Chapter 12: The Health of Canada's Young People: a mental health focus – Summary and conclusion

Summary and conclusion

by John Freeman and William Pickett

The final chapter of this report provides an overview of key findings from the 2010 national HBSC survey. It begins by summarizing key messages about core indicators of mental health in young Canadians, as this was the major focus of the current report.

New findings about topics that are known priorities for adolescent health in our country are also presented. These priorities include injury, healthy living, healthy weights, risk behaviours, bullying, and fighting. Relationships between priority health indicators and selected mental health outcomes are summarized.

Key messages about the various contexts that influence the health of young people (homes, schools, peers, and neighbourhoods) are summarized. This section is followed by a brief review of report findings surrounding relationships between these contexts and the mental health of young people.

Finally, one of the most novel components of this HBSC report was the engagement of youth in the interpretation of the key report findings. Some reflection is provided about the value of this experience in terms of provision of more informed interpretations of key patterns and findings.

Mental health status of young people in Canada

Two important findings emerge from this national HBSC report with respect to mental health. First, mental health varies strikingly by gender. Girls, compared to boys, reported higher levels of emotional problems and lower levels of emotional well‑being in many different parts of the survey. In contrast, boys indicated having higher levels of behavioural problems and lower levels of prosocial behaviour, although gender differences were not as pronounced with behavioural indicators of mental health as they were with emotional indicators. Furthermore, while behavioural indicators worsened for both genders in later grades, emotional indicators worsened only for girls.

Second, spurred by recent research that supports the complementary but distinct existence of both positive and negative aspects of mental health (Keyes, Dhingra & Simoes, 2010; Strauss, 2007), there has been a shift in focus toward positive mental health in the public health arena. This study indicates that both the positive and negative dimensions of mental health identify that the same basic groups of young people require special attention. Therefore, there is continued need for a comprehensive understanding of mental health, rather than a limited focus on any single aspect of it.

Other indicators of health status among young Canadians

Beyond the mental health indicators, a number of additional findings emerged from this report. These focus on public health problems that are clear priorities for adolescent health in Canada.

The report highlights that injury remains a leading cause of poor health in young Canadians. Yet major causes and patterns of injury mirrored past reports and seem to have remained stable over time. These facts are well understood by much of the Canadian public health community. What is new in this HBSC report is its documentation of overt risk-taking activities that can directly lead to injury. Substantial proportions of young people choose to engage in risks that vary from acts of omission like failing to use a helmet while riding a bicycle, to more serious behaviours such as operating a motorized vehicle after drinking or using substances. But not all news is bad or negative. For example, it is helpful to observe that the vast majority of young people do not take such risks, offering hope for the choices that they make in the future. These findings provide direction for the content and delivery of prevention programs.

Bullying and physical fighting represent two other major foci of the HBSC survey. While it was encouraging to note that fewer young people reported engagement in bullying and physical fighting than was reported in previous HBSC cycles, higher proportions of the survey participants reported being victims of such behaviours. Chapter authors point to lifelong effects of bullying and physical fighting, and societal needs to redouble efforts to implement evidence-based strategies to prevent these behaviours, aimed at responsible authorities, in home, school and community settings, as well as at youth themselves.

The healthy living and healthy weights chapters of this report focus upon obesity and its determinants – another major priority for adolescent health in Canada. While public health authorities can take some solace in the fact that levels of obesity stabilized between 2006 and 2010, there is still much work to be done. One in four boys and one in six girls in our country reported a BMI level that is considered overweight or obese, and less than 20% meet or exceed national physical activity guidelines. At the same time, the majority of young people in Canada report challenges with perceived body image. Findings of a more positive nature include the larger proportions of young people reporting healthier diets, but the epidemic of unhealthy weights continues to be driven by physical inactivity, large amounts of screen time, and poor nutritional choices.

Both positive and negative findings were noted in the risk behaviour chapter. Large proportions of young people in Canada experiment with and use cannabis on an ongoing basis, although the proportions reporting regular use seem to have declined slightly from a peak in 2002. With respect to smoking, proportions of young people reporting daily use of cigarettes are at historical lows. More stable proportions of various indicators of the use and misuse of alcohol were documented, with increases in binge drinking being a reported concern. Finally, while larger proportions of Grade 9 and 10 students are reporting engagement in sexual activity, high levels of at least some form of protection were also reported. Still, up to one-quarter of students who reported engagement in sexual intercourse also reported using no or unreliable methods of contraception the last time they had sex, which is of obvious concern assuming pregnancy is not intended.

Behavioural factors related to mental health

The relationship between health behaviours and mental health can be described using two kinds of patterns. In the first pattern, the health behaviour demonstrates similar connections to mental health for both genders. Physical activity injury, for instance, is related to better emotional well‑being for girls and boys, likely attributable to the activities as opposed to the injury events. Healthy living factors consistently connect to mental health, with better results for young people who engage in physical activity and consume fruits and vegetables, and with poorer results reported for those who engage in sedentary activity, drinking sugared soft drinks, and eating at fast food restaurants. Adolescents who see themselves as too fat or too thin and adolescents who are trying to lose weight have lower levels of emotional well‑being. Smoking and being involved in bullying link to greater behavioural and emotional problems; being involved in bullying is also a risk factor for poorer emotional well‑being. Adolescents who both bully and are victims of bullying are clearly at greatest risk.

Often, however, the patterns that underlie these relationships are complex and, again, gender-specific in nature. For example, reports of injuries are related to behavioural problems for both genders but the connection between injuries and emotional problems is significant only for girls. Fighting injuries connect negatively to emotional problems and emotional well‑being for boys. This relationship is inconsistent for girls. Measures of unhealthy weights relate much more strongly with emotional problems and emotional well‑being for girls than they do for boys. Similarly, binge drinking and cannabis use have stronger negative relationships with mental health for girls than for boys, while having had sex links to poorer emotional well‑being only in girls.

An obvious complication surrounding the interpretation of these relationships is the issue of causality. It is unclear in many situations whether the health behaviour leads to the mental health outcome or the mental health outcome leads to the health behaviour. Most likely, there is reciprocal causation with regard to health behaviours and mental health. Reciprocal causation suggests the need for a multi-pronged approach to the issue, so that neither health behaviour nor mental health outcome are ignored under the likely false hypothesis that ameliorating one will necessarily have positive effects on the other.

Context and health in young Canadians

The HBSC Study is built upon underlying population health theory that suggests that the health of young people is in part determined by the contextual factors of home, school, peers and neighbourhoods.

With respect to home environments, the majority of young people in Canada reported being in happy homes, with positive relationships and communication with at least one parent in their lives. Relationships with parents seem to be improving relative to historical norms. A more negative finding was the high levels of pressure that young people felt in terms of expectations that are placed upon them. Further, young girls appeared to be especially vulnerable to this pressure, with more reported negative feelings about their home environments.

Schools represent a second context that has a significant potential impact on the health of young people. The vast majority of young people report solid levels of support from their school environments, and a sense that they belong in these schools. A smaller but important minority of young people report feelings of alienation. Again, an increased sense of poor achievement was noted, consistent with academic pressures that students perceive from home environments. Satisfaction with school may ameliorate some of the effects of these increased pressures.

Peer influences were also an important determinant of health noted by survey responses. To illustrate, peers who engaged in multiple risk behaviours were reported by the majority of respondents, and these negative influences can have a strong effect on risk-taking behaviours. It was positive to note that most respondents report one or more close friendships that are reinforced by some of the more modern forms of communication. Chapter authors emphasized the need for vigilance and monitoring of peer relationships by responsible adults, to ensure choices that are optimal for young people's mental health and well‑being.

The report also provides a unique new look at neighbourhood factors that could influence the health of young people. Two major messages emerged from these findings. First, "location matters," in that both highly urban environments and highly rural or remote environments contain unique challenges to healthy growth and development. Second, crime and safety concerns, even in the presence of an aesthetically pleasing environment, are a recognized determinant of health choices that may be compromising.

Taken together, the report provides a comprehensive overview of the many contextual factors that influence health and health behaviours in young people. There is a need to understand the relative importance of each context as a determinant of health. Perceptions of the youth engagement workshop participants were that home influences drive many of the choices that young people make, although the effects of these environments should optimally not be considered in isolation.

Contextual factors and mental health

In examining the connections between contextual factors and mental health, one key theme emerges: interpersonal relationships make a difference. No matter how mental health is measured and no matter what interpersonal relationship is the focus, adolescents with positive interpersonal relationships tend to fare better in terms of mental health. At home, ease of communicating with father and with mother, having relatively few arguments with parents, and sitting down to eat as a family are all linked with improved mental health. At school, crucial elements related to mental health include: academic achievement, school climate, teacher support, and peer support. With peers, engaging in positive activities is a protective factor for mental health, while engaging in negative activities is a risk factor. Ease of talking to friends proves a "double-edged sword," with positive connections to emotional problems but negative connections to behavioural problems.

Perhaps surprisingly, structural features of environments seem to matter far less than the relationships within these environments. The negative implications of not living with both parents (once socio-economic status is controlled statistically), for example, are minimal. The presence of recreational facilities and parks in the neighbourhoods surrounding schools likewise has no consistent connection with any of the mental health outcomes, positive or negative, internalizing or externalizing.

Is there a dominant environment with respect to mental health, one environment where policy measures should be concentrated? Many youth at the workshop thought home was the most critical for fostering mental health. However, the youth who stood in the middle and declared that all environments shared responsibility in helping shape adolescents are probably more closely aligned with current research. As Mueller (2009) states, "adolescents, both gifted and non-gifted, benefit from strong and healthy attachments to those close to them, including friends, family, and teachers". A comprehensive approach to mental health needs to target all three groups.

The HBSC youth engagement workshop

The HBSC Youth Engagement Workshop represents an advance in the process used for the development of the national HBSC report. The insights that were provided by young people, who participated with both passion and clarity, provide additional substance to the statistics that form the main body of this document. The chapter authors have attempted to respect these students' thoughts and insights, by integrating both essential commentaries that emerged from discussions, as well as direct quotations from workshop participants. The latter were included to highlight the key themes that emerged from workshop proceedings.

The efforts made to integrate the perspectives of young people directly into this report were driven by a philosophy that the opinions and insights of youth matter. The United Nations Convention on the Rights of the Child supports this idea. In Article 12, the Convention states that countries shall "assure to the child who is capable of forming his or her own views, the right to express those views freely in all matters affecting the child" (UNICEF, 1999). Inclusion of the opinions of young people in this report is in keeping with the spirit of this convention.

How one approaches the process of obtaining such opinions and insights is also important. The Directors and staff at the Students Commission are well versed in this science, and provided both vision and leadership for the national workshop. The report authors are indebted to these professionals and this Centre, as well as the young people who gave of their time and talents to assist with this important process.

Conclusion

The 2010 HBSC Study involved a national survey of over 26,000 young Canadians. As well as providing contemporary estimates of a wide variety of indicators of health behaviours and health experiences among young people, the 2010 cycle developed a unique focus on mental health outcomes.

Findings from this report fill a recognized void in the Canadian adolescent health literature, in that they provide novel information about mental health and its correlates in a robust sample of young people from across the country.

The development of interventions, at both the population level and the individual level, to address leading health issues in Canadian youth requires reliable evidence. The HBSC Study represents one potential source for such basic evidence. With its general focus on the current health status of young people, and its specific focus on mental health, it is hoped that this sixth Canadian HBSC report adds concrete knowledge that will assist in the planning of health promotion efforts.

References

• Keyes, C.L.M., Dhingra, S.S. & Simoes, E.J. (2010). Change in level of positive mental health as a predictor of future risk of mental illness. American Journal of Public Health, 100:2366-2371.
• Mueller, C.E. (2009). Protective factors as barriers to depression in gifted and nongifted adolescents.
  Gifted Child Quarterly, 53:3-14.
• Strauss, R. (2007). A positive perspective on adolescent mental health. Continuing Medical Education, 25:232-235.
• UNICEF (1999). Convention of the Rights of the Child. Article 12. Office of the United Nations High Commissioner for Human Rights. Available at: http://www2.ohchr.org/english/law/pdf/crc.pdf. Accessed May 11, 2011.