Section 8: Healthy settings for young people in Canada – Conclusion

8 Conclusion

The last chapter of the report begins with an overview of HBSC findings regarding the health behaviours and health outcomes of Canada’s young people. It also highlights the influence of well-known factors such as age and gender on youth health. There are a number of positive trends as well as some ongoing concerns since the last HBSC survey in 2002.

Later in the chapter, we examine the relationships between the four social contexts – home, school, peers, and socio-economic conditions – and the health of young people to identify whether there are recurring patterns. At the same time, we emphasize that data patterns do not necessarily equal cause and effect relationships. Thus, we also raise important questions about how these contexts might operate.

Finally, we briefly discuss the implications of these findings for school and health personnel, policy-makers, researchers, students, and families. In particular, we conclude that youth health interventions are required at multiple levels.

Overview of health behaviours and health outcomes in Canada’s young people

Healthy living and healthy weight

There are several troublesome findings in this area. First, the percentage of physically inactive and sedentary young people in Canada is alarmingly high. In contrast, the percentage of children and youth reporting frequent fruit, vegetable, and milk consumption is alarmingly low. Given these findings, it is not surprising that 1 in 5 Canadian students are overweight or obese.

Health risk behaviours

This area shows a number of very positive trends since 2002. A significant decline in daily smoking is noticeable in both Grade 10 boys and Grade 10 girls. Consumption of beer, wine, and liquor and spirits has declined. Although fewer than 10% of students report drinking coolers at least once a week, these might be replacing more traditional alcoholic drinks. The proportion of Grade 10 students getting “really drunk” twice or more has declined slightly, yet almost 40% of all students surveyed still report this practice.

The proportion of boys in Grade 10 who report ever trying cannabis has dropped significantly. Heavier use of cannabis among students is quite low, although girls and boys are equally involved. A substantial number of drugs show a decline in use. Only ecstasy and medical drugs to get stoned show increases, and only for girls. The use of magic mushrooms is reported by a minority of students.

The proportion of sexually active students has not changed since the last HBSC survey. Around 20% of students in Grade 9 and 25% of students in Grade 10 report having had sexual intercourse. Condoms are still the method of choice for contraception in Grades 9 and 10; however, students’ decisions to use condoms seem more motivated by the intention to protect themselves from infection, rather than to prevent pregnancy. While birth control pills are the second method of contraceptive choice for students, withdrawal is still reported as a contraceptive practice by students in both grades, particularly by girls in Grade 10. Over one-third of students in Grade 9 and almost half of students in Grade 10 indicate not using any measure to prevent pregnancy.

Bullying and fighting

Both encouraging and worrying trends are evident in bullying and violent behaviour among young people. First, bullying remains a significant problem in Canada, with an alarming proportion of students reporting involvement in bullying, either as the aggressor, the victim, or both. Since 2002, however, most forms of bullying have decreased, although racial harassment of both boys and girls has increased, especially in primary school grades. The way that young people are victimized differs by gender. Boys are more likely to be victimized by physical and verbal bullying, whereas girls are more likely to be victimized by indirect and cyber bullying. Sexual harassment is higher for boys than girls in Grades 6 and 7, while the opposite is true in Grades 9 and 10.

In contrast, fighting behaviour has increased since 2002, especially in lower grades. Although more boys report fighting than girls, there are notable differences in whom they fight with. For example, boys are more likely to fight with strangers, whereas girls are more likely to fight with those they know.

Injury and physical trauma

Injury continues to be a leading health problem among Canadian young people. Large proportions of students, as many as 31 to 48%, report one or more medically-treated injuries in a 12-month period. These injuries are often serious, in that they require substantial medical treatment, and result in significant time lost from school or usual activities, reaching as high as 2452 days missed per 1000 students over one year. The cumulative burden of these injuries on youth populations and our society is enormous.

Emotional health and well-being

The influence of gender on emotional health presents increasing challenges among young people. For example, while emotional health tends to be similar for both boys and girls in Grade 6, by Grade 10, girls clearly are experiencing poorer emotional health than boys. The critical period for girls appears to be between Grades 6 and 7, when their emotional health becomes markedly poorer. This gender gap seems to be increasing from previous years of the survey.

Settings for youth health interventions

Traditionally, youth health interventions have focused on increasing healthy living practices, reducing risk behaviours and bullying/violence, and avoiding injuries and emotional health problems. A context approach to health suggests that these health objectives are achieved in particular settings (i.e., home, school, peer) and under particular conditions (i.e., socio-economic). Thus, knowing as much as possible about the contexts within which health interventions may be positioned is very important.

In the following discussion, we summarize the health-promoting and health-damaging relationships between the four contexts which have been central to our report and the above health intervention objectives. We indicate the strength and direction of these patterns as follows:

In this way, we can be aware that improving one contextual factor may have supportive, or even contradictory, effects on different health interventions and outcomes.

The home setting

Students living with both parents…

• …have a highly increased likelihood of:
  • engaging in some healthy living behaviours (consuming fruits, vegetables, and low-fat milk)
  • having better emotional health and well-being
• …have a greatly decreased likelihood of:
  • engaging in risk behaviours
  • being involved in bullying
• …have some decreased likelihood of:
  • consuming non-diet soft drinks
  • sustaining a serious injury
• …have the same likelihood as other students of:
  • being active; consuming sweets; being obese

Students with higher parent trust and communication…

• …have a highly increased likelihood of:
  • engaging in some healthy living behaviours (being active; consuming fruits, vegetables, and low-fat milk)
  • having better emotional health and well-being
• …have a greatly decreased likelihood of:
  • engaging in risk behaviours
  • being involved in bullying
• …have some decreased likelihood of:
  • consuming non-diet soft drinks
• …have the same likelihood as other students of:
  • consuming sweets; being obese
  • sustaining a serious injury

Overall, the home setting’s most positive association is with risk behaviours, bullying involvement, and emotional health outcomes in young people, but only partially with healthy living practices, and not with injuries.

The school setting

Students with higher academic achievement…

• …have a highly increased likelihood of:
  • engaging in healthy living behaviours
  • having better emotional health and well-being
• …have a greatly decreased likelihood of:
  • consuming sweets and non-diet soft drinks; being obese
  • engaging in risk behaviours
  • being involved in bullying
  • sustaining a serious injury

Students with a better attitude towards school…

• …have a highly increased likelihood of:
  • engaging in some healthy living behaviours (being active; consuming fruits and vegetables)
  • having better emotional health and well-being
• …have some increased likelihood of:
  • consuming low-fat milk
• …have a greatly decreased likelihood of:
  • consuming sweets and non-diet soft drinks
  • engaging in risk behaviours
  • being involved in bullying
  • sustaining a serious injury
• …have the same likelihood as other students of:
  • being obese

Overall, the school setting appears to have a positive association with most youth health behaviours and outcomes.

The peer context

Students whose friends have better pro-social attitudes…

• …have a highly increased likelihood of:
  • engaging in many healthy living behaviours
  • having better emotional health and well-being
• …have a greatly decreased likelihood of:
  • consuming sweets and non-diet soft drinks
  • engaging in risk behaviours
  • being involved in bullying
• …have some decreased likelihood of:
  • sustaining a serious injury
• …have the same likelihood as other students of:
  • being obese

Students who have better communication with their friends…

• …have a highly increased likelihood of:
  • engaging in some healthy living behaviours (being active; consuming fruits)
  • engaging in many risk behaviours
  • having a high emotional well-being score
• …have some increased likelihood of:
  • consuming vegetables and non-diet soft drinks
• …have a greatly decreased likelihood of:
  • being victimized
• …have the same likelihood as other students of:
  • consuming low-fat milk and sweets; being obese
  • smoking daily
  • bullying others; being a bully-victim
  • sustaining a serious injury
  • having fewer psychosomatic symptoms

The peer context has mixed results. Friends’ pro-social attitudes are associated with most positive youth health behaviours and outcomes. Good communication with friends, however, is associated both with positive and negative health behaviours/outcomes. Overall, the peer context may have both protective and risky influences on youth health.

Socio-economic conditions

Students with high family affluence…

• …have a highly increased likelihood of:
  • engaging in many healthy living behaviours
  • bullying others
  • sustaining a serious injury
  • having better emotional health and well-being
• …have some increased likelihood of:
  • being a bully-victim
• …have a greatly decreased likelihood of:
  • consuming non-diet soft drinks; being obese
  • engaging in some risk behaviours (smoking daily and having sexual intercourse)
• …have the same likelihood as other students of:
  • consuming sweets
  • engaging in some risk behaviours (getting drunk and using cannabis)
  • being victimized

Overall, socio-economic conditions appear to be associated with good emotional health outcomes and most healthy living practices. These conditions are associated with fewer risk behaviours, but are negatively associated with serious physical injuries and bullying others.

Summary

There is remarkable overall consistency in the patterns of the four social contexts in the health behaviours and outcomes of young people in Canada. Although some of these relationships have been observed in research with smaller groups, the 2006 HBSC study is the first broad investigation of such relationships in a nationally representative population of Canadian youth at this age level.

These various contexts for youth health seem to follow a particular order of frequency: from most consistent positive influence (school), to positive or neutral influences (home), to less frequent positive or more frequent negative influences (socio-economic conditions and peers). In particular:

• Assets at the school level are consistently and strongly associated with positive health behaviours and outcomes.
• Home and family assets are usually associated with positive health behaviours and outcomes. There are neutral relationships between particular family assets and injuries, physical activity, and obesity.
• Socio-economic assets are partially associated with positive health behaviours, including not smoking (in girls) and not having had sexual intercourse (both sexes). Socio-economic assets are not, however, associated with alcohol or cannabis use. Socio-economic advantages are associated with positive health outcomes, but also with higher risks of injury and bullying others.
• Peer and friend assets have both positive and negative associations with health (i.e., mixed influences for risk behaviours).

This order could indicate the best opportunity for success in interventions, that is, a focus on the home and school settings. At the same time, the reverse order could indicate the greatest need for interventions within the peer context and in social income policy.

The contextual measures that were chosen for this analysis may have partly determined these conclusions. For example, a measure of parental occupation (instead of family affluence) or a measure of parental monitoring (instead of parental trust and communication) may have yielded different results.

Since the HBSC study only collects data from students attending regular schools, we might be over-estimating the importance of the school setting. If the HBSC sample included young people who were being educated at home and/or street youth, the home setting and peer context might show increased associations with youth health.

Nonetheless, the preliminary view of youth health behaviours, outcomes, and social contexts presented in this report yields some fascinating questions, for example:

• If youth behaviours “lead to” health outcomes, why are the contexts of home and socio-economic conditions mostly associated with emotional health outcomes, but less with health behaviours?
• Why are physical health outcomes (injuries, obesity) less often associated with these four contexts than emotional health outcomes?
• Do some contexts that are more stable (for example, socio-economic conditions, family structure, and academic potential) “set the stage” for youth health, while others that are more fluid (for example, school atmosphere, friends’ pro-social attitudes, and parent communication patterns) “direct the action”?
• How are certain contexts linked to each other? For example, high parent trust and communication and good communication with friends seem to have opposite associations with most risk behaviours.
• Similarly, do good communication skills and high pro-social attitudes of friends create conflict for young people in risk-taking situations?
• How do multiple contexts, for example good home and school contexts together, maximize youth health? More importantly, can a good home or school setting counterbalance a poor socio-economic context?

Clearly, the answers to these questions will take further basic research and applied evaluation of youth health interventions in different contexts. Four categories, as described in the scientific literature,^{Footnote 1} can be used to describe actions that could be taken:

• strengthening youth and peer groups
• strengthening families
• improving school and neighbourhood conditions
• promoting social policy improvements.

Priority setting and planning are key elements of interventions and should take into account current knowledge about the health status of Canadian young people, their health problems, and trends over time. As well, further insights into the health contexts in which action occurs are essential. We hope that this fifth Canadian HBSC report adds concrete evidence to be applied in such planning.

Reference