ARCHIVED: Chapter 1: Young people in Canada: their health and well-being – Introduction



The first Health Behaviour in School-Aged Children (HBSC) survey was administered in 1982 by a small group of researchers from three countries - England, Finland, and Norway - to measure a range of adolescent health behaviours and a number of social and environmental variables. Four years later, the World Health Organization (WHO) (Europe) began to sponsor the survey, which had expanded to include 11 countries. The international HBSC research group invited Queen's University, in partnership with Health Canada, to take part in the 1989-90 survey as an associate member. Canada has participated as a full member in three further HBSC surveys conducted in 1993-94, 1997-98, and 2001-02. The HBSC surveys are now administered every four years to a representative sample of 11-, 13, and 15-year-olds in 35 participating countries.1

The population health approach, modelled by WHO and Health Canada, is the underlying framework for the HBSC survey. It acknowledges a broad set of determinants of health behaviours that shape the health of children and youth: social, economic, and political factors; psychological, genetic, and biological factors; gender; personal health practices; community resources; and the physical environment (Health Canada, 1994; 1996). Such determinants do not act in isolation from each other. Rather, it is the complex interaction among them that has an impact on the health of individuals and communities (Health Canada, 2000). Consequently, a full range of individual, social, and environmental factors are considered both in defining population health status and in developing programming and policies to improve health.

Within the population health model and the theoretical framework that guides the design of the HBSC questionnaires, adolescence is viewed as a natural developmental phase. Accordingly, tracking the changes that accompany each stage of development is at the core of the HBSC survey. This is achieved by following a repeated cross-sectional method, rather than a longitudinal one, the latter being difficult to implement due to both financial and logistic reasons. Three age groups are identified (11-, 13-, and 15-year-olds) as being representative of critical periods of adolescent development, and national samples of these age groups are surveyed every four years. In addition, many mandatory questions on the HBSC survey have remained essentially the same over the past years, allowing researchers to examine differences at each developmental milestone, as well as trends in the health of youth over time. The periodic addition of new items, such as variables assessing sexual behaviour in the 2001-02 survey, broadens the scope of the research, incorporates currently accepted scientifically tested items, and allows researchers to examine issues from a variety of disciplines. The selection of optional HBSC item packages and Canada-only items also permits customization of the HBSC survey to meet Canada's needs.

The main objective of this report is to examine the determinants of the health of Canadian youth in 2002. A further goal is to examine trends in the health of Canadian youth over time. The HBSC study is designed not for the purpose of assessing the impact of specific changes in social, environmental, or health systems on the health of youth but only to note whether changes in the determinants and outcomes of youth health have occurred.

For example, health promotion and disease prevention efforts in Canada have expanded to embrace a broad range of age groups as well as topics such as active lifestyles, healthy eating programs, and Comprehensive School Programs. In addition, there has been an increase in anti-smoking and anti-drug campaigns that target young people. The findings in this report provide an indirect indication of the success of these initiatives.

Previous Canadian findings from the HBSC surveys have been released in four reports. The first of these reports, The Health of Canada's Youth (King and Coles, 1992) published by Health Canada, focused on 1990 Canadian findings compared with those from 10 other countries and discussed their relevance for Canadian policies and programs. The second report, The Health of Youth (King, Tudor-Smith, and Harle, 1996) published by WHO-Europe, examined the 1994 findings of 23 countries. The third report, Trends in the Health of Canadian Youth (King, Boyce, and King, 1999) published by Health Canada, examined trends in the health of Canadian youth from 1990 to 1998. The 1998 Canadian findings were also included in a comparative format with those from more than 25 countries. That report, Health and Health Behaviour Among Young People, (Currie, Hurrelman, Settertobulte, Smith, and Todd, 2000), was published by WHO-Europe.

The Questionnaires

The mandatory HBSC questionnaire is administered to students aged 11, 13, and 15 in school classrooms across the 35 HBSC countries. In Canada, most of these students are in Grades 6, 8, and 10 and their equivalent levels in Quebec. The mandatory questionnaire is augmented to include optional packages that contain groups of questions focused on particular issues (used by some, but not all, countries) and country-specific questions. The questionnaire is developed in a collaborative fashion by HBSC researchers and then ratified at biannual research meetings. A strong effort has been made to retain a core of items on each survey to facilitate the monitoring of trends over time.

The HBSC researchers come from a variety of countries, disciplines, and theoretical perspectives, but they have developed a consensus around the two main research purposes. The first is to incorporate a developmental perspective to examine changes in health attitudes and behaviours from late childhood to the middle years of adolescence. The second is to identify health indicators and factors that may influence them. These indicators include behaviours such as smoking, alcohol use, and level of physical activity; psychosocial states such as happiness and loneliness; and problems such as injuries, headaches, and being bullied. Influencing factors or determinants include the school, parents, peers, and social inequalities. Indicators and determinants may interact and may therefore be interchangeable in analyses.

For each of the four Canadian HBSC surveys, additional items were included on the questionnaire. Items related to self-esteem, relationships with parents, and drug use (Grades 9 and 10 only) have always been used. For the 2001-02 survey, Canada added optional HBSC packages to examine social capital, smoking, bullying, injuries, and school experiences in greater depth. Canada-only items that address disabilities, asthma, and medication use were also added to the survey. As well, a Canadian principal's questionnaire on school composition and policies was included.

The surveys were administered to school classes identified through systematic sampling procedures and were designed to be given during one 40-minute class. While there were one or two open-ended questions, almost all of the questions could be answered by checking off a response alternative. Students were guaranteed anonymity, and teachers were asked to closely follow a specific set of instructions regarding active consent and survey administration.

It must be remembered that fundamental differences exist among HBSC countries with regard to language and other cultural aspects. While this is most obviously manifested in dietary practices, it also has implications for concepts such as bullying, for which equivalent terminology is difficult to find. Therefore, compromises were required that influenced the appropriateness of some items for all countries. Compromises were also required to acknowledge both the desire to use the same items in each survey to enable the monitoring of change and the need to improve the quality of certain mandatory items to international standards. Wording has been altered on certain mandatory items in 2001-02 to improve their validity and reliability. Such instances are noted in the text.

Table 1.1 Distribution of students in each grade for the 2001-02 HBSC survey
Grade 6
Grade 7
Grade 8
Grade 9
Grade 10
980 (47.5%)
694 (49.5%)
647 (46.7%)
525 (42.8%)
511 (44.2%)
1083 (52.5%)
709 (50.5%)
738 (53.3%)
703 (57.2%)
645 (55.8%)
2063 (100%)
1403 (100%)
1385 (100%)
1228 (100%)
1156 (100%)

The Sample

The sampling procedure employed for the Canadian survey was based on a systematic single-cluster procedure, with the cluster being the school class. Initially, the number of Grade 6, 7, 8, 9, and 10 classes was estimated for Canadian schools, and a list of these schools was prepared. The sample was designed to be self-weighting, which required that several characteristics of the Canadian population be considered for grouping schools on the sample list. These characteristics were province, language of instruction, geographic location, community size (urban/rural), and school type (public/ Roman Catholic). The list was systematically sampled assuming 25 students per class. Approximately 80 classes per grade were selected to reach the targeted sample size of 4,600 students for the HBSC international data file, which allowed for refusals. Selected school jurisdictions, and then schools, were contacted to request their participation. Substitute schools were selected using the same criteria. The overall consent rate at the parent/student level was 74 percent.

Minor variations in the sampling procedures were employed across HBSC countries to reflect differences in school structure and availabilty of financial resources. However, the basic sample was essentially the same; that is, target age groups that could be compared within and across countries. For some countries, where age at first entry into school and grade promotion were standardized, almost all the targeted age group could be found in the same grade. For others, where substantial numbers of students were held back for academic reasons, the targeted age groups could be spread over two, or even three, grades.

For the 1998 and 2002 Canadian surveys, a systematic cluster sampling procedure was used with five grades (6, 7, 8, 9, 10) to represent the three age groups (11-, 13-, 15-year-olds) more accurately. The 2002 survey was conducted later in the year than were the previous two surveys -from January to May, rather than from November to March. This resulted in within-grade samples for Grades 6, 8, and 10 in 2002 being on average two months older than the comparable groups in 1994 and 1998. This difference in administration period could have had an influence on such behaviours as smoking and drug use, leisure time activities (i.e., winter versus spring sports), and injuries and must be taken into consideration when interpreting the findings.

Presentation of Findings

Most of the findings are presented in bar graphs according to grade group, gender, and survey year. It was not possible to present all the HBSC survey findings in this report, and thus it was necessary to select key issues and items. It was often possible to report only one response alternative, or combination of response alternatives, to represent an issue. The response alternative could be the proportion of students who agreed with a particular statement, such as "I like going to school"; or who checked "every day" to a question such as "How often do you smoke tobacco at present?"; or who checked "most" or "all" to an item like "My friends smoke cigarettes." As a result, a great deal of important data had to be excluded from this report. Where appropriate, reference is made to data not shown in this report; however, the tables that include all the items and responses are available from Health Canada

When comparing across age groups and gender, little weight should be attached to differences of 3 percentage points or less. However, small differences that are clearly part of a trend are noted in the report. The sampling procedure was designed to produce confidence limits of plus or minus 3 percent at a 90 percent probability level; that is to say, 9 out of 10 times the sample will fall plus or minus 3 percentage points around the number presented. Several design factors, including the cluster sampling procedure, differences in school systems, and cultural and language differences, must also be considered in any comparative analysis. Since the school class was the cluster employed in the sampling procedure, it is possible that those who made up a cluster may have had a similar set of behaviours or attitudes; for example, they may have had access to the same cafeteria food or shared a view about a teacher or their school. On the other hand, relationships with parents or patterns of headaches or medication use were less likely to be shared by classmates. Therefore, greater weight can be given to smaller differences on certain measures that were not likely to be influenced by the fact that students were being drawn from the same class.

Since it is desirable to examine associations between health determinants, behaviours, and outcomes, additional information has been provided in the form of Pearson Correlation Coefficients regarding the relationships between the variables in question; for example, smoking and other factors. A Correlation coefficient identified as significant, indicates a meaningful relationship between the measures exists. If the coefficient is below .20 the relationship can be described as weak, If it is between .21 and .39 the relationship is moderate, if it is equal to .40 or greater the relationship is strong.

Composite Measures

Twelve composite measures, or scale scores, have been developed to measure broad concepts in adolescent health and to facilitate the examination of relationships across these concepts. The scale scores may be previously validated standard measures, as is the case with the family affluence scale, the parent relationship scale, and the psychosomatic scale. Alternatively, the scales were developed for this research through an examination of face validity, factor analysis, and reliability analysis. Each of the composite measures are listed below. Response options to these scales are provided in the report.

The family affluence scale (alpha = .39) consists of the following variables: (a) Does your family own a car, van, or truck? (b) Do you have your own bedroom for yourself? (c) How many computers does your family own? (d) During the past 12 months, how many times did you travel away on holiday (vacation) with your family?

The parent relationship scale (alpha = .84) consists of the following variables: (a) My parents understand me; (b) I have a happy home life; (c) My parents expect too much of me; (d) My parents trust me; (e) I have a lot of arguments with my parents; (f) There are times I would like to leave home; (g) What my parents think of me is important; (h) My parents expect too much of me at school.

The social integration scale (alpha = .58) consists of the following variables: (a) How easy is it to talk to your best friend about things that bother you? (b) How easy is it to talk to friends of the same sex about things that bother you? (c) How easy is it to talk to friends of the opposite sex about things that bother you? (d) At present, how many close male friends do you have? (e) At present, how many close female friends do you have? (f) How many days a week do you usually spend time with friends after school?

The peer influence scale (alpha = .73) consists of the following variables: (a) My friends smoke cigarettes; (b) My friends like school; (c) My friends think getting good marks at school is important; (d) My friends get along with their parents; (e) My friends carry weapons, like knives; (f) My friends use drugs to get stoned; (g) My friends have been drunk.

The parent support at school scale (alpha = .86) consists of the following variables: (a) If I have a problem at school, my parents are ready to help; (b) My parents are willing to come to school to talk to teachers; (c) My parents encourage me to do well at school; (d) My parents are interested in what happens to me at school; (e) My parents are willing to help me with my homework.

The school satisfaction scale (alpha = .88) consists of the following variables: (a) How do you feel about school at present? (b) Our school is a nice place to be; (c) I feel I belong at this school; (d) I feel safe at this school; (e) I look forward to going to school; (f) I like being in school; (g) There are many things about school that I do not like; (h) I wish I didn't have to go to school; (i) I enjoy school activities.

The school climate scale (alpha = .84) consists of the following variables: (a) The rules in this school are fair; (b) I am encouraged to express my own views in class; (c) Our teachers treat us fairly; (d) When I need extra help, I can get it; (e) My teachers are interested in me as a person; (f) Most of my teachers are friendly.

The school student autonomy scale (alpha = .72) consists of the following variables: (a) In our school, students take part in making the rules; (b) Students are allowed to work at their own pace; (c) Students choose their partners for group work; (d) Students have a say in how class time is used; (e) Students have a say in deciding what activities they do; (f) The teacher decides which students should work together.

The school student support scale (alpha = .77) consists of the following variables: (a) The students in my class(es) enjoy being together; (b) Most of the students in my class(es) are kind and helpful; (c) Other students accept me as I am; (d) When a student in my class(es) is feeling down, someone else in class tries to help.

The school achievement scale (alpha = .80) consists of the following variables: (a) In your opinion, what does your class teacher(s) think about your school performance compared with your classmates? (b) I find school work difficult; (c) I feel I am just as smart as others my age; (d) I am pretty slow in finishing my homework; (e) I do very well at my classwork; (f) I have trouble figuring out the answers in school; (g) I feel that I am pretty intelligent.

The multiple risk behaviour index consists of four items: (a) Have you ever had so much alcohol that you were really drunk? (b) How often do you smoke tobacco at present? (c) How often have you taken part in bullying other students in school this term? (d) How often do you use a seat belt when you ride in a car? Students' responses to these items were dichotomized into two groups: (1) presence of the risk factor - when the student was involved in the risk behaviour at least once, except for use of seat belts, where the risk factor is associated with rarely, never, or sometimes using a seat belt; and (2) absence of the risk factor - when the student was never involved in the risk behaviour, except for use of seat belts, where absence of a risk factor is associated with regular use.

The psychosomatic scale (alpha = .80) consists of the following variables. In the past six months, how often have you had the following: (a)headache; (b) stomach ache; (c) backache; (d) feeling low (depressed); (e) irritability or

Organization of the Report


The report has been organized around the broad themes that constitute the population health perspective. The findings in each chapter are typically introduced with a brief review of relevant literature, followed by an examination of findings on individual items and trends over time. Finally, key relationships between variables and scales are reported and major findings in the chapter highlighted.

Chapter 2 deals with the theme of social inequalities, which is a broader approach than the analysis of traditional socio-economic inequities. It examines variables that relate to adolescent social inequalities, such as family affluence, occupation, and poverty, as well as perceptions of wealth. Some associations between socio-economic status and youth health outcomes are reported. Chapters 3, 4, and 5 examine the three major social systems in which an adolescent lives - the home, the peer group, and the school -and present relationships between attachments to these social systems and adolescent emotions, health behaviours, and achievement. Chapter 6 examines adolescent smoking, alcohol use, drug use, and sexual behaviours and the implications of being involved in these behaviours. Chapter 7 presents findings related to physical health issues for youth, such as eating patterns, dental hygiene, and physical and leisure activities; it also addresses asthma and common medication usage. Chapter 8 presents items concerning violence and bullying among Canadian youth and the extent of these behaviours. Chapter 9 examines common injuries and their consequences, as well as safety practices among youth in terms of seat belt and bicycle helmet use. Chapter 10 examines adolescent emotional health and factors such as self-esteem that enable young people to cope with the strains of adolescence. Problems that arise from stress, such as psychosomatic symptoms, are also presented. The report concludes with a brief chapter on the policy implications of the findings.

1. The 2002 survey was administered in Austria, Belgium (Flemish), Belgium (French), Canada, Croatia, Czech Republic, Denmark, England, Estonia, Finland, France, Germany, Greece, Greenland, Hungary, Ireland, Israel, Italy, Latvia, Lithuania, Macedonia, Malta, the Netherlands, Norway, Poland, Portugal, Russia, Scotland, Slovenia, Spain, Sweden, Switzerland, Ukraine, United States, and Wales.

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