ARCHIVED: Chapter 11: Young people in Canada: their health and well-being – Conclusions

The main purpose of this report was to examine patterns in the determinants of health of Canadian youth. A further goal was to examine selected trends in the health of Canadian youth from 1990 to 2002. The HBSC study was not designed to assess the impact of specific social, educational, and health system changes on the health of youth but to note only whether changes in the outcomes and determinants of youth health have occurred.

In this study, gender was a strong determinant of many aspects of adolescent life: physical and emotional health; satisfaction with school and home; healthy living patterns; and bullying and injuries. Socio-economic inequalities associated with family wealth and social status (for example, parent occupation) were also pronounced. A significant proportion of students indicated that their families were not well off, and alarming, although small, numbers of adolescents reported that they sometimes went to bed hungry. One-quarter of students reported that either their father or mother was unemployed. However, the majority of youth also stated that their families had material possessions such as cars and computers. The inequality between these two extremes may lead to compromised population health outcomes. For instance, an important relationship between socio-economic inequality and adolescent health outcomes was indicated by the fact that students who had a middle or high family affluence scale score were significantly more likely to report better health status, higher life satisfaction, and better home and parent relationships. The causes of these differences in socio-economic determinants of adolescent health need to be addressed by a variety of income support and employment strategies.

This research has confirmed other studies that show how connectedness to one's parents, exemplified by feelings of trust, openness, and support, appear to be essential protective factors associated with positive health and healthy behaviours (Resnick and colleagues, 1997; Resnick, 2000). Lower levels of connectedness to parents in older girls may indicate conflict with parents over young women's roles in society. Most adolescents considered their parents as primary attachment figures, even as their social allegiances shifted more toward their peers. These HBSC findings concur with others which show that adolescents with strong connectedness to their parents demonstrate positive psychosocial functioning (Jackson, Bijstra, Oostra, and Bosma, 1998) and less involvement in risk taking (Garnier and Stein, 2002). As mentioned previously, the relationship of adequate socio-economic status (SES) to a positive home environment appears to be crucial. Community level interventions that facilitate the home setting, such as parent-school collaborations, parent-youth social interactions, and parent involvement in youth organizations, may provide opportunities not only to solidify individual families but also to test models of community cooperation and responsibility for youth well-being.

In the HBSC survey, adolescent friendships with peers had both positive and negative features. Social integration with friends had significant beneficial impacts on psychosocial and behavioural outcomes. In contrast, adolescents whose friends were involved in risk behaviours were more likely to be involved in those behaviours themselves. However, having friends who were not involved in risk behaviours was associated with less risk taking in those students who did not have many friends. It appeared that students who were not well integrated socially and who had negative peer influences felt unhappy at home, had a desire to leave home at times, did not feel that they belonged at school, and felt lonely or left out of things. Finally, girls seemed to be slightly less comfortable in cross-gender peer communication.

A large portion of adolescents' lives are spent in schools interacting with teachers and peers. In terms of the school experience, two general patterns were found throughout the study. First, students who had positive experiences in school were less likely to participate in health risk behaviours or to have negative views of their lives. Teachers, parents, and peers each had an influence on the decisions and behaviours of school-aged youth, and positive school experiences were associated with healthy teacher, parent, and peer relationships. These students were more likely to feel good about their health and their overall lives. Unfortunately, it is not possible from this survey to determine whether negative school experiences result in increased health risk behaviours; it can show only that these associations are present.

As well, secondary students' perception of school tended to be more negative than that of elementary students. Similarly, boys had more overall negative views of school than did girls. This decline in positive attitudes toward secondary school may be associated with the changing school structure found in the upper grade levels; it also may be attributable to these students having external competing interests. Certainly, students believed the secondary classroom to be less student-centred than the elementary classroom, a situation that may be contrary to their developmental needs for autonomy. However, boys also reported higher levels of outside activities that directly or indirectly compete with school. A case may be made that boys increasingly find secondary school less relevant to their immediate lives. On the other hand, girls appeared to adapt better to secondary school, in contrast to their experiences at home. Overall, these findings fit with other evidence that the number of male post-secondary students is decreasing relative to the number of females pursuing post-secondary education.

In regard to adolescent risk behaviours, smoking, substance use, and early unprotected sexual activity are linked to various preventable diseases and illnesses. However, these behaviours occur within such a complex interaction of psychosocial, economic, and environmental determinants that targeting a single cause in health promotion efforts is unlikely to be successful. Consequently, monitoring adolescent smoking and substance use and their correlates is crucial for health and social service programs aimed at young people. Although smoking rates for boys remained unchanged since the last survey in 1998, it is encouraging to notice a decline in the proportion of Grade 10 girls in the 2002 HBSC sample who smoked. Experimentation with alcohol is a behaviour that occurred early, with rates of alcohol consumption increasing significantly between the ages of 12 and 14 years. Interestingly, almost as many girls as boys reported engaging in binge drinking, indicating that excessive alcohol use is a feature of adolescent social events.

The Canadian Association of Liquor Jurisdictions considers underage drinking and its consequences a serious issue, and since 2003, with the participation of all 13 provincial and territorial liquor boards and corporations, has coordinated an awareness campaign to educate the public on the issue of minors and alcohol, and the fact that supplying alcohol to minors is a major offence.

Marijuana use was still popular among adolescents and increased in use among Grade 10 boys. The use of other drugs remained fairly stable among youth, except for LSD use, which decreased considerably since the last survey.

Findings in the 2002 HBSC survey indicate that slightly over one-quarter of Canadian students in Grade 10 engaged in sexual intercourse. Over two-thirds of those sexually active students used condoms the last time they had sexual intercourse, and just under one-half used birth control pills. However, students who engaged in sexual intercourse at least once by Grade 10 were substantially more likely to be involved with risk behaviours such as smoking, marijuana use, and getting drunk. These findings support the notion that early sexual activity occurs within the context of other risk taking. Harm reduction programs for such adolescent risk behaviours may have a good chance of reversing the risks of sexually related disease and social problems in adulthood. However, the increased vulnerability of younger adolescents to coercion, pregnancy, and sexually transmitted disease suggests that more attention should be paid to this age group in sexual health promotion and disease prevention efforts in schools.

Thus, early onset of risk behaviours and involvement with risk-taking peers are two of the strongest predictors of negative adolescent health outcomes. However, debate arises regarding the manner in which this association between peers and risk taking develops. One explanation, known as peer pressure, suggests that peers impose values and behaviours on others to maintain the social attractiveness and power dynamics of the peer group. One intervention appropriate to this theory would be to encourage youth to set their own standards and to withstand pressure from others by building their self-confidence. The other explanation, known as social selection and socialization (Reed and Rountree, 1997), suggests that adverse circumstances in the lives of adolescents, such as dissatisfaction with home or school, initiates risk-taking behaviours by youth as expressions of discontent with their lives and society as a whole. Youths with similar problems, and similar reactions, then gather together for social support; risk behaviours become a medium for their social interaction. An intervention appropriate to this theory would be to address the student's lack of connection with the home or school environment, rather than changing the peer group. The HBSC survey does not allow full examination of either theory, since it cannot identify which occurred first, the peer involvement or the risk behaviour. Yet it is clear that those adolescents whose friends were involved in risk behaviours were more likely to be involved in those behaviours themselves.

Healthy living for youth encompasses a wide range of behaviours, such as nutritional habits, involvement in both organized and casual physical activities, and weight maintenance. Physical activity and nutritional behaviours that are learned in childhood are more likely to carry through into adulthood and affect one's lifestyle and health status. Personal dental hygiene is also a component of living in a healthy way, as is moderate use of medication to counteract some of the physical symptoms experienced by young people.

While the fact that the HBSC survey measured frequency, rather than quantity, of food consumption makes the overall assessment of nutritional well-being difficult, the study results do have general relevance and point to areas of concern. Many younger students seemed to be following healthy eating habits, such as having breakfast during weekdays and consuming fruits and vegetables. This pattern changed for older students as they spend more time away from home and rely more on their own choices regarding what they eat.

Student levels of physical activity were encouraging, although surprisingly low levels of exercise within schools were reported. This is not surprising considering the tightening in school budgets across Canada and the impact that has had on physical education and extracurricular programs (Andersen, 2000). It is interesting to note a significant gender difference in physical activity, both in and out of school, indicating that engagement in sports is still primarily a male domain and that schools could do more to involve girls in physical activities.

Overall, the results of the Body Mass Index measure for adolescents appeared satisfactory, with only moderate proportions of overweight and obese youth, but weight management practices of adolescents varied. For example, girls, especially in Grade 10, were concerned about their weight more than boys were and reported lower consumption of soft drinks and potato chips; but they were also less physically active, compared with boys, and often relied on diets to control their weights. Girls' obsession with body image that is constantly portrayed by the media may cause them to engage in “ineffective and harmful weight loss behaviours” (LeBlanc, 2003, p. 329).

Instead of engaging in sports and exercise during leisure time, younger girls seemed to participate more in clubs or organizations, although the gender difference disappeared in Grades 9 and 10. Levels of television watching can be an indication of a sedentary lifestyle. A high proportion of students reported that they watched several hours or more of television each day. Recreational computer use was also quite high as more than one-half of older students indicated that they spent a moderate amount of time each weekday playing computer games.

Regarding health symptoms, older girls were far more likely to indicate regular use of medications for headaches, and to report wheezing as a common symptom; however, a slightly lower proportion of girls than boys indicated that they had been actually diagnosed with asthma. This could possibly reflect an unconscious bias in diagnostic practices.

The prevalence and characteristics of bullying in youth have several policy implications. First, adolescents varied in their involvement in bullying and/or victimization and consequently require different levels of support and intervention. Not all youth were equally at risk for involvement in bullying and/or victimization – and the risks associated with these may relate to the severity, frequency, duration, and pervasiveness of the involvement. The majority of students in the study were relatively uninvolved as the perpetrator or the victim of bullying, although they were negatively influenced when they formed the peer group that watched bullying. For these youth, a universal program (directed to all students) will likely be effective in the prevention of bullying. The group of students who were more directly involved at least occasionally in bullying may experience some negative effects. These youth may require support, such as school intervention and mediation, which goes beyond a universal program. Finally, a small minority of students were involved in frequent and serious bullying and/or victim problems. These youth have the most significant adjustment difficulties and require identification and more intensive interventions such as counselling.

Second, there were changes in bullying and victimization with age. The reported prevalence of bullying and victimization generally peaked in Grade 8 for girls and in Grade 10 for boys. In the case of girls, the behaviour tended to decrease over time, while the patterns were not consistent for boys. From a policy perspective, early intervention (i.e., before bullying increases in prevalence) would prevent or reduce the problem behaviours before they emerge. Thus, prevention programs need to be put in place long before Grade 8 to reduce bullying effectively.

Third, the various types of bullying behaviours need different targets of intervention for youth. The HBSC results suggest that bullying is a behaviour that takes many forms and that some, such as verbal harassment, are more common than others. The range of harassing behaviours experienced by victimized young people highlights the need to help aggressive youth identify these behaviours as forms of harassment and to teach them respect for differences, whether these be sexual, ethnic, or religious. There is also a need to design intervention programs that recognize the changing forms of bullying as students age.

Finally, there is mounting evidence to suggest that students who bully others, or are victimized by others, are at the highest risk for long-term difficulties. In Canada, there is also a particularly high number of bully/victims. The high prevalence of students who reported bullying others, being victimized by others, or engaging in both types of behaviours highlights the urgency to address this significant problem and ensure that every student is safe at school.

Injury is one of the most serious health problems facing school-aged youth throughout the world. As many as 50 percent of Canadian students in the 2002 survey reported having had an injury during the past year requiring medical attention. These injuries, and their consequences in terms of treatment and in time lost from school, contribute an enormous burden to the health of young Canadians and society. The HBSC survey shows that some students are more at risk for injury than are others. Boys consistently experienced more injuries than did girls, and the incidence of injuries peaked in Grade 8. As young people began to engage in multiple risk behaviours, such as smoking, drinking, bullying, and a failure to use seat belts, their risk for injury consistently increased. This association has also been observed internationally (Pickett, Schmid, Boyce, and colleagues, 2002).

The HBSC study profiles circumstances that are common to youth injuries. While sports injuries happened during various activities and in many locations, the percentage of injuries that occurred during organized activities grew substantially in the older grades. The vast majority of sports and other types of injuries happened in controlled environments, including the home, school, or sports facilities. Major types of physical damage ranged from sprains and strains to lacerations, bruises, fractures, and head injuries. While the forms of health care treatment sought were consistent for both genders, treatment in doctors' offices or health care clinics and emergency departments was highest for Grade 10 students, while the need for admission to hospital peaked for Grade 6 boys.

Results of the HBSC survey are helpful in identifying priorities for injury prevention among school-aged youth in Canada. They provide direction to injury control efforts and where these could be best targeted. They also illustrate the need to continually improve the safety of school and sports-related environments and to enhance first aid and other programs aimed at the initial response to these injuries. Finally, the importance that multiple risk behaviours play as a potential cause of injury among youth throughout the world needs to be recognized and addressed in prevention initiatives.

In terms of youth emotional health, the various HBSC measures present a fairly consistent picture. Most of the adolescents in the 2002 survey reported good emotional health. However, a substantial minority (20 to 30 percent, depending on the HBSC item) of students experienced less than optimal emotional health. Girls, compared with boys, reported higher levels of depression and headaches, and lower levels of life satisfaction and subjective health. Backaches and irritability were similar between the genders. On each measure, emotional health tended to worsen with age. An especially critical point for girls appeared at the end of Grade 7, when they may require additional support to cope with life and body changes.

Parents may be the best defence against poor emotional health. Adolescents who reported strong parental support had greater life satisfaction and subjective health. The influence of peers on emotional measures of health was relatively weaker, although having a strong network of peers contributed somewhat to better emotional health. This may indicate that peer group influence, which is often associated with risk taking, also has some influence on overall health through mechanisms of social interaction and support.

In sum, adolescent socialization occurs within three main social systems: the home, the peer group, and the school. As such, efforts that target adolescents require multi-modal intervention strategies that involve entire communities, rather than focusing only on a single student or family or school (Schneider, 2000). Multi-modal intervention strategies reflect a population health approach to dealing with youth and allow a broader understanding of adolescents and their problems within a social context (Caputo, 2000). Policies to address the problems of adolescents in home, school, and neighbourhoods should centre on opportunities that allow for youth participation and engagement in wide-based programs that help them to identify their needs and to be active participants in implementing change in their local environments.

Over the past four years, health promotion and prevention efforts for youth in Canada have expanded and consolidated to embrace a broader range of age groups and topics, such as active lifestyle and healthy eating programs and the Comprehensive School Programs. In addition, there has been an increase in anti-smoking and anti-drug campaigns that target young people. Some of these initiatives have involved youth adequately, and some have not. The findings in this report provide a very general indication of the success of these initiatives.

From a population health perspective, the most powerful determinants of youth physical and emotional health that were evident from the 2002 HBSC survey were related to gender, family affluence, school conditions, and the influence of peers on risk taking. Further analysis of these data is necessary to explore these possibilities. Clearly, policy responses for this range of potential determinants will need to be broad. Federal, provincial, territorial, municipal, professional, and business sectors need to openly discuss the health of the next generation with youth themselves. Youth have had insufficient attention among these sectors, in part because of the transitional character and independence-seeking nature of adolescence. When attention is focused on initiatives for adolescents, efforts to engage youth in policy and program development need to be strengthened. The development of an inclusive, cross-sectoral "Middle Childhood and Adolescent Agenda" in Canada would contribute to the visibility and viability of policy initiatives and may also earn widespread youth approval and participation.