Abstract
Adolescence is a period of accelerated growth and change, bridging the complex transition from childhood to adulthood. This period offers adolescents an opportunity to begin planning for their futures and to adopt healthy attitudes about risk behaviors that can continue into adulthood, thus setting the stage for a lifetime of desirable health behaviors. This study used the Youth Risk Behavior Survey on middle school students and examined the gender differences of health risk behaviors among 674 8th-graders from an urban setting. The results showed that males were more likely to be involved in fights, to initiate alcohol use, and to participate in physical activity; whereas females were more likely to try to lose weight with unhealthy practices, such as fasting and laxatives. School nurses are in a prime position to promote adolescent health in the school setting by providing health-related services and teaching to help students initiate and maintain healthy lifestyles.
Keywords
INTRODUCTION
A large proportion of morbidity and mortality in the United States can be attributed to a small number of health risk behaviors: smoking, poor diet, sedentary lifestyle, alcohol and substance use, and sexual risk behaviors. As a result, a primary goal of Healthy People 2010 is to promote healthy behaviors in the general population (U.S. Department of Health and Human Services [USDHHS], 2000). One population that needs to be more carefully examined is adolescents. Adolescents often engage in health risk behaviors that are dangerous to themselves and others, with immediate or long-term consequences to their health and well-being. The pattern of health behaviors initiated during the adolescent years is associated with adult morbidity and mortality (National Center for Health Statistics, 2000). Grunbaum and colleagues (2004) reported that there are four major causes of death among youths and young adults aged 10 to 24: motor-vehicle crashes, unintentional injuries, homicide, and suicide. Deaths from these four causes total 70.6% of all deaths. Unfortunately, since 1960 there has been no reported decrease in the rates of morbidity and mortality among adolescents (Chopak, Vicary, & Crockett, 1998).
A comprehensive national surveillance system, the Youth Risk Behavior Survey (YRBS), has been administered biennially since 1991 in large urban schools in 40 states and has documented and monitored the prevalence of health risk behaviors among high school students. The results from the YRBS consistently show that risk behaviors are often initiated during early adolescence, probably in the early middle school years (Grunbaum et al., 2004). Nevertheless, a comprehensive literature review shows that limited data sets were available to describe the prevalence of health risk behaviors in middle school students. Previous studies also suggest that more detailed information needs to be collected to fully understand the patterns of health risk behaviors among male and female adolescents (DuRant, Krowchuk, Kreiter, Sinai, & Woods, 1999; Fetro, Coyle, & Pham, 2001).
Health risk behaviors that are established early during adolescence are often difficult to modify in adulthood and have harmful effects on these individuals’ long-term health. The purpose of the study was to describe (a) the types and frequency of the health risk behaviors being performed by 8th-grade students from the midwestern United States and (b) the differences and similarities of these behaviors in male and female students. By using the YRBS with young adolescents, the current study provides new information by examining a younger population that has been less frequently documented in the literature.
LITERATURE REVIEW
The leading causes of mortality and morbidity in the United States are related to the following categories of health behavior: (a) behaviors that contribute to unintentional injuries, (b) violence, (c) tobacco use, (d) alcohol and other drug use, (e) unhealthy dietary behaviors, and (f) physical inactivity (Grunbaum et al., 2002). These behaviors are frequently interrelated and are often established during youth and extend into adulthood. Schools can most effectively and efficiently meet the health needs of young people by focusing their efforts on these priority health risk behaviors, in addition to addressing such other important health problems as asthma and infectious diseases (Centers for Disease Control and Prevention [CDC], 2005).
Schools can most effectively and efficiently meet the health needs of young people by focusing their efforts on these priority health risk behaviors . . .
Behaviors Related to Unintentional Injuries and Violence
Teenage violence is a major public health concern in the United States that affects youths of all ages and various socioeconomic backgrounds. Although school is expected to be a safe environment to facilitate learning experiences, unfortunately, violence in schools has been reported to be increasing (DuRant et al., 1999). Homicide is the second leading cause of death in youths aged 15 to 24 (Lowry, Cohen, Modzeleski, Kann, Collins, & Kolbe, 1999). With school shootings as a potential occurrence in a teen’s school life, it is not surprising that some schools are equipped with metal detectors, drug surveillance, and security guards. Not only do physical problems result from violence, but psychological problems can result from exposure to violence that specifically affects adolescent girls, including depression, low self-esteem, and post-traumatic stress disorder. In addition to psychological problems, exposure to violence has been shown to be a strong predictor of substance abuse and violent behavior (Berenson, Wiemann, & McCombs, 2001).
Substance Use
Health risk behaviors such as alcohol use, tobacco use, and substance abuse are leading causes of premature mortality in adults—behaviors that appear early in adolescence (Nicholson, 2000). Beal, Ausiello, and Perrin (2001) reported that more than 50% of 7th-graders in an urban public school had used alcohol, 20% had used cigarettes, and about 13% had used marijuana. Alcohol abuse negatively affects adolescents’ psychological and cognitive well-being and is associated with violence, school dropout, and other drug use (Lowry et al., 1999). In addition, research suggests that the earlier an individual begins drinking alcohol, the more likely he or she is to become dependent on it (USDHHS, 2000). Up to a million adolescents become smokers annually, making cigarettes the most frequently used addictive substance on a daily basis. A longitudinal national study, Monitoring the Future, revealed that smoking among adolescents has not declined since the 1970s and indeed has increased since the mid-1990s (Johnson, O’Malley, & Bachman, 2000).
Behaviors Related to Obesity
There is an epidemic of obesity in children and adults. In the United States, 9 million (15%) children and adolescents aged 6 to 19 are considered overweight (CDC, 2005). Because development of obesity requires that energy intake exceed energy expenditure, behaviors affecting both intake and expenditure of energy need to be considered for preventing and treating obesity. A healthy diet is essential during adolescence for rapid growth and sound development; however, national surveys indicate the majority of young people have excessive fat intake, consume fewer fruits and vegetables than recommended (CDC, 2001), and have poor nutritional patterns, including skipping meals (particularly breakfast; Sweeney & Horishita, 2005) and unhealthy snacking (Dowdell & Santucci, 2004). Unhealthy nutritional habits, such as the use of fasting, diet pills, vomiting, or laxatives for the purpose of weight control, were reported among female adolescents (Lowry, Galuska, Fulton, Wechsler, Kann, & Collins, 2000).
Healthy People 2010 identified physical activity as a major objective (USDHHS, 2000). Studies indicate that physical activity declines as age and grade increase (CDC, 1999). National surveys report that participation in vigorous physical activity dropped abruptly between grades 9 and 12 (Kann, 2001). Previous studies also have shown that gender is a significant factor in exercise (i.e., boys have been shown to be more active than girls; Sallis, Zakarian, Hovell, & Hofstetter, 1996).
To achieve a positive health outcome for adolescents, the issue of how health risk behaviors such as violence, substance misuse, poor diet patterns, and physical inactivity affect physical, psychological, and behavioral development needs to be addressed. As a result, developing positive health and lifestyle choices during adolescence will increase the likelihood of healthy habits continuing during adulthood.
METHODS
This cross-sectional study used a descriptive design to collect data from 8th-graders at three schools in southeastern Michigan. The school principals approved distribution of the anonymous survey, and the survey was administered in various class periods after obtaining permission from teachers. Before data collection, the study protocol was reviewed and approved by the Institutional Review Board at the sponsoring university. Internal approval was obtained through the individual school district’s established process for obtaining passive consent for student participation in surveys. Before administering the survey, parents or guardians were notified in writing (i.e., periodic newsletters), about the purpose of the survey and when it was to be administered; and they were given an opportunity to review the survey and to decline to have their child participate (opt-out).
All 8th-graders at these three schools were recruited to participate in the study; voluntary participation was emphasized. To maintain anonymity, no identifiable information was required in the questionnaire. Students completed the self-administered questionnaire during class and recorded their responses on scannable computer answer sheets. About 695 questionnaires were distributed throughout the schools; 674 were returned, yielding a response rate of 97%.
Student Profile
The sample comprised 674 8th-graders between the ages of 10 and 16 (M = 13.42, SD = 0.64); 95% were 13 or 14 years old. The study had 344 (51%) male and 326 (48.6%) female participants. The two largest ethnic groups in the sample were White (44.1%) and Black or African American (30.1%). Other ethnic groups represented were Asian or Pacific Islander (3.1%) and Hispanic (2.7%). Most of the students surveyed (93%) lived with either one or both parents.
Instrument
The study instrument was adapted from the Youth Risk Behaviors Surveillance System (YRBSS) questionnaire (i.e., the YRBS) developed by the CDC. In 1992 and 2000, psychometric studies were conducted at the CDC to measure the reliability of the questions. Results showed that the questions were reliable over time (Kann, 2001; Brener et al., 2004).
Questions from the YRBSS used in this study measured health risk behaviors related to unintentional and intentional injuries (i.e., seat belt use, helmet use, suicide plans and attempts, and violence); tobacco, alcohol and other drug use; dietary behavior; and physical activity. The survey included seven demographic items (i.e., age, gender, ethnicity, weight, height, living condition, and grade), seven items about personal safety and violence related behaviors, three items about attempted suicide, nine questions about tobacco use, six items about alcohol use, six items about marijuana and other drug use, seven items about eating patterns and body weight perception, and five items about physical activity. The survey contained a total of 51 multiple-choice questions written at a 7th-grade reading level.
RESULTS
Data was entered into the SPSS (Statistical Package for the Social Sciences (SPSS), Version 11.5, Chicago, IL) and analyzed using descriptive statistics. Frequencies and cross-tabulations were generated to show the relationships between male and female participants. The chi-square test was used to examine the associations of gender on risk-taking behaviors, and a p value of .05 was the cut-off for determining the level of significance. Results are reported in Table 1.
Behaviors Related to Unintentional Injuries
About 13% of students reported rarely or never wearing a seat belt while riding in a car driven by someone else. In terms of bicycle helmet use, 87.1% rarely or never wore helmets. Helmet use during inline skating or skateboarding was slightly higher; however, 86.4% of 8th-graders reported they rarely or never wore bike or skateboard helmets at all times. Although male students were more likely than their female counterparts not to wear seat belts or use helmets, the chi-square analysis (χ2 = 0.03 and 2.06, respectively) did not reach statistical significance (p < .05).
Almost half of the students (46.2%) reported they had ridden with an individual who they knew had been drinking. Interestingly, female students (50.2%) were more likely than their male counterparts (42.5%) to have ridden with a driver who had been drinking alcohol, but the comparison approached but did not reach statistical significance (χ2 = 3.24, p = .07).
Behaviors Related to Violence
About 21% of students reported that they had carried a weapon (i.e., gun, knife, or club) to school with the intent of using it, although 79% stated that they had not. More male students than female students reported carrying a weapon to school, but the p value did not reach statistical significance. Almost 70% of the students stated they had been in some sort of fight, while 10.5% reported that some sort of medical treatment was necessary due to a fight. Male students (77.3%) were significantly more likely than female students (62.0%) to have been in a physical fight (χ2 = 18.34, p < .001).
When students were asked about their thoughts, plans, and attempts toward suicide, the results showed that female students have a higher prevalence than male students in all three categories; nevertheless, the chi-square statistics did not reach statistical significance.
Substance Abuse
Tobacco Use. In this study, 40.6% of students reported trying to smoke a cigarette. About 13% of students had smoked more than one cigarette a day during the last 30 days. When asked at what age they had started smoking a whole cigarette for the first time, 44.7% replied at the age of 13 and younger, and the greatest proportion (11.0%) started between the ages of 12 and 13. Chewing tobacco and cigar use was less frequent than cigarette use.
Alcohol Use. Fewer than half (48.2%) of the students stated they had had one drink of alcohol, with male students (52.1%) showing a greater prevalence than female students (44.1%) for experimentation (χ2 = 4.12, p < .05). More than 34% of the students reported initiating alcohol use before the age of 13. Among students who reported the use of alcohol during the past 30 days, more than 21% reported drinking more than once a day (current alcohol use) and about 2% had five or more drinks of alcohol when they drank. Alarmingly, 12% of the students stated that at some point they had consumed at least one drink on a daily basis.
Other Drug Use. Among marijuana, cocaine, inhalant, steroid, and injection drugs, students reported a higher percentage of use of marijuana than the other drugs. However, female students had a higher prevalence for using all other drugs except marijuana.
Body Perceptions and Unhealthy Eating Patterns
When asked about their current weight perception, 31.3% of students perceived themselves as overweight. Female students were more likely than male students (29.5%) to report being overweight, and male students (23.3%) were more likely than female students (15.1%) to report being underweight. More female students than male students reported their intention to lose weight, and, not surprisingly, they were also more likely to skip breakfast and use intake reduction, fasting, vomiting, and laxatives for the purpose of weight loss. Specifically, female students reported 2 times greater use of unhealthy methods in losing weight than their male counterparts.
Behaviors Related to Active Lifestyles
Vigorous and Moderate Physical Activity. In this study, 64.1% of the students reported having participated in activities that made them sweat and breathe hard 3–7 days during the last week. However, 16% reported no vigorous activity during the last week. During a typical week, 47.4% stated they were active on 5 or more days a week, and 13% stated that they did not participate in any activity. The t test showed that although male students reported more days of participating in vigorous (M = 4.81, SD = 2.51) and typical (M = 4.98, SD = 2.51) physical activity than female students (M = 4.58, SD = 2.39; M = 4.80, SD = 2.34, respectively), both tests did not reach statistical significance.
Television Viewing. More than half of the students (55.1%) watched 3 or more hours of television each day, although only 4.9% of the students did not watch any television. The results showed that female students reported slightly more hours (M = 2.9, SD = 1.6) of television viewing than male students (M = 2.8, SD = 1.6).
Physical Education and Sports Participation. Gym class is one way that students get physical activity during the school day; however, 58.9% reported spending 0 days in gym class, although 25.1% stated they participated in gym 5 days a week. Male students reported more gym class participation than female students (χ2 = 25.34, p < .001). In terms of involvement in some type of team sport run by their school or community, female and male participation in team sports was similar.
DISCUSSION
This study documented health risk behaviors and participation in physical activity by using the YRBS on 8th-graders from an urban midwestern region. Although the YRBSS was established to determine the prevalence of health risk behaviors among high school students (9th–12th grades), this study makes a unique contribution by examining young adolescents to better understand how these behaviors made the transition to high school. In addition, the study reported the gender differences of health risk behaviors in this population, which has important implications in the timing, planning, and delivery of health education.
The findings demonstrated gender differences in weight perception and the methods used for weight management. Consistent with the findings of a study that performed secondary analysis from the 1990 Youth Risk Behavior Survey (Brener et al., 2004), female 8th-graders are more likely than males to report being overweight and having a greater need to lose weight. Although female students reported they had tried exercising and consuming less food and fewer calories to lose weight, they also had a higher tendency to use unhealthy practices, such as vomiting, taking laxatives, and skipping breakfast. These findings are consistent with those of other studies that found high school girls and adolescent athletes are at a greater risk for unhealthy weight-control behaviors (Pesa & Turner, 2001; Rainey, McKeown, Sargent, & Valois, 1998). Fetro and colleagues (2001) also documented that minority middle-school female students use unhealthy dieting behaviors, such as the use of vomiting, laxatives, and diet pills, to control their weight more often than their male counterparts.
The prevalence of obesity among children and youths has increased rapidly over the past 30 years, and the strategies of treating obesity have focused on preventive efforts mainly because the etiology of obesity is largely due to lifestyle factors, such as diet and physical activity patterns (Goran, Ryenolds, & Lindquist, 1999). In addition, both intervention and epidemiological studies support the important role of television viewing time in predicting obesity (Epstein, Saelens, Myers, & Vito, 1997; Gortmaker et al., 1999). The YRBS study in 2003 (Grunbaum et al., 2004) found that more 8th-graders (55.1%) watched 3 or more hours of television a day than older adolescents (38.2%). In relation to physical activity, this data validated that these female middle-school students are at greater risk of leading sedentary lifestyles than their male counterparts; in particular, 8th-grade girls reported less participation in physical education class, fewer hours of vigorous and regular physical activity, and a greater number of hours of television viewing. These findings are consistent with those of other American studies (Sallis et al., 1996; Harrell et al., 2003) and international studies (Wu, Pender, & Nourredine, 2003).
The results of this study showed that male 8th-graders are more likely than female 8th-graders to be involved in physical fights. When this data was further analyzed, the results showed that male students with a tendency to fight are also more involved in using cigarettes, drugs (i.e., marijuana, cocaine, and glue snuffing), and alcohol. This association was not demonstrated in females. The findings of the current study are consistent with those of other studies that identified the associations among violence and the use of tobacco, alcohol, and marijuana (Berenson et al., 2001; Everett, Malarcher, Sharp, Husten, & Giovino, 2000). Experiencing violence may alter the adolescent’s personality and environment by introducing fear and feelings of learned helplessness and by leading them to engage in risky behaviors (Berenson et al., 2001). The study findings suggest that interventions should start in elementary school and continue throughout adolescence, if the interventions are to prevent the onset of these health risk behaviors.
Limitations
Interpretation of the study findings must take into account the study’s limitations, particularly its reliance on self-report measures that can be flawed by recall error, with the possibility of overreporting and underreporting, and by the effects of social desirability on selective sensitive items. Recent research has found that self-report measures are valid for adolescent alcohol consumption, cigarette smoking, and illegal drug use (Solbergsdottir, Bjornsson, Gudmundsson, Tyrfingsson, & Kristinsson, 2004; Dolcini, Adler, Lee, & Bauman, 2003). In addition, not all potential health behaviors were examined, among them, a healthy diet that included fruit and vegetable consumption, fat, and other nutritional intakes. This study did not obtain actual body weight and height; therefore, it is not clear whether the students had realistic body perceptions based on their body composition.
Future studies should include more comprehensive questions related to the individual diet, for example, collecting data from 24-hour diet recall to better determine the daily nutritional intake of adolescents. To successfully encourage behaviors that prevent or remediate obesity, future studies need to identify causal mechanisms that explain adolescents’ physical activity and dietary patterns so effective strategies can be developed to assist them in making plans to stay fit and healthy.
Finally, additional research is needed to further identify and address the complicated factors within individuals, families, and environments that substance abuse and violence have in common. Given that substance abuse and violence are interrelated, additional intervention studies need to focus on evaluating the effectiveness of a curriculum that coordinates and integrates both substance use and violence for prevention of both behaviors in school settings.
IMPLICATIONS FOR SCHOOL NURSING PRACTICE
The findings of this study urge that prevention is essential and that intervention needs to start early in middle school. In particular, the study suggests areas for further interventions for 8th-graders regarding the health risk behaviors of carrying a weapon; involvement in physical fights; use of tobacco, alcohol, and other drugs; undesirable diet patterns; and inactivity. School nurses can incorporate questions from the YRBS to systematically screen for and detect problems among high-risk populations. Determining what health risk behaviors students are engaging in and what behaviors co-occur with other risk-taking behaviors (e.g., violence and substance use) provides baseline data for planning and implementing a comprehensive program for health promotion and risk reduction.
The findings of this study urge that prevention is essential and that intervention needs to start early in middle school.
This study confirms that the use of unhealthy methods to control or lose weight among female adolescents is a serious concern. This presents a challenge for school nurses to work on with parents as early as in middle school to alter poor eating habits and stop the dangerous weight-control practices. Counseling strategies on weight controls for this age group should be congruent with the developmental level and sociocultural perspectives and practices of this population. Efforts need to focus on encouraging healthy foods and promoting physical activity, as well as addressing concerns about weight and appearance.
Health promotion programs that incorporate systematic assessment of and evidence-based interventions for youths who are in the critical stage of establishing lifestyle behaviors will have both short-term and long-term effects in the lives of today’s adolescents.
SUMMARY
The strengths of this study include examining gender differences in the areas of health risk behaviors. The findings will assist school nurses, health educators, and researchers in identifying the gender-specific strategies and services that focus on these health risk behaviors for male and female middle-school students. Health promotion programs that incorporate systematic assessment of and evidence-based interventions for youths who are in the critical stage of establishing lifestyle behaviors will have both short-term and long-term effects in the lives of today’s adolescents.
Footnotes
Acknowledgments
This study was supported by a faculty research fellowship at Eastern Michigan University. The authors express appreciation to Jennifer Salerno, Grant Salada, Kristy Postlewaite, and Jessica Bible for their assistance in data collection and to Brady West for his helpful suggestions and statistical consultation.