Our results indicated age-dependent developmental changes throughout the high school years. As adolescents age, the likelihood of involvement in risk-taking behaviors increases [15,17,33]. This may be owing to peer norms and changing social expectations associated with age. Equipping young people with appropriate skills to cope with life’s changes is the challenge of parents and educators. However, given the age-related changes seen in health behaviors, we should prioritize developmentally appropriate risk reduction strategies in, and out of, school. Logistic regression produced different predictive models based on the two definitions of healthy choices. In both models, significant predictive variables were: stress index, academic performance, peer approval, and parental upset. In addition, peer approval for risky behaviors was a negative predictor and inversely correlated to parental upset at children’s risky behaviors. Parents who delivered the message that they would be extremely upset by their
Multivariate analysis Variables
OR
95% CI
1.52 1.58 0.76 1.35 0.91 1.11
1.02–2.25 1.06 –2.36 0.66 – 0.87 1.05–1.74 0.86 – 0.95 1.07–1.15
0.85 0.79 0.70 1.55 0.89 1.08
0.73– 0.98 0.72– 0.88 0.50 – 0.99 1.25–1.91 0.82– 0.93 1.04 –1.11
a
Strict definitions Female Immigrants Stress index Academic performance Peers approval of substance use Parents upset of substance use Broad definitionsa School grade in year Stress index Caucasian Academic performance Peers’ approval of substance use Parents’ upset of substance use
n ⫽ 1286 (strict), n ⫽ 1246 (broad); adjusted for whether had close friend(s), whether received special education service, whether family received public assistance, mother’s education levels and father’s education levels. Six selected variables include alcohol use, tobacco use, hard drug use, marijuana use, sexual behavior and suicidal attempt. Female: females coded (1), males coded (0). Immigrants: immigrants coded (1), U.S.-born coded (0). Stress index: self-reported stress. From mild to severe, sum of coding scores from 0 to 14. Academic performance: grade A to F coding as 5 to 1. Peers’ approval of substance use: level of perceived friends’ approval of substance use, from disapproval to approval, sum of coding score from 6 to 24. Parents’ upset of substance use: parents’ upset level on substances use, from not upset at all to very upset, sum of coding score from 9 to 36. School grade in year: freshman coded (1), sophomore coded (2), junior coded (3), senior coded (4). Caucasian: Caucasian coded (1), non-Caucasian coded (0). a Strict and broad definitions of health choices on each healthrelated behavior are described in the Methods section.
grant students were more likely than U.S.-born teenagers to avoid substance use. As noted in previous studies, higher levels of acculturation have been associated with higher incidence of risky behaviors [27]. Social norms of immigrants may be different from U.S.-born students based on traditional cultures and/or religious beliefs and may serve as a protective factor [5]. Families that immigrate to this country may represent very resilient, motivated individuals who are more likely to make positive choices in many areas of life. More research on immigrant health behaviors and cultural and familial factors is needed to identify important assets that support healthy lifestyles. Females in this study were more likely to make healthy choices overall than their male counterparts.
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children’s risky behaviors may be a powerful social support for their children’s healthy behaviors and well-being. Our results indicated the important role that school, peers, and family have in supporting positive behavior choices. However, there were differences between the two models. Using strict definitions, gender and immigration status were significant predictors of healthy behaviors, which was not the case with broad definitions. Using broad definitions, Caucasian race and school grade were significant predictors, which was not true using strict definitions. Using a broad definition of healthy behaviors, it appeared that gender was no longer of significant consequence. This may be because many boys practice experimental health behaviors. So too, with immigrants, as we looked at broader definitions of healthy behaviors, more nonimmigrants were practicing experimental behaviors. Whereas race was not a significant predictor of healthy behavior using a strict definition, it was using a broad one suggesting that white teens may be more involved in experimenting than their nonwhite peers. Recent data has suggested that white youth are more likely to be involved in substance use than nonwhite youth [34]. Difference in race and risk-taking is worth further examination and it would be interesting to learn how parental attitudes and local politics influence this activity. Also, as youngsters age, they are more likely to be involved in experimental behaviors and so are more likely to be captured in the broad definition of healthy behavior. It appears that the narrow group of young persons who are practicing strict healthy behaviors, females and immigrants, broadens once you expand the definition to allow experimentation. This group merits further research to understand the nature and long-term impact of what we have termed “experimental behaviors.”
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We acknowledged that healthy choices could not be objectively defined and made an effort to establish two sets of criteria to satisfy our constituents. However, we believe we can potentially advance this field of research by creating new definitions that future researchers can use. Given the findings of this study, it is clear that many areas merit further investigation. Why were certain populations more resilient than others? What factors were involved in U.S.-born versus immigrant teenagers’ health choices? Why were differences noted between health behaviors of the special education population and regular education teens? Most importantly, more research is needed to understand the wisdom of recommending a strict or broad definition of healthy lifestyle. We recognize that there are important cultural differences regarding “experimentation” and that more research is needed to determine whether or not “experimentation” is harmless. Future studies should consider the importance of the social milieu and community norms on adolescents’ health choices. Conclusion This study has reiterated a number of important variables that support teenagers, including academic success, parental concern, and low stress. Families and schools clearly play an important role in adolescent health behavior. This study also focuses attention on a preventive approach, helping teens avoid problems, rather than waiting until problems are established to take action. The authors gratefully acknowledge the Cambridge Public Schools, specifically Barbara Black in the Office of Development and Assessment and William Bates and Kim DeAndrade in the Department of Health, Physical Education and Athletics; Lynn Schoeff of the Cambridge Public Health Department; and Jack Vondras of the Cambridge Prevention Coalition for their valuable work on the Teen Health Survey and their input to the study. We also wish to thank Suzy Feinberg for her comments and editing.
Limitations There were several limitations to this study. First, the study was done in an urban diverse school system that may not be generalizable to nonurban schools. Local politics may play a role in defining appropriate health behaviors and in the messages that parents give their children about appropriate behavior. Social norms may also vary from place to place leading to a different “experimental” definition. Second, our definitions of healthy behaviors did not incorporate all healthy behaviors so other factors might be important and could have confounded our findings.
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21. Israili ZH. Gender and ethnic differences in some risk behaviors in high school students in the United States. Ethn Dis 1998;8:413–4. 22. Tuinstra J, Groothoff JW, Van den Heuvel WJ, Post D. Socioeconomic differences in health risk behaviors in adolescence: Do they exist? Soc Sci Med 1998;47:67–74. 23. Byrd RS, Weitzman M, Doniger A. Increased drug use among old-for-grade adolescents. Arch Pediatr Adolesc Med 1996; 150:470 –6. 24. Brindis C, Wolfe AL, McCarter V, et al. The associations between immigrant status and risk-behavior patterns in latino adolescents. J Adolesc Health 1995;17:99 –105. 25. Everett SA, Kann L, McReynolds L. The youth risk behavior surveillance system: Policy and program applications. J Sch Health 1997;67:333–5. 26. O’Malley PM. The Monitoring the Future Study. New York: Macmillan Publishing, 1995. 27. Ebin VJ, Sneed CD, Morisky DE, et al. Acculturation and interrelationships between problem and health-promoting behaviors among latino adolescents. J Adolesc Health 2001;28: 62–72. 28. Grunbaum JA, Lowry R, Kann L. Prevalence of health-related behaviors among alternative high school students as compared with students attending regular high schools. J Adolesc Health 2001;29:337–43. 29. Hacker K, Drainoni ML. Mental health and illness in Boston’s children and adolescents: One city’s experience and its implications for mental health policy makers. Public Health Rep 2001;116:317–26. 30. Hacker K, Amare Y, Strunk N, Horst L. Listening to youth: Teen perspectives on pregnancy perspectives. J Adolesc Health 2000;26:279 –88. 31. Jessor S. Transition from virginity to nonvirginity among youth: A social-psychological study over time. Dev Psychol 1975;11:473–84. 32. Zhang L, Welte JW, Wieczorek WF. Peer and parental influences on male adolescent drinking. Subst Use Misuse 1997;32: 2121–36. 33. Brener ND, Collins JL. Co-occurrence of health-risk behaviors among adolescents in the United States. J Adolesc Health 1998;22:209 –13. 34. Wallace JM, Bachman JG, O’Malley PM, et al. Tobacco, alcohol, and illicit drug use: Racial and ethnic differences among U.S. high school seniors, 1976 –2000. Public Health Rep 2002; 117(Suppl 1):S67–75.
ORIGINAL ARTICLE
Defining and Understanding Healthy Lifestyles Choices for Adolescents KA HE, M.D., Sc.D., ELLEN KRAMER, Sc.D., ROBERT F. HOUSER, Ph.D., VIRGINIA R. CHOMITZ, PhD., AND KAREN A. HACKER, M.D., M.P.H.
Purpose: To: (a) establish criteria for defining positive health behaviors and lifestyle; and (b) identify characteristics of adolescents who practice a healthy lifestyle. Methods: Responses from a 1998 survey via questionnaire, of 1487 students, from a public high school, Cambridge, Massachusetts, were used to assess correlates of healthy lifestyle choices. Strict and broad assessments of healthy behaviors were defined for students: use of alcohol, tobacco, and illegal drugs; sexual behavior; attempted suicide. Whereas the “strict” criteria included only those adolescents who did not practice any of the behaviors in question, the broad criteria reflected experimentation and moderate risk-taking. The prevalence of positive behaviors was assessed by demographic and student characteristics. In addition, logistic regression models were created to predict determinants of teenagers’ healthy lifestyles using both strict and broad definitions. Results: Using strict criteria of healthy lifestyle, significant predictors were being female, born outside the United States, higher academic performance, and fewer stressful life events. Using a broad definition of a healthy lifestyle, significant predictors were being non-Caucasian, in the lower grade levels at the school, higher academic performance, and fewer stressful life events. In both models, peers’ approval of risky behaviors nega-
From the Department of Preventive Medicine, Northwestern University School of Medicine, Chicago, Illinois (K.H.); The Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Medford, Massachusetts (R.F.H.); and Cambridge Institute for Community Health, Cambridge, Massachusetts (E.K., V.R.C., K.A.H.). Address correspondence to: Dr. Ka He, Department of Preventive Medicine, Northwestern University School of Medicine, Suite 1102, 680 North Lake Shore Drive, Chicago, IL 60611. E-mail: [email protected] Manuscript accepted September 18, 2003. 1054-139X/04/$–see front matter doi:10.1016/j.jadohealth.2003.09.004
tively influenced teens’ lifestyles, whereas parents’ disapproval of risky behaviors was a positive influence. Conclusions: These results reinforce the importance of school, peer, and parent support of positive behaviors. It is important for public health workers and families to understand and define healthy lifestyles choices for adolescents. © Society for Adolescent Medicine, 2004 KEY WORDS:
Adolescents Gender differences Healthy lifestyle Positive health behavior
Adolescence is a time of risk-taking and experimentation. By and large, the leading causes of morbidity and mortality in this age group are behaviorally mediated. A wealth of literature exists on the myriad of adolescent risky health behaviors that have been linked to disability and disease in later life [1– 4]. Historically, these studies have focused on negative choices teens have made and the resulting morbidity and mortality [5– 8]. As the field of youth development evolves, clinicians and researchers are now arguing that using a risk factor model burdens already at-risk children with the expectation of failure rather than identifying their strengths. An individual can bounce back from adversity and go on with his/her life [9], recognizing that not all people are devastated by bad events [10]. An increasing number of researchers and community activists argue that instead of focusing on youth problems, attention should focus on youth assets: the positive relationships, opportunities, skills, and values that help young people grow up healthy [11,12]. © Society for Adolescent Medicine, 2004 Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010
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The characteristics of individuals who choose healthy lifestyles are extremely important to the overall understanding of positive health behaviors. A variety of protective factors has been associated with positive health behaviors and practices, including connectedness to family, school and peers, as well as higher self-esteem [13–15]. Additionally, recent studies have demonstrated the co-occurrence of health-promoting behaviors [16]. Understanding health behaviors of teens requires consideration of many personal and social environmental factors, including the family and school context as well as individual characteristics [8,17,18]. It may be possible to identify both youth who choose positive health behaviors and the correlates to such activities. Identifying characteristics of adolescents who make positive health choices could improve the ability of health professionals to target at-risk youth, develop innovative preventive strategies, support inherent strengths, and ultimately, modify negative health behaviors. To the best of our knowledge, there are no universal, objective definitions of positive health behaviors among teenagers. This is particularly true for behaviors like alcohol use and sexual activity. Previous studies have introduced a variety of definitions to describe adolescent health behaviors [16,19]. However, these definitions tend to classify behaviors in strict terms such as “never used alcohol,” and “never had sexual intercourse.” This approach fails to capture an important group of adolescents; teenagers who engage in modest risk-taking health behaviors that are considered experimental in nature. For example, many adolescents have tried alcohol and some drink in moderation. It is not clear that the best definition of healthy teen behavior related to alcohol use is complete abstinence. Does one-time experimentation with marijuana have negative effects on health? Should the teenager who briefly experiments with alcohol or marijuana be considered at-risk? In the present study, we developed two sets of definitions of positive health behaviors to identify adolescent healthy behaviors strictly and broadly. According to literature and previous studies [17,20 – 24], we postulated that gender, race, immigration status, grade in school, academic performance, whether the respondents had close friend(s), whether they received special educational services, whether their families received public assistance, parents’ education level, stress index (a summary measurement of stress), peer approval, and perception that their parents would be upset by their engagement in risky behaviors were all important
factors in influencing how teens make decision about health behaviors. The objectives of our study were to: (a) establish criteria for defining positive health behaviors and lifestyle; and (b) identify characteristics of adolescents practicing a healthy lifestyle.
27
Methods Participants Cambridge, Massachusetts is an urban community of approximately 100,000 people outside of Boston, with one high school, Cambridge Rindge and Latin. The school population was 1936 (grades 9 –12) during the 1997–1998 academic year. Fifty-three percent of the students were female, whereas 36.7% were African-American, 14.4% Hispanic, 40.5% Caucasian, 8.3% Asian, and 0.2% were Native American [20]. The survey was administered to all consenting students in attendance at Cambridge Rindge and Latin high school on the day of survey administration. An “opt-out” form was sent home to parents before the survey. Parents wishing to exclude their child from the survey were advised to inform their child’s teacher. On the day of administration, only students who were absent or whose parents excluded them from the survey did not participate in the survey. Additionally, obvious cases of frivolous or invalid responds were excluded, as were questionnaires in which fewer than 75% of questions were answered. A total of 1487 students (77.9%) completed the survey and were included in this analysis. The study protocol was approved by the Institutional Review Board of the Cambridge Health Alliance.
Questionnaire The questionnaire used in this survey was based on the Youth Risk Behavior Surveillance System (YRBSS) questions from the Centers for Disease Control and Prevention (CDC), as well as Michigan Model Surveys, Monitoring the Future, and locally designed questions [25,26]. The questions covered information on demographics; family constellation; access to health care; stressful events such as a death in the family; violence; suicide; sexuality; use of alcohol, tobacco and illegal drugs; delinquency; and personal habits (for example, nutrition, physical activity). Surveys were available in Spanish, Portuguese, Chinese, and Haitian Creole. Before distributing the survey, teachers and staff gave the students directions on taking the survey and emphasized that
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participation was voluntary, anonymous, and confidential. Students were instructed that there were no right or wrong answers. Although they were encouraged to answer all of the survey questions, students were also told that they could skip particular questions if they did not want to answer them.
Defining Healthy Behavior Working with local community leaders, teachers, health professionals, and parents in both group and individual informant sessions, we developed two sets of definitions of positive health behaviors. The first set was based on a restrictive set of criteria called “strict.” The second set was based on broader criteria. The “broad” definitions reflected the mindset of some health professionals that experimentation and moderate risk-taking in adolescence is normal behavior. We selected and classified six health-related behaviors: suicidal attempts, sexual behavior, use of “hard drugs” (including psychedelics, cocaine, amphetamines, tranquilizers, barbiturates, heroin, narcotics, and glue), and use of marijuana, tobacco, and alcohol, based on determined “strict” and “broad” definitions of healthy behaviors. In the “strict” definition, we defined healthy behaviors as alcohol use: did not drink during the last 30 days; tobacco use: never smoked; “hard drug” use: never tried; marijuana use: never tried; sexual behavior: never had sexual intercourse; and suicidal behavior: no attempted suicide during the past 12 months. In contrast, we determined “broad” definitions as alcohol use: (a) did not consume 5 or more drinks in a row during the last 30 days, and (b) did not drink enough to feel drunk or high during the last 30 days; tobacco use: (a) did not use smokeless tobacco during the last 30 days, and (b) did not use cigars during the last 12 months, and (c) did not use cigarettes during the last 30 days; “hard drug” use: did not use any “hard drug” during the last 30 days; marijuana use: did not use marijuana during the last 30 days; sexual behavior: (a) had no more than one partner during the past 3 months, and (b) always used condoms to protect against sexual transmitted diseases or AIDS; and suicidal behavior: same as “strict” definition.
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explore relationships among the various health choices and between health choices and demographic characteristics of the participants. In addition, logistic regression was used to test models predicting possible determinants of teenagers’ healthy lifestyles based on their avoidance of risk behaviors. We made two binary-dependent “healthy lifestyle” variables according to strict or broad definitions of healthy behaviors by combining healthy choices on the six selected behaviors. Participants were divided into either the strict lifestyle group, which was composed of those who made healthy choices on all six behaviors based on the strict definition, or the broad group, which consisted of those who qualified under the broader definitions of healthy behavior. Independent variables measuring stress, social influence, and parental concern were created for use in the logistic regression. The stress score was an index from 0 –14 and included 14 stressful events, including failing grades, divorce or separation in family, moving, verbal, physical and sexual abuse, witnessing violence in the family, and being threatened with a knife or gun. A social influence measurement, “peers approval,” was created to measure teens’ perception of friends’ approval of substance use. It was based on six questions on substance use with four answer options. We coded “disapprove and stop being my friend” as “1,” “disapprove but still be my friend” as “2,” “they would not care” as “3,” and “they would approve” as “4.” Summarized scores ranged from 6 to 24. Similarly, student perception of parents’ potential level of upset was based on nine questions on substance use with four possible answers. We coded parents would be “not upset at all” as “1,” “a little upset” as “2,” “pretty upset” as “3,” and “very upset” as “4.” Summarized scores ranged from 9 to 36. Because marijuana is the most popular illegal drug in this cohort, we analyzed marijuana use separately from other drugs. We defined “hard drugs” as all illegal drugs except marijuana. All reported p values were two-tailed, and less than .05 was considered statistically significant. SPSS 9.0 package (SPSS Inc., Chicago, IL) was used for all analyses.
Data Analysis
Results
The outcomes of interest were binary results of healthy choices on all six selected behaviors at strict and broad levels. Chi-square analysis was used to
Of 1487 participants, 48.2% were female. The median age was 16 years (range 13–22). Participants were ethnically and racially diverse, including white
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Table 1. Proportions of Students (N ⫽ 1487) Making Healthy Choices on Each Health-related Behavior Under Strict and Broad Definitions Behaviors
Percentage of healthy choice based on strict definitiona
Percentage of healthy choice based on broad definitiona
Suicidal attempt Hard drug use Sexual behavior Marijuana use Alcohol use Tobacco use Those who exhibited all six behaviors
92.3 (n ⫽ 1348/1461) 80.0 (n ⫽ 1122/1402) 55.9 (n ⫽ 785/1405) 50.8 (n ⫽ 727/1432) 49.6 (n ⫽ 687/1386) 46.9 (n ⫽ 663/1413) 19.6 (n ⫽ 256/1306)
92.3 (n ⫽ 1348/1461) 92.3 (n ⫽ 1261/1366) 75.2 (n ⫽ 1060/1409) 69.4 (n ⫽ 983/1416) 61.5 (n ⫽ 885/1439) 65.6 (n ⫽ 893/1362) 37.6 (n ⫽ 496/1319)
a Strict and broad definitions of healthy choices on each health-related behavior are described in the Methods section of the text; the denominators not equal to 1487 are owing to missing data.
(34.6%), African-American (27.3%), Hispanic (12.2%), Asian-American/Pacific Islander (7.4%), biracial (5.9%), Native American (0.3%), and other (12.3%). About one-third (30.2%) of participants were born outside the United States. Approximately 17% of the students belonged to families who received public assistance. Nearly a half of the students’ mothers (45.8%) and fathers (49.3%) had completed college or graduate school. The differences between behaviors under the strict and broad definitions are shown in Table 1. Whereas 19.6% of adolescents made positive health choices for all six health-related behaviors under the strict definition, 37.6% did so under the broad definition. Healthy choices regarding sexual behavior showed the largest difference between the broad and strict definitions; 75% of participants met the criteria under the broad definition and 56% met the criteria under the strict definition of abstinence. Differences in the association of personal and social-environmental factors to positive health choices based on strict and broad definitions are presented in Table 2. Under both definition sets, there were significant associations with regard to gender, race, immigration status, grade in school, academic performance, stress index, peer approval, and parental upset of substance use, respectively. For special education service, there was significant difference when broad definitions were applied. In the multivariate analysis based on the strict definitions, the significant predictors of healthy behaviors were gender, immigration status, stress index, academic performance, peer approval, and parental upset at risky health behaviors (Table 3). Females were 52% more likely to make healthy choices than males. Immigrants were 58% more likely than U.S.-born teens to make healthy choices. With each additional stressful life event, there was about 24% decrease in the likelihood of making
healthy choices. Positive health behaviors were also associated with improved academic achievement. If teenagers’ average grades increased by one ordinal level, for example, from C to B, the probability of making healthy choices would be expected to increase 35%. Teenagers with friends who approved of substance use were 9% less likely to make healthy choices. In contrast, teens who reported that their parents would be upset to learn of their children’s involvement in substance use were 11% more likely to make healthy choices. Under the broad definitions, the significant predictors of healthy behaviors were grade level, stress index, Caucasian or not, academic performance, peer approval and parental upset. There was a 55% increase in the likelihood of making healthy choices if teenagers’ grade point average improved by one ordinal level. In addition, participants who perceived that their parents would be upset to learn about their children’s substance use were 8% more likely to make healthy choices. Nevertheless, with each increasing year in school, teens were 15% less likely to make healthy choices, and they were 21% less likely to make healthy choices by one additional stressful event. Caucasian teens were 30% less likely to make healthy choices than non-Caucasian teens.
Discussion This study examined personal and social-environmental factors that influence adolescents’ health choices. Teenagers’ health choices and behaviors were investigated by using two different definitions, one strict and another broad, and employing them in two sets of analyses. The broad definition identified students with modest risk-taking behaviors and thus included more participants in the healthy groups. However,
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Table 2 . Proportions of Students (N ⫽ 1487) Who Had Healthy Choices in All Six Selected Health-related Behaviors Under Strict and Broad Definitions According to Selected Predictors Strict definitionsa Personal and socialenvironmental factors Gender Male Female Race Caucasian Non–Caucasian Immigration status Born in the US Immigrant Having close friend(s) Yes No Special education service Yes No Family receiving public assistance Yes No School grade in year Freshman Sophomore Junior Senior Academic performance A B C D F Mother’s education levels College or above Some college High school or below Father’s education levels College or above Some college High school or below Stress indexc ⱖ median score ⬍ median score Peers’ approval of substance usec ⱖ median score ⬍ median score Parents’ upset substance usec ⱖ median score ⬍ median score
Broad definitionsa
Those with healthy behaviors %b
p value
Those with healthy behaviors %b
p value
16.2 (n ⫽ 105/650) 23.2 (n ⫽ 151/650)
*
33.4 (n ⫽ 217/650) 41.9 (n ⫽ 277/661)
*
15.3 (n ⫽ 72/472) 22.2 (n ⫽ 180/811)
*
33.2 (n ⫽ 158/476) 39.8 (n ⫽ 326/819)
*
15.8 (n ⫽ 148/937) 29.5 (n ⫽ 108/366)
**
33.9 (n ⫽ 321/947) 47.0 (n ⫽ 174/370)
**
19.6 (n ⫽ 245/1249) 18.2 (n ⫽ 10/55)
NS
37.5 (n ⫽ 472/1259) 39.5 (n ⫽ 23/58)
NS
14.7 (n ⫽ 17/116) 19.6 (n ⫽ 214/1093)
NS
28.2 (n ⫽ 33/117) 38.3 (n ⫽ 422/1103)
*
17.4 (n ⫽ 35/201) 19.3 (n ⫽ 201/1042)
NS
37.3 (n ⫽ 75/201) 37.3 (n ⫽ 395/1058)
NS
22.2 (n ⫽ 80/361) 24.9 (n ⫽ 83/333) 17.8 (n ⫽ 57/320) 12.3 (n ⫽ 35/284) 31.7 (n ⫽ 84/265) 18.3 (n ⫽ 96/524) 14.4 (n ⫽ 52/360) 10.3 (n ⫽ 10/97) 6.7 (n ⫽ 1/15)
*
45.5 (n ⫽ 167/367) 39.4 (n ⫽ 134/340) 35.4 (n ⫽ 113/319) 28.3 (n ⫽ 80/283)
**
**
52.8 (n ⫽ 140/265) 39.2 (n ⫽ 207/528) 31.0 (n ⫽ 112/361) 20.8 (n ⫽ 21/101) 11.8 (n ⫽ 2/17)
**
18.6 (n ⫽ 99/532) 18.0 (n ⫽ 78/434) 24.3 (n ⫽ 44/181)
NS
38.0 (n ⫽ 206/542) 36.7 (n ⫽ 160/436) 39.7 (n ⫽ 71/179)
NS
22.1 (n ⫽ 113/512) 16.6 (n ⫽ 55/332) 22.7 (n ⫽ 39/172)
NS
41.5 (n ⫽ 214/516) 34.5 (n ⫽ 115/333) 38.5 (n ⫽ 67/174)
NS
11.7 (n ⫽ 91/781) 25.5 (n ⫽ 154/603)
**
26.5 (n ⫽ 207/781) 45.6 (n ⫽ 275/603)
**
9.8 (n ⫽ 69/701) 26.5 (n ⫽ 178/671)
**
21.5 (n ⫽ 151/701) 49.6 (n ⫽ 333/671)
**
26.7 (n ⫽ 188/703) 9.9 (n ⫽ 66/668)
**
47.1 (n ⫽ 331/703) 23.7 (n ⫽ 158/668)
**
* p ⬍ .05, ** p ⬍ .01, NS ⫽ nonsignificant. Strict and broad definitions of health choices on each health-related behavior are described in the Methods section of the text. b Total numbers not equal to 1487 are owing to missing data. c See Methods for definitions. Median scores of stress index, peers’ approval of substance use and parents’ upset substance use are 2, 16, and 15, respectively. a
even under the broad definitions, only 37.6% of participants made healthy choices for all six behaviors.
Our results highlight certain subgroups that were more likely to be practicing healthy behaviors: immigrants, females, and academic achievers. Immi-
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Table 3. Significant Variables for Teens Who Had Healthy Lifestyle Choices in All Six Selected Health Behaviors Under Strict and Broad Definitions
However, they were 50% more likely than male students to have attempted suicide during the last 12 months. This is consistent with other research, which has shown males to be at higher risk for substance abuse, violence, and early sexual activity [15,17,28], and females have been shown to have higher levels of depression and more suicide attempts [17,29]. Perhaps where males tend to act out their feelings with behaviors, females are more likely to express their stress through self-harming behaviors. The gender differences demonstrated here certainly merit further investigation. Multivariate analysis based on both strict and broad definitions showed that teenagers with higher academic achievement were significantly more likely to choose healthy behaviors. Academic success has been correlated with a greater likelihood of abstinence, less depression, and lower drug and alcohol use [30,31]. Consistent with previous studies [15,32], teenagers in higher-grade levels were less likely to make healthy choices about substance use and sexual behavior. The correlation between age/grade level and riskier behavior has been demonstrated elsewhere [17]. In addition, students receiving special education reported more frequent sexual intercourse than non-special-education students. We think this may be attributed to the fact that students receiving special education were older than other students in the study, owing, in part, to lower rates of grade advancement. However, the relationship between special education and risk-taking behavior for teens merits further research. Our results indicated age-dependent developmental changes throughout the high school years. As adolescents age, the likelihood of involvement in risk-taking behaviors increases [15,17,33]. This may be owing to peer norms and changing social expectations associated with age. Equipping young people with appropriate skills to cope with life’s changes is the challenge of parents and educators. However, given the age-related changes seen in health behaviors, we should prioritize developmentally appropriate risk reduction strategies in, and out of, school. Logistic regression produced different predictive models based on the two definitions of healthy choices. In both models, significant predictive variables were: stress index, academic performance, peer approval, and parental upset. In addition, peer approval for risky behaviors was a negative predictor and inversely correlated to parental upset at children’s risky behaviors. Parents who delivered the message that they would be extremely upset by their
Multivariate analysis Variables
OR
95% CI
1.52 1.58 0.76 1.35 0.91 1.11
1.02–2.25 1.06 –2.36 0.66 – 0.87 1.05–1.74 0.86 – 0.95 1.07–1.15
0.85 0.79 0.70 1.55 0.89 1.08
0.73– 0.98 0.72– 0.88 0.50 – 0.99 1.25–1.91 0.82– 0.93 1.04 –1.11
a
Strict definitions Female Immigrants Stress index Academic performance Peers approval of substance use Parents upset of substance use Broad definitionsa School grade in year Stress index Caucasian Academic performance Peers’ approval of substance use Parents’ upset of substance use
n ⫽ 1286 (strict), n ⫽ 1246 (broad); adjusted for whether had close friend(s), whether received special education service, whether family received public assistance, mother’s education levels and father’s education levels. Six selected variables include alcohol use, tobacco use, hard drug use, marijuana use, sexual behavior and suicidal attempt. Female: females coded (1), males coded (0). Immigrants: immigrants coded (1), U.S.-born coded (0). Stress index: self-reported stress. From mild to severe, sum of coding scores from 0 to 14. Academic performance: grade A to F coding as 5 to 1. Peers’ approval of substance use: level of perceived friends’ approval of substance use, from disapproval to approval, sum of coding score from 6 to 24. Parents’ upset of substance use: parents’ upset level on substances use, from not upset at all to very upset, sum of coding score from 9 to 36. School grade in year: freshman coded (1), sophomore coded (2), junior coded (3), senior coded (4). Caucasian: Caucasian coded (1), non-Caucasian coded (0). a Strict and broad definitions of health choices on each healthrelated behavior are described in the Methods section.
grant students were more likely than U.S.-born teenagers to avoid substance use. As noted in previous studies, higher levels of acculturation have been associated with higher incidence of risky behaviors [27]. Social norms of immigrants may be different from U.S.-born students based on traditional cultures and/or religious beliefs and may serve as a protective factor [5]. Families that immigrate to this country may represent very resilient, motivated individuals who are more likely to make positive choices in many areas of life. More research on immigrant health behaviors and cultural and familial factors is needed to identify important assets that support healthy lifestyles. Females in this study were more likely to make healthy choices overall than their male counterparts.
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children’s risky behaviors may be a powerful social support for their children’s healthy behaviors and well-being. Our results indicated the important role that school, peers, and family have in supporting positive behavior choices. However, there were differences between the two models. Using strict definitions, gender and immigration status were significant predictors of healthy behaviors, which was not the case with broad definitions. Using broad definitions, Caucasian race and school grade were significant predictors, which was not true using strict definitions. Using a broad definition of healthy behaviors, it appeared that gender was no longer of significant consequence. This may be because many boys practice experimental health behaviors. So too, with immigrants, as we looked at broader definitions of healthy behaviors, more nonimmigrants were practicing experimental behaviors. Whereas race was not a significant predictor of healthy behavior using a strict definition, it was using a broad one suggesting that white teens may be more involved in experimenting than their nonwhite peers. Recent data has suggested that white youth are more likely to be involved in substance use than nonwhite youth [34]. Difference in race and risk-taking is worth further examination and it would be interesting to learn how parental attitudes and local politics influence this activity. Also, as youngsters age, they are more likely to be involved in experimental behaviors and so are more likely to be captured in the broad definition of healthy behavior. It appears that the narrow group of young persons who are practicing strict healthy behaviors, females and immigrants, broadens once you expand the definition to allow experimentation. This group merits further research to understand the nature and long-term impact of what we have termed “experimental behaviors.”
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We acknowledged that healthy choices could not be objectively defined and made an effort to establish two sets of criteria to satisfy our constituents. However, we believe we can potentially advance this field of research by creating new definitions that future researchers can use. Given the findings of this study, it is clear that many areas merit further investigation. Why were certain populations more resilient than others? What factors were involved in U.S.-born versus immigrant teenagers’ health choices? Why were differences noted between health behaviors of the special education population and regular education teens? Most importantly, more research is needed to understand the wisdom of recommending a strict or broad definition of healthy lifestyle. We recognize that there are important cultural differences regarding “experimentation” and that more research is needed to determine whether or not “experimentation” is harmless. Future studies should consider the importance of the social milieu and community norms on adolescents’ health choices. Conclusion This study has reiterated a number of important variables that support teenagers, including academic success, parental concern, and low stress. Families and schools clearly play an important role in adolescent health behavior. This study also focuses attention on a preventive approach, helping teens avoid problems, rather than waiting until problems are established to take action. The authors gratefully acknowledge the Cambridge Public Schools, specifically Barbara Black in the Office of Development and Assessment and William Bates and Kim DeAndrade in the Department of Health, Physical Education and Athletics; Lynn Schoeff of the Cambridge Public Health Department; and Jack Vondras of the Cambridge Prevention Coalition for their valuable work on the Teen Health Survey and their input to the study. We also wish to thank Suzy Feinberg for her comments and editing.
Limitations There were several limitations to this study. First, the study was done in an urban diverse school system that may not be generalizable to nonurban schools. Local politics may play a role in defining appropriate health behaviors and in the messages that parents give their children about appropriate behavior. Social norms may also vary from place to place leading to a different “experimental” definition. Second, our definitions of healthy behaviors did not incorporate all healthy behaviors so other factors might be important and could have confounded our findings.
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