Improving the Health of Canadians Young

Improving the Health of Canadians Young
Patterns of health and disease are largely
a consequence of how we learn, live and work
g
n
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Yo
Improving the Health of Canadians
C a n a d i a n
P o p u l a t i o n
H e a l t h
I n i t i a t i v e
The contents of this publication may be reproduced in whole or in part provided
the intended use is for non-commercial purposes and full acknowledgement
is given to the Canadian Institute for Health Information.
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ISBN 1-55392-680-3 (PDF)
© 2005 Canadian Institute for Health Information
Cette publication est aussi disponible en français sous le titre :
Améliorer la santé des jeunes Canadiens, 2005 ISBN 1-55392-682-X (PDF)
Dedication
This report is dedicated to Chantal Belley (1974–2005)
Senior Analyst, Reports and Analysis
Canadian Population Health Initiative
Canadian Institute for Health Information
Table of Contents
About the Canadian Population Health Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
About the Canadian Institute for Health Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
CPHI Council . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v
Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Population Health Approach to Healthy Adolescent Development . . . . . . . . . . . . . . . . . . 5
Adolescence: A Life Stage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Adolescent Health and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Common Themes From the Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
“Clustering” of Behaviours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Empowerment and Engagement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Resilience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Developmental Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
Adolescent Development and the Social Environment . . . . . . . . . . . . . . . . . . . . . . . . . . 37
Family . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
School . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Peers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Multiple Assets and Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Assets and Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Creating Environments and Opportunities
for Healthy Adolescent Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
What Is the Key Message in This Report? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Building Positive Assets: What Appears to Work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Summary and Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Key Messages and Information Gaps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
For More Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
There’s More on the Web . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Appendix A—Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
It’s Your Turn . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Fact Sheets
Just the Facts #1. A Portrait of Canada’s Adolescents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Just the Facts #2. A Profile of Canadian Adolescents’ Health Status . . . . . . . . . . . . . . . . . 30
Just the Facts #3. A Profile of Canadian Adolescents’ Health Status . . . . . . . . . . . . . . . . . 32
Figures
Figure 1.
Adolescents’ Health Status and Behaviours in Relation to Their
Perceptions of Parental Nurturance Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Figure 2. Adolescents’ Health Status and Behaviours in Relation to Their
Perceptions of Parental Monitoring Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Figure 3. Adolescents’ Health Status and Behaviours in Relation to Their
Perceptions of School Engagement Level . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
Figure 4. Health Status and Behaviours of Adolescent Volunteers
and Non-Volunteers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Figure 5. Proportion of Adolescents Reporting a Very Strong and
Somewhat Strong Sense of Community Belonging . . . . . . . . . . . . . . . . . . . . . 46
Figure 6. Female Adolescents’ Health Status and Behaviours in Relation
to Their Perceptions of Peer Connectedness . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Figure 7. Male Adolescents’ Health Status and Behaviours in Relation
to Their Perceptions of Peer Connectedness . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Figure 8. Proportion of Adolescents (12 to 15 Years) Reporting
High Levels of Various Positive Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Figure 9. Adolescents’ Health Status and Behaviours in Relation to the
Number of Positive Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Figure 10. Distribution of High Level of Assets by Income Adequacy Level . . . . . . . . . 55
Figure 11. Distribution of High Level of Assets by Household Education Level . . . . . . 55
Tables
Summary Table. Adolescents’ Health Status and Behaviours in Relation to
the Individual Positive Assets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Table 1.
Examples of Evaluated Adolescent Healthy Development
Initiatives in Canada . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
ii
About the Canadian Population Health Initiative
The Canadian Population Health Initiative (CPHI), a part of the Canadian
Institute for Health Information (CIHI), was created in 1999. CPHI’s mission
is twofold:
• To foster a better understanding of factors that affect the health of
individuals and communities; and
• To contribute to the development of policies which reduce inequities
and improve the health and well-being of Canadians.
As a key actor in population health, CPHI:
• Provides analysis of Canadian and international population health evidence
to inform policies that improve the health of Canadians;
• Commissions research and builds research partnerships to enhance
understanding of research findings and to promote analysis of strategies
that improve population health;
• Synthesizes evidence about policy experiences, analyzes evidence on the
effectiveness of policy initiatives and develops policy options;
• Works to improve public knowledge and understanding of the determinants
that affect individual and community health and well-being; and
• Works within the Canadian Institute for Health Information to contribute to
improvements in Canada’s health system and the health of Canadians.
About the Canadian Institute for Health Information
The Canadian Institute for Health Information (CIHI) is an independent, pan-Canadian,
not-for-profit organization working to improve the health of Canadians and the health
care system by providing quality health information. CIHI’s mandate, as established by
Canada’s health ministers, is to coordinate the development and maintenance of a common
approach to health information for Canada. To this end, CIHI is responsible for providing
accurate and timely information that is needed to establish sound health policies, manage
the Canadian health system effectively and create public awareness of factors affecting
good health.
iii
CPHI Council
A council of respected researchers and decision-makers from across Canada guides CPHI
in its work.
• Richard Lessard (Chair), Director,
Prevention and Public Health, Agence
de développement de réseaux locaux
de services de santé et de services sociaux
de Montréal, Quebec
• Monique Bégin, Professor Emeritus,
Faculty of Health Sciences and Visiting
Professor, Health Administration,
University of Ottawa, Ontario
• André Corriveau, Chief Medical Officer
of Health and Director, Population
Health, Health and Social Services,
Government of Northwest Territories,
Northwest Territories
• Cordell Neudorf, Vice President, Research,
and Chief Medical Health Officer,
Saskatoon Health Region, Saskatchewan
• Ian Potter, Assistant Deputy Minister,
First Nations and Inuit Health Branch,
Health Canada, Ontario
• Gerry Predy, Medical Officer of Health,
Capital Health, Alberta
• Douglas Willms, Professor,
Faculty of Education and Canada
Research Chair (Tier 1) in Human
Development, University of New
Brunswick, New Brunswick
• Richard Jock, Chief Executive Officer,
Assembly of First Nations, Ontario
• Elinor Wilson, Chief Executive
Officer, Canadian Public Health
Association, Ontario
• Lynn McIntyre, Professor, Faculty of
Health Professions, Dalhousie University,
Nova Scotia
• Michael Wolfson (ex officio), Assistant
Chief Statistician of Analysis and
Development, Statistics Canada, Ontario
• John Millar, Executive Director,
Population Health Surveillance and
Disease Control Planning, Provincial
Health Services Authority, Vancouver,
British Columbia
• Gregory Taylor (ex officio), Director
General, Centre for Chronic Disease
Prevention and Control, Public Health
Agency of Canada, Ontario
v
Acknowledgements
The Canadian Population Health Initiative (CPHI), a part of the Canadian Institute
for Health Information (CIHI), acknowledges the contributions of many individuals
and organizations to the development of Improving the Health of Young Canadians.
We would like to express our appreciation to the members of the Expert Advisory
Group, who provided invaluable advice throughout the development of Improving
the Health of Young Canadians. Members included:
• Ian Potter (Chair), Assistant Deputy
Minister, First Nations and Inuit Health
Branch, Health Canada, Ontario
• Dianne Bascombe, Director,
National Children’s Alliance, Ontario
• Catherine Donovan, Medical Officer
of Health, Health and Community
Services—Eastern Region, Newfoundland
and Labrador
• Leanne Boyd, Manager, Policy Development, Research and Evaluation, Healthy
Child Manitoba, Manitoba
• Rodney Laprise (Youth Representative),
The Students’ Commission, Centre
of Excellence for Youth Engagement,
Saskatchewan
• Satya Brink, Director, Learning Policy
Directorate, Human Resources and
Skills Development Canada, Ontario
• Douglas McCall, Executive Director,
Joint Consortium for School Health,
British Columbia
• Tom McIntosh, Director, Health
Network, Canadian Policy Research
Networks, Saskatchewan
We would also like to express our appreciation to those individuals who peer
reviewed the report and provided invaluable feedback to its development.
• Will Boyce, Director, Social Program
Evaluation Group, Queen’s University,
Ontario
• Roger Tonkin, Professor Emeritus,
University of British Columbia; Member,
Board of Directors, McCreary Centre
Society, British Columbia
• Douglas Willms, Professor, Faculty
of Education and Canada Research
Chair (Tier 1) in Human Development,
University of New Brunswick,
New Brunswick
Please note that the analyses and conclusions in this report do not necessarily reflect those of
the individual members of the Expert Advisory Group, CPHI Council, peer reviewers or their
affiliated organizations.
vii
Improving the Health of Young Canadians
CPHI would like to express its appreciation to the CIHI Board and CPHI Council for their
invaluable support and guidance in the strategic direction of this report.
CPHI staff that comprised the project team for this report included:
• Elizabeth Votta, Project Manager
• Keith Denny, Primary Researcher and Writer
• Uma Palaniappan, Data Coordinator
• Melanie Yugo, Data Analyst
• Mélanie Josée Cadieux, Data Analyst
• Nadine Valk, Policy Coordinator
• Carol Brulé, Researcher and Writer
• Lorna Malone, Researcher and Writer
• Chantal Belley, Senior Data Analyst
• Kim Boudreau, Dissemination Coordinator
• Mellissa Blaauwbroek, Administrative Support
• Susan Charron, Administrative Support
• John Beauchamp, Fact-Checker
• Marissa McGuire, Fact-Checker
• Stephanie Paolin, Fact-Checker
• Anne Markhauser, Fact-Checker
• Les Foster, Consultant
• Elizabeth Gyorfi-Dyke, Editor
• Jennifer Zelmer, Editor
Production of a report such as this involves many people and many aspects of the CIHI
organization. We want to thank all CIHI staff for their contribution to this report, including
individuals from the Canadian Population Health Initiative, Health Human Resources
(Physicians Databases), Publishing, Translation, Web Team, Information Technology and
Infostructure Standards, Communication and Distribution Services.
We would like to gratefully acknowledge the staff at Statistics Canada. Statistics Canada is
recognized as an invaluable source of rigorous and available data and information, which
makes reports like this possible. Statistics Canada information is used with the permission of
Statistics Canada. Users are forbidden to copy the data and re-disseminate them, in an original
or modified form, for commercial purposes, without the expressed permission of Statistics
Canada. Information on the availability of the wide range of data from Statistics Canada can
be obtained from Statistics Canada’s regional offices, its World Wide Web site at www.statcan.ca
and its toll-free access number 1 (800) 263-1136.
We appreciate the ongoing efforts of researchers working in the field of population health
to further our knowledge and understanding of the important issues surrounding health
determinants and related health improvements.
viii
1
1
Introduction
Just as early childhood experiences can have an important
impact on health throughout a person’s life,1 teens’ experiences are also linked to health status many years later.2
Improving the Health of Young Canadians explores links between
adolescents’ social environments (families, schools, peers and
communities) and their health. Our focus is on the health of
Canadian youth aged 12 to 19 years.
Adolescence is the life phase between childhood and adulthood and
is marked by biological, intellectual and psychosocial development.
It is a developmental phase that begins at different times for different
people and progresses at varying rates. It marks a period during
which adolescents move from relying on the judgement and
authority of others to learning to make independent and responsible
choices. Physical changes, including the remodelling of the brain’s
basic structure in areas that affect logic, impulse control, intuition
and language, also occur.3
Adolescence is a time of changing social roles, relationships,
experiences and expectations. It is a time for developing skills
for healthy adulthood and of experimentation in activities that
may be beneficial or harmful to health. Lifelong behaviour patterns,
which can become protective factors against or long-term risk
factors for many chronic health conditions, may be established
or strengthened.2
3
Improving the Health of Young Canadians
Although adolescence is generally a time of good health, injury,
depression, substance use, violence and risky sexual activities can
present threats to the health and well-being of this age group.4
A broad range of factors—“determinants of health”—may interact
to affect health and well-being during this life phase. One such
factor includes “positive relationships, opportunities, competencies,
values and self-perceptions” (p. 1) that help adolescents succeed.5
Research from other countries has shown that the more of these
“assets” adolescents possess, the greater their likelihood of
engaging in health-enhancing practices and the less likely they
are to engage in practices potentially harmful to their health.6–11
To date, little is known about the relationship between these
assets and health among Canadian teens. New analyses of data
from the National Longitudinal Survey of Children and Youth
(NLSCY) and the Canadian Community Health Survey (CCHS)
attempts to fill this gap.* Improving the Health of Young Canadians
explores the association between positive assets in adolescents’
social environments (families, schools, peers and communities)
and their health behaviours and status (for example, health status,
self-worth, tobacco, drug and alcohol use).
Speaking to such themes as the clustering of behaviours,12 youth
engagement,13, 14 resilience15 and developmental assets,5 there are a
number of adolescent development models that focus on healthy
development. This report also highlights this and other research
relevant to understanding adolescent health and development. It
concludes with a discussion of themes arising from current research
and analyses, as well as a review of relevant policies and programs.
4
* Unless otherwise noted, all analyses involving CCHS 2.1 (2003) and NLSCY Cycle 4 (2000–2001) data were conducted
by the Canadian Population Health Initiative (CPHI) and are based on youth who responded to all relevant survey
questions. Graphs in the report were produced by CPHI. Please refer to Appendix A for an outline of the methodology
and statistical analyses used in this report.
Population Health
Approach to
Healthy Adolescent
Development
The health and well-being of Canadians is linked to a number of
factors, including health services; social, economic, cultural and
physical environments; and interactions between individual biology
and behaviour.
A population health approach acknowledges this range of individual
and collective factors that affect our health. It focuses on how the
determinants are interrelated and associated with long-term health,
it explores health disparities and it applies the resulting knowledge
to understanding and informing policies and actions to improve the
health and well-being of populations.16–20
The pages that follow highlight recent research on how 12 such
factors are linked to the health of young Canadians.
What the Research Says . . .
Income and
Socioeconomic
Status
• United States research suggests that youth from higherincome backgrounds are healthier than those from
lower-income backgrounds in terms of self-reported
health, health-related behaviours, growth and obesity.21
• A Canadian study found “preliminary evidence for an
association between income adequacy and several
dimensions of well-being,” (p. 66) such as physical activity
and self-esteem among teens aged 12 to 19 years.22
• Family income is associated with living conditions. For
example, lower-income families may have more challenges
than higher-income families in accessing housing and
sufficient healthy food.23, 24
Education
• Those with higher levels of education tend to have
better health in adulthood.25, 26
• How well young people do in school is linked
to a number of factors, including socioeconomic
status (SES), parents’ education level, sex of the
youth and the school environment.27–29
• Education can influence future employment opportunities
and income.25 It may also equip people with the knowledge
and skills needed for problem solving, a sense of control
over their life circumstances and ability to access and
understand information to keep them healthy.25
Social Support
Networks and
Social Environment
• Positive relationships with family, friends and people in the
community are important to healthy youth development.30
• Adolescents’ social environment is shaped by their
experiences with parents and caregivers, peers and
schools—and by their community.12
• Adolescents are more likely to engage in potentially risky
activities (such as getting drunk or using drugs) when their
friends use alcohol or drugs, are often in trouble or have a
low commitment to school.32
Employment and
Working Conditions
• Parental employment status and working conditions
may affect parents’ economic opportunities, levels
of stress and their ability to manage both work and
family responsibilities.17 These factors can in turn affect
adolescents’ health.17, 33
• Positive work experiences for adolescents can be associated
with increased leadership skills and career motivation;34
students who work are also more likely to be physically
active during their leisure time than students who do
not work.35
• On the other hand, adolescents who work 20 hours per
week or more report higher levels of emotional distress.36
High school seniors who work fewer than 20 hours per
week tend to perform better academically.37 New CPHI
analyses of NLSCY data show that of Canadian youth
aged 14 to 17 who reported working in 2000–2001,
81% worked less than 20 hours per week; 19% worked
20 hours or more per week.
• Students who work are more likely than non-working
students to use tobacco, as well as to consume alcohol
regularly (and occasionally heavily).35
Early Child
Development
• Experiences in early childhood can influence health and
well-being throughout the lifespan.39
• A British study found that social class at birth explains
more of the variation in cognitive skills later in life than
does birth weight.40
• Researchers use the phrase “readiness to learn” to describe
the cognitive and social skills, knowledge, dispositions and
personal experiences children bring to kindergarten.41
Children who do not arrive at school “ready to learn”
are more prone to drop out of high school and engage
in behaviours that break the law.42
Physical
Environment
• More research is needed to assess whether the physical
environment has specific effects during adolescence, a
period during which reproductive, respiratory, skeletal,
immune and central nervous systems mature.43
• A systematic review of evidence on the effectiveness of
strategies to prevent injuries during sports and recreational
activities found that safety modifications to aspects of the
physical environment, such as the use of break-away bases
in baseball, well-maintained playing surfaces for football
and larger ice hockey surfaces, are associated with reduced
risk of injuries.44
Personal Health
Practices and
Coping Skills
• Health practices, such as not smoking and practising safe
sex, can play a key role in one’s health.17
• Many of the practices that contribute to health and well-being
in adulthood are often established during adolescence.2
• Having a positive self-concept appears to protect against
depression, particularly among teenage girls,45 as well
as against engagement in risky sexual behaviours (for
example unprotected sex).11
Biological and
Genetic Factors
• Emerging research suggests that physical changes in the
brain during adolescence play an important role in adolescent development.4
• Different parts of the brain develop at different rates.
The ability to control impulses, to weigh the consequences
of decisions and to prioritize and strategize continues to
develop from the teen years into the early 20s.3
Health Services
• Adolescents’ use of reproductive health services in particular
tends to increase when youth perceive services as specific,
sensitive and responsive to their needs and when confidentiality is assured.46
• CCHS data indicate that in 2003, 8% of Canadian youth
aged 12 to 19 reported unmet health care needs during
the previous year. The following were the four most cited
reasons for their unmet needs: waiting time too long (24%),
did not get around to it (18%), decided not to get the
service (18%) and too busy (13%). Other reasons cited
were services not available at the time (11%), cost (7%)
and lack of available services in one’s area (5%).
Gender
• For 15- to 19-year-olds, mortality rates are higher among
male youth.47
• During adolescence, the most common reason for hospital
admission for males is injury; for females, it is mental
disorders (if hospitalization for pregnancy is excluded).47
• Self-reported rates of depression are higher among females
than males.48
• Adolescent girls are more likely to report wanting to lose
weight than adolescent boys.48
Culture
• In a survey of 88 Canadian health and social service
agencies serving immigrant children and youth, including
public health departments and community health centres,
language was the most commonly identified barrier to
service access.49
• Resettlement, discrimination, isolation and conflicting
cultural values between “old” and “new” worlds can
affect psychosocial adjustment in a new country, especially
during adolescence.17, 49
• Suicide rates are five to six times higher among Aboriginal
youth than among their non-Aboriginal peers.50 However,
suicide rates are lower among Aboriginal youth in communities in British Columbia with band-controlled schools,
community self-government, control over their traditional
land base, control over health services, presence of
cultural facilities and control over police and fire services
than in other Aboriginal communities.51
Mass Media and
Technology
• In 2003, Canadian youth aged 12 to 17 spent an average
of 14.8 hours per week watching television.52
• Research has found that young people who are exposed
to “thin media images” are more likely to have a negative
body image.53
• There is an association between eating while watching TV
and weight gain.54
• Over 80% of Canadian households with children under
18 had access to the Internet in 2003.55
• Girls are more likely than boys to say that they have been
in contact with a stranger on the Internet who made them
feel unsafe.56
2
2
Adolescence:
A Life Stage
Chapter 2: Adolescence: A Life Stage
Adolescence begins with puberty and ends with adulthood.57
For many adolescents, the transition to adult status
involves a balance of school, extracurricular activities
and engagement in the labour force. Researchers
define successful transition to adult status by various
outcomes, including:
• Secure attachments (to parents);
• Readiness for personal relationships and family life;
• Movement from school to meaningful employment;
• Readiness for employment;
• Social connectedness (to peers and school);
• Engagement with and participation in the community;
• Sense of identity (psychological well-being and values);
• Social competence and citizenship;
• Realistic hope for the future;
• Empowerment to make healthy and responsible choices; and
• Good health.57–59
21
Improving the Health of Young Canadians
Adolescence can also be a time of experimentation in activities that
are potentially harmful, such as taking drugs, drinking alcohol,
smoking and engaging in risky sexual behaviours. For most, these
experiences may be exciting and challenging, but not ultimately
damaging. Others, however, go beyond experimentation, which
may lead to behaviours that may be harmful to their health in
adolescence and later life. Research suggests that supportive
relationships in different settings, such as with families and peers
and in schools and communities, may lessen the potential harm
of risky activities and encourage health-enhancing behaviours
among adolescents.6–8, 11
22
Chapter 2: Adolescence: A Life Stage
Just the Facts #1: A Portrait of Canada’s Adolescents
How many
adolescents are
there in Canada?
• Adolescents aged 12 to 19 comprise 11% of Canada’s population (3,256,265 adolescents
in 2001);** 51% are males.*
Who is raising
Canada’s youth?
• 80% of youth aged 10 to 19 live in two-parent homes (that is, married or common-law parents).*
How many
children and
youth are in
the care of
the state?
• There are over 80,000 children and youth in child welfare care in Canada.60
How many
children and
youth live in
low-income
families or
poverty?
• 18% of children aged 17 and under live in low-income families as defined by the
Statistics Canada low-income cut-off (LICO).***
• 16% of youth aged 10 to 19 live with single mothers and 4% with single fathers.*
• There are 25,000 youth in youth justice facilities and detention centres.60
• Relative to the Canadian average (18%), Newfoundland and Labrador has the highest
percentage of children 17 years and under living in low-income families (23%).***
• Poverty rates are higher among families of Aboriginal and immigrant children and
youth, as well as in families of children and youth with disabilities.61
Where do Canada’s youth
aged 12 to 19 live?**
Who are Canada’s youth
aged 12 to 19?**
%
of Youth
of Aboriginal
Identity
%
of Immigrant
Youth or
Non-Permanent
Residents
N.L.
5
1
P.E.I.
1
1
48
N.B.
3
1
11
53
N.S.
3
3
Que.
10
78
Que.
2
7
Ont.
11
83
Ont.
2
16
Man.
12
67
Man.
19
6
Sask.
13
60
Sask.
19
2
Alta.
12
77
Alta.
7
7
B.C.
11
83
B.C.
6
16
Y.T.
13
63
Y.T.
25
3
N.W.T.
13
55
N.W.T.
62
2
Nun.
16
27
Nun.
95
>1
Canada
11
77
Canada
5
11
%
of Youth
in Total
Population
%
of Youth
in Urban Areas
N.L.
12
55
P.E.I.
12
41
N.B.
11
N.S.
1
2
Source: Unless otherwise noted, *Census 2001, **Census Custom Tabulation; ***Census CANSIM (109-0200);
Statistics Canada.
23
3
3
Adolescent Health
and Development
Adolescent health and development is often measured by
“risky” activities and “problem” behaviours.62 For example,
the health status of Canada’s youth is often reported in terms of
their injuries, substance and tobacco use, risky sexual behaviours,
obesity, mental health problems and poor physical health. An
emerging body of research is pointing to the limitations of
approaches that are problem-focused in nature.11, 57, 62–65
A more complete picture may also include indicators that emphasize
more positive aspects of adolescent health and development, such
as higher perceived self-worth and self-reported health, positive
body image, general life satisfaction, helpful and pro-social
behaviours, doing well in school, regular physical activity and
good nutrition habits.† (See Just the Facts #2 and #3.)
† Issues relating to healthy weight, nutrition and physical activity among youth will be covered in more detail in
CPHI’s second report in the Improving the Health of Canadians 2005–2006 Report Series on healthy weights, to be
released in the winter of 2006.
27
Improving the Health of Young Canadians
Focusing on risk behaviours and indicators of poor health
does not provide a complete picture of adolescent health
and development.
Approaches that emphasize this broader perspective on adolescent
health share a number of common themes, some of which are drawn
upon in this report. One theme, for example, looks at how both
positive and negative behaviours appear to occur in “clusters”
and what typically leads to their occurrence (personal characteristics, social situations, socio-cultural environment).12 Another
key theme is a focus on the “engagement” of young people in
activities that empower them to make decisions for themselves.13, 14
A third theme is the concept of “resilience,” which refers to the
capacity of individuals to cope successfully in the face of adversity
or risk.15 A fourth theme suggests that the presence of “assets,” such
as “positive relationships, opportunities, competencies, values and
self-perceptions,” (p. 1) contribute to healthy development.5
“
28
What’s so hard about being a youth? Making a difference.
School, society, they all tell us we’re tomorrow’s leaders.
But they don’t give us the tools. Our minds and our actions
are what will change the world.
—youth66
”
Chapter 3: Adolescent Health and Development
The following analyses focus on the association between the social
environment and health status. The social environment is measured
in terms of contexts that have been associated with healthy adolescent
development: families, schools, peers and communities.59 Adolescents’
health status is measured in terms of the following indicators:
reported health status, self-worth, anxiety levels, tobacco use,
alcohol use and drug use. Additional information on these health
indicators, as well as on adolescents’ success in school, sexual
practices, injuries, mental health status and level of physical
activity, is presented in the fact sheets.
Canada’s Teens: Today, Yesterday and Tomorrow67
draws on data compiled in 2001 from 3,500 youth
aged 15 to 19 years from across Canada to compare
today’s teens with teens of previous generations.
What do today’s teens value and enjoy?
• Females’ most valued goals are friendship, being
loved and freedom. Males’ most valued goals
are freedom, friendship and having choices.
• Both males and females value the traits of
honesty and humour.
• Today’s teens are more accepting of racial,
cultural, religious and sexual diversity than
were their parents as teenagers.
• Email is a frequent means of communication
between friends.
What worries teens?
• Teens feel the strain over lack of time,
money and not being understood by
their parents.
• 20% of teens report not feeling safe at school.
What Do
Canada’s
Teens Say
Is Important
to Them?
How do teens feel about their family, friends
and other people in their lives?
• Teens recognize the role of their upbringing in
who they are and what they will become, but
also emphasize the role they themselves play.
• Teens’ primary resources during times of
need are friends and family.
29
Improving the Health of Young Canadians
Just the Facts #2: A Profile of Canadian Adolescents’ Health Status
How do
teens rate
their health?
• In 2003, approximately 67% of teens rated their health as being excellent or very good;
another 28% rated it as good.*
How do teens
perceive their
self-worth?
• New CPHI analyses of NLSCY data indicate that 71% of Canadian youth aged
12 to 15 years report high levels of self-worth; more males (76%) than females (66%)
report a high sense of self-worth.**
What is the
prevalence of
self-reported
anxiety and
headaches?
• 92% of youth aged 12 to 15 years self-reported low levels of anxiety in 2000–2001.**
To what extent
are teens
engaging in
pro-social
behaviours?
• New CPHI analyses of NLSCY data indicate that among Canadian youth aged
12 to 15 years, 68% of youth report high levels of pro-social behaviour defined
as sympathy towards others, willingness to help those in need, willingness to
include others in activities and attempts to resolve conflict.**
How physically
active are teens?
• In 2003, 76% of 12- to 14-year-old males and 71% of 12- to 14-year old females were
moderately active or active in leisure-time physical activity; among youth aged
15 to 19 years, rates decreased slightly for males to 74% and decreased significantly
for females to 61%.* †
How many
fruits and
vegetables
do teens
consume daily?
• In 2003, among 12- to 14-year-olds, 41% of males and 46% of females consumed fruit
and vegetables five or more times per day; proportions were slightly lower for 15- to
19-year olds at 38% for males and 45% for females.*
How do
teens perform
academically?
• In international comparative studies of 41 countries, Canadian youth ranked second
in reading, third in mathematics and fifth in science in 2003.29
• Rates of very good or excellent self-rated health were significantly higher than the
Canadian average in four health regions and lower in nine health regions.*
• Higher levels of self-worth among youth aged 12 to 15 are associated with less use of
alcohol, tobacco and marijuana and fewer experiences with bullying.**
• In 2000–2001, 33% of youth aged 12 to 17 years reported getting headaches once
a week or more; more females (40%) than males (26%) reported getting headaches
once a week or more.**
• Females (81%) report higher levels of pro-social behaviours than males (56%).**
• 2003 PISA data further indicate that the performance of students in Alberta was
significantly higher than the Canadian average in combined scales for reading,
math and science.29
• Canada has seen a steady increase in both college and university enrolment in
the past two decades.68 A survey that interviewed youth in 2001 indicated that
71% had participated in postsecondary education by age 20 to 22.68
Source: *Canadian Community Health Survey (CCHS) 2.1 (2003) [CANSIM Tables 105-0222,
105-0233,105-0249], Statistics Canada. **CPHI analysis of the National Longitudinal Survey of
Children and Youth (NLSCY) (Cycle 4, 2000–2001), Statistics Canada.
30
† These results are based on the Physical Activity Index using adult categories and thus may not reflect other studies
focusing on children and youth.
Chapter 3: Adolescent Health and Development
Common Themes
From the Research
“Clustering”
of Behaviours
Individuals who engage in one “risky”
behaviour, such as smoking, are more
likely to engage in other risky behaviours,
such as insufficient physical activity and
excess alcohol use.69 A review of theories
of adolescent health behaviour concludes
that behaviours cluster this way because
all behaviours tend to be associated with
three common underlying factors: personal
characteristics, social situations and the
broader socio-cultural environment.12
Resilience
The concept of resilience has been used
to explain why some individuals and groups
overcome obstacles better than others.15
Resilience is a sort of insulating capacity
that enables people to cope successfully
(to “bounce back”) in the face of adversity
or risk.15 This capacity develops and changes
over time and it helps individuals to maintain
and enhance their health.15 Resilience is not
a characteristic that individuals possess
in isolation. It results from a complex and
ever-changing interaction between individuals
and features of their environment, such as
families, neighbourhoods or communities
and the broader environment.15
Individuals who engage in one risky behaviour are more
likely to engage in others.
Empowerment
and Engagement
Canada’s Centre of Excellence for Youth
Engagement14 defines engagement as the
“meaningful participation and sustained
involvement of a young person in an activity
that has a focus outside himself or herself.”133
(p. 49) This can mean participation in almost
any kind of activity such as school, music,
politics, the arts or community work, so
long as the activity is felt to be meaningful,
significant and structured (that is, it is performed with a specific purpose in mind).14, 133
A review of the literature found that these
kinds of activities can be empowering for
youth when the adults who are involved
in them create social spaces that youth find
welcoming and safe and in which adults
enable youth to play a role in planning
and decision-making.70
31
Improving the Health of Young Canadians
Just the Facts #3: A Profile of Canadian Adolescents’ Health Status
What is the
prevalence of
alcohol and
drug use?
• In 2002, the rate of weekly alcohol use increased from 3 to 23% between Grades 6 and
10 for girls and from 6 to 34% for boys.48
What is the
prevalence of
tobacco use?
• Smoking among teens declined from 22% in 2002 to 18% in 2003.71
How many
youth are
homeless, and
what are their
health risks?
• The exact number of homeless youth is unknown; the majority are male, but the
number of homeless female youth is growing.72, 73
What is the
prevalence of
unintentional
and intentional
injuries among
adolescents?
• Over one in five adolescents aged 12 to 19 years had an injury that limited their activities
in 2000–2001; 75 sports and falls are major causes of non-fatal injuries among all youth.48, 75
To what extent
are adolescents
engaging in risky
sexual activity?
• Between 1989 and 2002, the proportion of youth in Grades 9 to 11 reporting having sex
decreased; however, those having sex said that they did so more often.79
• In 2002, 16% of Grade 8 students reported having used alcohol to get drunk at least
twice; by Grades 9 and 10, the proportion had increased to 31% and 44%, respectively.48
• Among males and females aged 12 to 17, 31% said that they had tried marijuana in
2000–2001; 13% had tried other illicit drugs (for example, cocaine or crack).**
• In 2003, more girls (20%) reported smoking than boys (17%).71
• In 2003, 23% of teens aged 12 to 19 said that they were exposed to second-hand
smoke at home.*
• Aboriginal youth tend to be over-represented in the homeless population of larger
urban centres.73
• Homeless youth are at higher risk for injuries, poor physical health, sexually
transmitted infections, violence, substance abuse disorders, conflicts with the
law, suicide and other mental health problems.72–74
• In 1999, unintentional injuries were the leading cause of death among children (1 to 14 years)
and youth (15 to 24 years).77 Death rates from injuries are higher among male youth.47
• In 1998–1999, males aged 15 to 19 years were more likely to complete their suicide attempts;
hospitalization rates for suicide attempts were over two times higher among females aged
15 to 19 years.78
• 12% of boys and 13% of girls reported having had sex by ages 14 or 15;80 in 2003, 22%
of youth aged 15 to 17 and 33% of youth aged 18 to 19 reported having had sex without
a condom.81
• In 2002, less than 1% reported having been diagnosed with a sexually transmitted disease.79
• Rates of chlamydia cases among males and female aged 15 to 19 increased from 623 to
802 per 100,000 youth between 1991 and 2002.82
• Pregnancy rates among girls aged 15 to 19 years declined from 43 to 36 per 1,000 girls
between 1997 and 2001.83
What are teens’
experiences
with mental
health problems?
• In 2002, 21% and 25% of boys in Grade 6 and 10, respectively, reported that they felt
low at least weekly in the previous six months; 23% and 36% of girls in Grade 6 and
10, respectively, reported feeling low at least weekly in the previous six months.48
• Hospitalization rates for eating disorders in girls under age 15 increased by 34%
from 1987 to 1999.84
Source: *Canadian Community Health Survey (CCHS) 2.1 (2003) [CANSIM: Table 105-0256],
Statistics Canada. **CPHI analysis of the National Longitudial Survey of Children and Youth
(NLSCY) (Cycle 4, 2000–2001), Statistics Canada.
32
Chapter 3: Adolescent Health and Development
Developmental Assets
The U.S.-based Search Institute defines
developmental assets as the “positive
relationships, opportunities, competencies,
values and self-perceptions” (p. 1) that
adolescents need to succeed.5 Assets fall
into two broad categories:
• External (for example, support,
empowerment, boundaries, expectations,
constructive use of time); and
• Internal (for example, commitment to
learning, positive values, social
competencies, positive identity).5, 85
Research indicates that assets and feelings of
connectedness play important roles in healthy
development, including protecting youth
against risky behaviours, promoting positive
and healthy choices and building resiliency
in youth to help them cope with challenges
and difficulties.5, 56 Further, the more assets
adolescents possess, the more likely they are
to engage in health-enhancing activities and
the less likely they are to engage in activities
potentially harmful to their health.7, 8, 10
“
The hardest thing about being a youth is having to make
so many decisions about everything, especially about school
and your friends.
—youth66
”
33
4
4
Adolescent
Development
and the Social
Environment
Researchers suggest that when adolescents engage in risky
behaviours, negative effects of the behaviours may be limited
by supportive relationships with family, community, peers and
school,12 as well as by positive personal experiences, values,
competencies and self-perceptions.5 These factors, or pieces
of the puzzle, which are referred to as “developmental assets,”
are interrelated.11, 59, 63–65, 86–91 For example, positive parenting may
act as a buffer that moderates the effects of other determinants
such that “the effects of living in a poor neighbourhood may have
far different implications for an adolescent with close family ties
than for an adolescent without such support.”92 (p. 202)
When adolescents engage in risky behaviours, a number of
protective factors may limit their impact.
37
Improving the Health of Young Canadians
Consistent with this, an extensive literature review commissioned
by the New Zealand Ministry of Youth Affairs59 also identifies family,
schools, communities and peers as key influences on healthy
adolescent development. This review further indicates that the
best developmental outcomes for adolescents are facilitated by a
number of factors:
• families characterized by a nurturing parenting style;
• environments that support positive parenting;
• schools where students feel connected;
• schools that are well resourced, provide education that is
accepting, set limits and have high expectations for students;
• communities in which young people feel a sense of belonging
and where they have opportunities to participate; and
• positive relationships with peers.59
The review did not look specifically at health outcomes.
This report attempts to fill this gap. We look first, one by one,
at the link between each of these factors and a range of health
behaviours and outcomes. Then we explore the inter-relationships
between these factors and health behaviours and outcomes.§ The
results of these analyses are presented in a summary table at the
end of this section.
38
§ Scoring levels (that is, high and medium-low) for the variables were based on Statistics Canada guidelines for use
of the NLSCY and literature that used similar variables and scoring strategies and are identified in greater detail
in Appendix A.
Chapter 4: Adolescent Development and the Social Environment
Family
Family characteristics such as household income,
family composition, parental employment
and parental education can make a difference
in how adolescents develop by influencing
parenting style, stress, conflict and the time
parents can spend with their children.33, 93
Higher levels of family connectedness and
more positive relationships with parents are
associated with a lower likelihood of engaging
in unprotected sex, lower levels of teen
pregnancy, less violence and substance use,11, 36
less likelihood of experiencing emotional
distress and higher self-rated health status.56
Among Aboriginal youth in the U.S., those
reporting a sense of connectedness with their
family are less likely to report a past suicide
attempt.65 Suicidal youth tend to report poorer
relationships with their parents, on average,
than non-suicidal youth.36, 86
Environments
that foster
positive
parenting
The National Longitudinal Survey of
Children and Youth (NLSCY) measures
a number of dynamics within families
and between parents and youth. Among
those dynamics are adolescents’ reports
of the level of parental nurturance and
degree of parental monitoring.
Higher levels of parental nurturance are associated with
higher levels of self-rated health among youth.
Studies have found that when parents have
a parenting style that is nurturing, sets limits
on behaviour, models constructive conflict
resolution and encourages independence with
a democratic approach, this tends to favour
positive outcomes for their children including
pro-social behaviours, high school completion
and pursuing higher levels of education.59, 94
Parental nurturance refers to the extent to which
parents praise and show pride in their child,
ensure their child feels appreciated, listen
to their child’s ideas and problem-solve with
the child when disagreements occur.
Just as attachment between parents and infants
supports early childhood development, attachment or connections between parents and
adolescents can be important in supporting
adolescents’ transition to increased autonomy
and healthy adulthood.95, 96
They are also less likely to have mental
health problems, weight-related concerns
and eating disorders and poorer transitions
between schools.95, 96
Secure parental attachment appears to facilitate
adolescents’ emotional, cognitive and social
development. Recent reviews of the literature
indicate that adolescents with secure parental
attachments are less likely to engage in drug use,
excessive drinking and risky sexual behaviour.95, 96
Parental monitoring refers to the extent to
which parents take an interest in where their
child is going, with whom and what they are
doing, set curfews and limit the frequency
with which their children go out.
ParentAdolescent
Attachment
To support secure attachments, research
suggests that parents be attentive, active
listeners, monitor behaviour, set limits, accept
individuality, negotiate rules and responsibilities
and maintain “connectedness,” even when
disagreeing on important issues.95, 96
39
Improving the Health of Young Canadians
Fifty-three percent (53%) of Canadian
youth aged 12 to 15 years report high
levels of parental nurturance.** The level
of parental nurturance is associated with
adolescents’ health behaviours and outcomes.
New CPHI analyses indicate that among youth
aged 12 to 15 years, higher levels of parental
nurturance are associated with higher levels
of self-rated health and self-worth; lower
anxiety levels; fewer contacts with peers who
engage in criminal behaviours; and less use
of alcohol, tobacco and marijuana (see Figure 1).
Youth with higher levels of parental monitoring are less likely
to report using alcohol, tobacco and marijuana, but they rate
their health about the same as other youth.
Fifty-three percent (53%) of Canadian youth
aged 12 to 15 years also report high levels
of parental monitoring.†† The level of
parental monitoring is also associated with
adolescents’ health behaviours and outcomes.
New CPHI analyses indicate that higher levels
of parental monitoring are also associated with
less use of tobacco, alcohol and marijuana.
The level of parental monitoring is not related
to levels of self-worth, self-rated health or
anxiety, or to levels of contact with peers who
engage in criminal behaviours (see Figure 2).
** Parental nurturance values are based on a 72% response rate.
†† Parental monitoring values are based on a 74% response rate.
40
Chapter 4: Adolescent Development and the Social Environment
100
Figure 1
80
% of Youth (12–15 years)
60
40
Low Level of
Anxiety
Contact With
Peers Who
Commit Crimes
Alcohol Use
Tobacco Use
Marijuana Use
0
Excellent or
Very Good Health
20
High Self-Worth
Adolescents’
Health Status
and Behaviours
in Relation
to Their
Perceptions
of Parental
Nurturance
Level
85 *
83 *
94 *
15 *
26 *
11 *
12 *
59
69
86
27
46
24
26
High Parental Nurturance
Medium-Low Parental Nurturance
100
Figure 2
80
% of Youth (12–15 years)
60
40
Low Level of
Anxiety
Contact With
Peers Who
Commit Crimes
Alcohol Use
Tobacco Use
Marijuana Use
0
Excellent or
Very Good Health
20
High Self-Worth
Adolescents’
Health Status
and Behaviours
in Relation
to Their
Perceptions
of Parental
Monitoring Level
74
80
89
19
30 *
15 *
15 *
72
74
91
24
40
20
23
High Parental Monitoring
Medium-Low Parental Monitoring
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* Statistically significant difference between high and medium-low levels at p <.05.
41
Improving the Health of Young Canadians
School
Most teens spend significant amounts of their
time in school. Seventy-seven percent (77%)
of youth aged 15 to 19 years are currently
attending school; of those, 95% attend on
a full-time basis.97
The school context is a key element of
the adolescent development process. It is
a setting in which youth can experience
opportunities and challenges to the
development of their academic, social,
athletic and interpersonal skills.98
Research indicates that students who are
engaged in the learning process tend to
learn more and are more willing to pursue
knowledge.29 More specifically, how well
students perform in and enjoy mathematics
can affect the courses they select, as well
as both their education and career goals.29
Education
that is accepting,
sets limits and has
high expectations
Feeling safe at school is linked to better physical
and emotional health and less likelihood
of risk-taking.56 Further, students who take
fewer risks tend to have better health, get better
grades and have greater postsecondary
education aspirations.56 Later in life, adults
with higher levels of education are more
likely to report being in good health.25, 26
Feeling safe at school is linked to better physical and emotional
health and less likelihood of risk-taking.
Youths’ participation in postsecondary
education tends to be related to parental
educational attainment and parental
values towards postsecondary education,
particularly university participation.68, 99
Youth who participate in postsecondary
education are also more likely to report
having had a high level of academic
achievement and social engagement in
high school.68
Evaluations of Canadian employment programs
for youth indicate that educational attainment
is associated with adolescents’ success in the
labour market. Evaluations further demonstrate
the importance of linking vocational training
to both school curricula and academic studies
for all youth, particularly for economically
disadvantaged youth.100, 101
42
A U.S. study based on a survey of 75, 515
students found that higher levels of student
connectedness were associated with climates
that encouraged students to make decisions,
as well as smaller school size, disciplinary
policies that were not perceived as “severe”
and participation in extracurricular activities. 102
A literature review for the New Zealand
Ministry of Youth Affairs also found that
students feel more connected to smaller
schools in which they feel that teachers care
about them and where discipline is perceived
to be “moderate.”59
School engagement or connectedness
refers to the degree of importance a youth
places on doing well academically, learning
new things, making friends, participating in
extracurricular activities, getting involved
with student council or similar groups and
expressing their opinion in class.
Chapter 4: Adolescent Development and the Social Environment
Seventy-four percent (74%) of Canadian
youth aged 12 to 15 years report a high
level of school engagement.‡‡ Levels of school
engagement are higher among female youth
(77%) than male youth (71%). Relative to the
Canadian average, youths’ reported levels
of school engagement were highest in
Newfoundland and Labrador (86%) and
lowest in Quebec (65%) in 2000–2001.
well-being among youth and may also be
a protective factor with regard to suicidal
behaviour103 and engagement in both violent
and risky sexual behaviours.36, 105 Consistent
with this, new CPHI analyses indicate that
among youth aged 12 to 15 years, students who
report feeling highly engaged with their school
are less likely to report using marijuana,
alcohol and tobacco and more likely to report
high self-worth, excellent or very good selfrated health status, lower levels of anxiety
and fewer associations with peers who
engage in criminal behaviours (see Figure 3).
Previous research has shown that feeling
connected to or engaged with one’s school
is associated with higher levels of emotional
Figure 3
100
80
% of Youth (12–15 Years)
60
40
Contact With
Peers Who
Commit Crimes
Alcohol Use
Tobacco Use
Marijuana Use
0
Low Level
of Anxiety
20
Excellent or
Very Good Health
Adolescents’
Health Status
and Behaviours
in Relation
to Their
Perceptions
of School
Engagement
Level
”
High Self-Worth
“
The hardest thing about being a youth is probably school
and also your parents’ pressure to do well at school.
—youth66
77 *
80 *
91 *
17 *
29 *
12 *
14 *
59
61
83
32
50
30
31
High School Engagement
Medium-Low School Engagement
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* Statistically significant difference between high and medium-low levels of school engagement at p <.05.
‡‡ School engagement values are based on a 76% response rate.
43
Improving the Health of Young Canadians
Community
Community engagement and feelings of
community belonging are facilitated through
opportunities for youth to participate outside
of school in clubs, sports, music, the arts,
fundraising, volunteer activities and other
community organizations and activities.14
Participation in extra-curricular activities
and community youth organizations is
associated with better self-reported health,
higher perceived self-esteem and feelings
of control.10, 56 Current research indicates
that children’s participation in organized
activities is associated with family income
level. Children in low-income families, in
single-parent families and of caregivers
with less than a high school education
are less likely to have ever participated
in organized activities.106
Involving young
people in community
activities outside
school and work
analyses show that compared to nonvolunteers, youth who volunteer are less
likely to report using tobacco and marijuana
and more likely to report high self-worth
and excellent or very good self-rated health
(see Figure 4). Non-volunteers, on the other
hand, report lower levels of anxiety. This
73% of Canadian youth aged 12 to 17 engage in
volunteer activities.
Among Canadian youth aged 12 to 17 years,
73% engage in volunteer activities.§§ Rates of
volunteerism are higher among females (77%)
than males (70%). Relative to the Canadian
average (73%), volunteerism was highest among
youth in Alberta (82%) and lowest among youth
in Quebec (61%) in 2000–2001.
Previous research shows an association
between higher levels of community
involvement and never having had sexual
intercourse.8 Further to this, new CPHI
§§ Volunteer values are based on a 78% response rate.
44
finding is in line with current research that
shows that while adolescents’ participation in
physically active leisure, sports and activities
increased from the early 1990s to the late
1990s, so did their reported levels of feeling
rushed and time-stressed.93 In the CPHI
analyses, adolescents’ use of alcohol and
their contact with peers who engage in
criminal behaviours were not associated
with whether or not they volunteer.
Chapter 4: Adolescent Development and the Social Environment
100
Figure 4
80
% of Youth (12–17 Years)
60
40
Low Level
of Anxietyß
Contact With
Peers Who
Commit Crimes
Alcohol Use
Tobacco Use
Marijuana Use
0
Excellent or
Very Good Health
20
High Self-Worthß
Health Status
and Behaviours
of Adolescent
Volunteers and
Non-Volunteers
68 *
77 *
56 *
22
46
22 *
27 *
63
72
63
22
48
29
34
Volunteers
Non-Volunteers
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* Statistically significant difference between volunteers and non-volunteers at p <.05.
ß Includes only youth aged 12 to 15 years.
45
Improving the Health of Young Canadians
Evidence also indicates that feeling a sense
of belonging to one’s community is associated
with higher levels of health status.31 A recent
study among First Nations youth in British
Columbia found that Aboriginal control of key
aspects of community and cultural life are
strongly associated with lower youth suicide
rates.51 The term “cultural continuity” is used
to describe efforts to preserve and promote
cultural practices and to control and manage
available resources.51 Markers used to create
the cultural continuity index for the B.C.
study include community self-government,
control over a traditional land base, bandcontrolled schools, community control over
health services, presence of cultural facilities
and control over police and fire services. In
communities without any of these markers,
the rate of youth suicide was 138 per 100,000
population, compared to virtually no suicides
in communities with all six markers.51
Among male and female youth aged 12 to
19 years across the 10 provinces, 17% report
a very strong sense of belonging to their
community and 55% a somewhat strong sense
of belonging*** (see Figure 5). Across the three
territories, 26% report a very strong sense of
belonging and 52% report a somewhat strong
sense of belonging.†††
A sense of belonging in one’s community is associated with higher
levels of health status.
100
Figure 5
80
% of Youth (12–19 Years)
Proportion of
Adolescents
Reporting a
Very Strong
and Somewhat
Strong Sense
of Community
Belonging
60
40
20
0
N.L.
P.E.I.
N.S.
N.B.
Que.
Ont.
Man.
Sask.
Alta.
B.C.
Canada
58
52
59
55
52 *
56
53
57
56
57
55
25 *
21
19
24 *
14 *
16
21 *
20
17
18
17
Somewhat Strong
Very Strong
Source: CCHS 2.1 (2003), Statistics Canada, Custom Tabulation.
* Statistically significant difference from Canadian estimate at p <.05.
*** Canadian estimate is based on population excluding the territories.
††† Data specific to the Yukon Territory and Nunavut are of marginal quality and should be interpreted with caution.
46
Chapter 4: Adolescent Development and the Social Environment
Peers
Friendships become increasingly important
as young people get older, and it has been
suggested that adolescent friendships provide
a space in which to develop social and emotional skills.59 Some studies reviewed for
a report for the New Zealand Ministry of
Youth Affairs found that friendships can be
associated with improved grades, reduced
impact of parental divorce, reduced emotional
problems and enhanced cognitive skills.59
There is increasing evidence to suggest that
when youth interact with peers who model
positive behaviours, these relationships
contribute to good outcomes.59 For example,
having friends with good grades and who
engage in few risky behaviours is associated
with less likelihood of teen pregnancy.11
Further, youth with positive peer models
are more likely to abstain from using tobacco,
drugs or alcohol.6, 107
Encouraging
positive peer
relationships
Among Canadian youth aged 12 to 17 years,
80% report a high level of connectedness with
their peers.‡‡‡ Survey data reported here do not
indicate whether peers modelled behaviours
that were risky or health-promoting. New
CPHI analyses indicate that youth who report
high levels of peer connectedness are more
likely to report high self-worth, excellent
Youth who report high levels of peer connectedness also tend
to report high levels of self-worth and excellent or very good
health status.
As an index of peer connectedness, the NLSCY
“Friends” score asks youth to indicate whether
or not they have many friends, the ease with
which they get along with others their own
age and whether other youth their own age
like them and want to be their friend.
or very good health status and low levels
of anxiety. Adolescents’ reported use of
tobacco, alcohol and marijuana are not
associated with their reported level of
peer connectedness.
‡‡‡ Peer connectedness values are based on a 76% response rate.
47
Improving the Health of Young Canadians
Additional CPHI analyses noted differences
between male and female youth and peer
connectedness levels. Fewer male youth (76%)
than female youth (84%) report high levels
of peer connectedness. Among female youth,
higher levels of peer connectedness are
associated with higher levels of self-worth
and health status and lower levels of anxiety
(see Figure 6). Tobacco, alcohol and marijuana
use are not associated with levels of peer
connectedness among female youth. Similar
findings were obtained for male youth
with the exception that anxiety levels
were not associated with the level of peer
connectedness (see Figure 7).
“
We have more chances of being pressured into doing things
just because the people that we hang out with do it too.
—youth66
Although these findings suggest that
having a high level of connectedness
with peers is generally linked with
health-promoting outcomes, one exception
should be noted. Males with a high level
of peer connectedness report significantly
more injuries than males with a mediumlow level of peer connectedness, indicating
an association between level of peer connectedness and risk of injury among males.
48
”
Chapter 4: Adolescent Development and the Social Environment
Figure 6
80
60
40
Low Level
of Anxietyß
Alcohol Use
Tobacco Use
Marijuana Use
Injuries
0
Excellent or
Very Good Health
20
High Self-Worthß
% of Female Youth (12–17 Years)
Female
Adolescents’
Health Status
and Behaviours
in Relation
to Their
Perceptions
of Peer
Connectedness
100
70 *
75 *
61 *
51
28
30
15
43
53
40
53
32
34
15
High Peer Connectedness
Medium-Low Peer Connectedness
Figure 7
80
60
40
Low Level
of Anxietyß
Alcohol Use
Tobacco Use
Marijuana Use
Injuries
0
Excellent or
Very Good Health
20
High Self-Worthß
% of Male Youth (12–17 Years)
Male
Adolescents’
Health Status
and Behaviours
in Relation
to Their
Perceptions
of Peer
Connectedness
100
81 *
79 *
62
48
21
31
24 *
51
66
57
41
19
24
16
High Peer Connectedness
Medium-Low Peer Connectedness
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* Statistically significant difference between high and medium-low levels of peer connectedness at p <.05.
ß Includes only youth aged 12 to 15 years.
49
Improving the Health of Young Canadians
Summary Table
Adolescents’
Health Status
and Behaviours
in Relation to
the Individual
Positive Assets
Positive Assets
Parental
Parental
School
Nurturance
Monitoring
Engagement
Volunteerism
Connectedness
Peer
(%)
(%)
(%)
(%)
(%)
Health-Related
Behaviours and
H
M-L
H
M-L
H
M-L
V
NV
H
M-L
High Self-Worth
85*
59
74
72
77*
59
68**
63
75*
48
Excellent or
83*
69
80
74
80*
61
77**ß
72ß
77*ß
61ß
94*
86
89
91
91*
83
56**
63
62*
50
15*
27
19
24
17*
32
22ß
22ß
---
---
Alcohol Use
26*
46
30*
40
29*
50
46ß
48ß
49ß
46ß
Tobacco Use
11*
24
15*
20
12*
30
22**ß
29ß
25ß
24ß
Marijuana Use
12*
26
15*
23
14*
31
27**ß
34ß
30ß
28ß
Outcomes
Very Good
Health Status
Low Level
of Anxiety
Contact With
Peers Who
Commit Crimes
H: High
M-L: Medium-Low
V: Volunteers
NV: Non-Volunteers
50
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* Statistically significant difference between high and medium-low levels of given asset at p <.05.
** Statistically significant difference between volunteers and non-volunteers at p <.05.
Youth aged 12 to 15 years, unless otherwise noted.
ß Includes youth aged 12 to 17 years.
Chapter 4: Adolescent Development and the Social Environment
Multiple Assets and Health
Youth live in a complex world with many
factors influencing them at the same time.
The previous sections demonstrate the
advantages to adolescents’ health behaviours
and outcomes of possessing various assets
related to family, school, peers and the
community (see Summary Table on page 50).
Recent U.S. studies illustrate that the more
assets adolescents possess, the greater their
likelihood of engaging in health-enhancing
practices (for example, wearing a bicycle
helmet or seatbelt and engaging in physical
activity) and the less likely they are to
engage in practices potentially harmful
to their health (for example, tobacco use,
risky sexual activity, violence, alcohol and
drug use).6–11 For example, the U.S.-based
Search Institute conducted surveys of
over 217,000 Grade 6 to 12 youth in over
300 communities during the 1999–2000
school year.108 They found that having
more assets was associated with a greater
likelihood that adolescents would engage
in more positive behaviours and that youth
with the most assets were least likely to
engage in risky health behaviours.108 This
research further suggests that this is true
among youth of all racial/ethnic backgrounds
and different socioeconomic levels.108
Schools and
communities that
provide opportunities
for all youth
high levels of two or three assets and 9%
report zero or one asset (see Figure 8).
The number of assets Canadian youth have is
related to their health and health behaviours.
In general, the more assets youth have, the
more likely they are to report positive health
outcomes and the less likely they are to
engage in risky health behaviours. Among
youth aged 12 to 15 years, youth with four
or five assets are more likely to report high
levels of self-worth and health status than
youth with two or three assets. In turn, youth
with two or three assets are more likely to
report high levels of self-worth and health
status than youth with zero or one asset.
Youth with four or five assets are also more
likely to report low levels of anxiety and less
Youth with four or five assets report higher levels of selfworth and health status than youth with two or three
assets . . . In turn, youth with two or three assets report
higher levels of self-worth and health status than youth
with zero or one asset.
Until now, we have not known if this also
held true in Canada. Accordingly, CPHI used
NLSCY data to examine the association
between five assets (parental nurturance,
parental monitoring, school engagement,
volunteerism, peer connectedness) and seven
health behaviours and outcomes (self-worth,
health status, anxiety, contact with peers who
commit crimes, alcohol use, tobacco use, marijuana use). Fifty-one percent (51%) of Canadian youth aged 12 to 15 report high levels
of four or five assets; 40% report possessing
likely to report using alcohol, tobacco and
marijuana than youth with fewer assets.
Youth with zero or one asset do not appear
to differ significantly from youth with two
or three assets in their levels of anxiety or
their use of alcohol and tobacco, but they
tend to be more likely to report using
marijuana. Youth reporting no assets or
only one asset are also more likely than
youth with a greater number of assets to
associate with peers who commit crimes
(see Figure 9).
51
Improving the Health of Young Canadians
Figure 8
Proportion
of Adolescents
(12 to 15 Years)
Reporting
High Levels
of Various
Positive Assets
9%
51%
40%
0–1 Positive Asset
2–3 Positive Assets
4–5 Positive Assets
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
52
Chapter 4: Adolescent Development and the Social Environment
Figure 9
100
80
60
40
68*
74*
88
23
44
22
24*
82*
83*
94**
17
26**
11**
12*
Marijuana Use
84
Tobacco Use
54*
Alcohol Use
48*
Contact With
Peers Who
Commit Crimes
Excellent or Very
Good Health
0
Low Level
of Anxiety
20
High Self-Worth
% of Youth (12–15 Years)
Adolescents’
Health Status
and Behaviours
in Relation to
the Number
of Positive Assets
37***
55
31
36*
0–1 Positive Asset
2–3 Positive Assets
4–5 Positive Assets
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* All pair-wise comparisons statistically significant at p <.05.
** Statistically significantly different from two or three assets and zero or one asset at p <.05.
*** Statistically significantly different from two or three assets and four or five assets at at p <.05.
53
Improving the Health of Young Canadians
Assets and
Socioeconomic Status
There are different theories about why youth
with more assets are more likely to report
positive health outcomes and behaviours.
One is that youth with more assets tend to
share other characteristics. For instance, they
might be more likely than their peers to live
in high-income or -education households. If
this is the case, this raises the following
question: is the relationship that we see
between positive assets and health driven
by underlying socioeconomic differences
between the groups?
The relationship of socioeconomic status (SES)
and health has been the focus of extensive
research in Canada and other countries. Little
is known about the association for Canadian
youth specifically,22 although there are indications that SES, as measured by parental
income, occupational status and education
level, is associated with adolescent health.21, 48
higher in households with college or university graduation compared to households with
some college or university. The proportion
of youth reporting high levels of parental
monitoring, peer connectedness, school
and community engagement did not vary
significantly by income or education level.
Further analyses show that the links between
health and SES are complex. For example,
analyses of NLSCY data indicate that higher
or lower levels of household income and
education††† do not appear to be related
to increased odds that youth aged 12 to
15 years will report high levels of health
status and self-worth. Similarly, household
income and education levels do not appear
to increase the odds that youth will report
using tobacco, alcohol or marijuana.
These results differ from recent U.S.21 and
Canadian48 studies that included youth up
to ages 17 and 18, respectively. These studies
found that youth from families of higher SES
were more likely to report better health than
those of lower SES. As noted earlier in this
The relationship between SES and health is complex.
CPHI conducted analyses to determine the
distribution of adolescents’ assets in relation
to income adequacy and education in the
household where they live. As illustrated in
Figures 10 and 11, the distribution of assets
was relatively consistent across the different
income and education levels. The only
exception to note is that the proportion
of youth reporting high levels of parental
nurturance is higher in the highest income
level (Q5) than in any of the other income
groups.†† The proportion of youth reporting
high levels of parental nurturance is also
report, income is an important determinant
of health.21–24 The lack of variation across the
different SES levels may be due to a potential
loss in sensitivity produced by the grouping
together of different levels of the variables.†††
Had it been possible to make comparisons
between each of the five income levels,
differences consistent with previous studies
in the literature might have been found.
†† Due to a small sample size in the lowest income adequacy level (Q1), the lowest and lower-middle income adequacy
levels (Q1 and 2) were grouped together. The standard low-income cut-off is <$10,000 for households with one to four
persons or <$15,000 for five or more persons. For the purposes of CPHI’s analyses, the lowest income level represented
this minimum to a maximum of $15,000 for a household size of one or two persons, $19,999 for three or four persons or
$29,999 for a household size of five or more persons.
54
††† Lowest and lower-middle income adequacy levels (Q1 and 2) were grouped together and compared with higher
income levels (Q3, 4 and 5 combined). Similarly, education levels were divided into higher/lower levels of education;
that is, households with secondary school graduation or less and households with some college/university education
or more.
Chapter 4: Adolescent Development and the Social Environment
Distribution
of High Level
of Assets
by Income
Adequacy Level
100
% Youth (12–15 Years) Reporting High Asset Level
Figure 10
90
80
70
60
50
40
30
20
10
0
Parental
Nurturance
School
Engagement
Community
Engagement
Peer
Connectedness
Lowest Income
(Adequacy Levels 1 and 2)
30
28
50
46
54
Middle Income
(Adequacy Level 3)
42
34
59
50
60
Upper-Middle Income
(Adequacy Level 4)
39
37
55
54
60
Highest Income
(Adequacy Level 5)
41
45*
61
57
67
Figure 11
100
% Youth (12–15 Years) Reporting High Asset Level
Distribution
of High Level
of Assets
by Household
Education Level
Parental
Monitoring
90
80
70
60
50
40
30
20
10
0
Parental
Monitoring
Parental
Nurturance
School
Engagement
Community
Engagement
Peer
Connectedness
Less Than Secondary
School Graduation
37
33
51
48
59
Secondary School
Graduation
37
37
56
49
60
Some College or University
36
32
56
54
58
College or University
Graduation
43
43**
60
55
64
Source: CPHI analysis of NLSCY (Cycle 4, 2000–2001), Statistics Canada.
* Statistically significantly different from lowest (Q1 and 2), middle (Q3) and upper-middle (Q4) income adequacy
levels at p <.05.
** Statistically significantly different from “Some College or University” at p <.05.
55
5
5
Creating
Environments and
Opportunities
for Healthy
Adolescent
Development
The evidence presented in Improving the Health of Young
Canadians indicates that adolescence is a complex time
of transition, during which adolescent health behaviours and
outcomes may be associated with various determinants. In
particular, this report has focused on a range of health behaviours
and outcomes and their association with the positive relationships
youth have in four settings: in their families, schools and communities, as well as with their peers. Positive relationships in these
areas have been identified as positive assets.
What Is the Key Message
in This Report?
Building Positive Assets:
What Appears to Work?
Youth who feel nurtured by their parents
and who feel connected to their school,
their community and their peers tend to
report better health and a higher sense of
self-worth. In addition, youth who reported
feeling cared for by their parents (nurtured,
monitored) and/or felt engaged in their
school were less likely to report engaging
in risky behaviours such as smoking,
drinking alcohol and using marijuana.
Many youth initiatives focus on specific
“problems” such as violence, injuries
or tobacco use. Some also incorporate,
to varying degrees, some or all of the
characteristics and strategies of a broad
healthy youth development approach (see
Table 1). No comprehensive inventory of
Canadian youth programs currently exists.
An extensive search for evaluated youth
programs was carried out during the
preparation of this report. Despite the
number of such initiatives across Canada,
relatively few have been formally evaluated.
Further, the evaluations that exist tend to focus
on formative and process evaluation rather
than outcomes such as health impacts. In
addition, they rarely use experimental, quasiexperimental or longitudinal designs that tend
to support stronger inferences based on the
results. Perhaps most youth programs improve
health in adolescence and in later life, but the
current evidence base leaves much that we
do not know.
Evidence suggests that the association between
positive assets and self-worth and health status
is cumulative. Youth who report four or five
assets rate their health and self-worth better
than youth with two or three assets, who in
turn rate their health and self-worth better
than youth with zero or one asset. In general,
youth with more assets are less likely to
engage in risky behaviours and are more
likely to report low levels of anxiety.
59
Improving the Health of Young Canadians
To identify successful policies and programs,
appropriate standards of evidence are
necessary.58 Identifying where links to healthrelated outcomes exist (or do not) would
also help to inform decisions. In particular,
evaluation evidence is needed to understand
the relationship between a program, its costs,
critical success factors and health outcomes.
Evaluations that demonstrate how health
outcomes are associated with or can be attributed to specific youth initiatives can be used
by policy- and decision-makers, as well as
communities, to determine which initiatives:
• get the best results for a
particular population;
• are most cost effective; and
• can be generalized or applied
to other groups and settings.
“
Each area is explored in more detail in the pages
that follow. It should be noted however, that the
scarcity of evaluative research in Canada means
that few conclusions regarding the relative
effectiveness of these strategies can be made.
The strategies may not be effective in all cases
and some may be more effective than others.
People have to realize that youth have lots of ideas and a
fresh outlook. We always hear that we are the future . . .
give us a chance to show what we can do.
—youth66
Is a Population
Health
Approach to
Adolescent
Development
Cost Effective?
60
Based on the evidence that does exist,
researchers have identified three characteristics of programs/policies that may
contribute to healthy youth development
by increasing the number and the quality
of the relationships that adolescents have
with their families, schools, peers
and communities:
1. Interventions that are comprehensive
and address common factors associated
with multiple behaviours;
2. Approaches that support healthy youth
development; and
3. Approaches that engage youth.12–14, 58, 126–127
Estimates (based on figures from the 1990s) indicate that mental illness, alcohol use, tobacco use
and drug use cost Canada millions of dollars per
year.130–132 Given research which shows a relationship
between behaviours engaged in during adolescence
and future health,2 these estimates suggest that
effective interventions to prevent or limit the
occurrence of these behaviours and thereby
promote healthy adolescent development
may generate positive returns on investment.
Estimating the returns from a particular type
of program is difficult. It requires using available
research to make assumptions about how programs
will affect health in the short and long term,
about program costs (for example, when implemented in a different context or at a different
scale) and about how to value benefits or
problems in the future relative to those that
occur today. Nevertheless, a few studies have
”
been done. For example, U.S. researchers estimate
the annual costs of youth development programs
to be $3,060 per youth based on the program
costs of organizations such as Big Brothers/Big
Sisters, the Boys and Girls Clubs and Girl Scouts of
America. This includes after-school programming,
mentoring, prevention and recreation opportunities for 1,200 hours per year per youth.
Using this figure, the Academy for Educational
Development Centre for Youth Development
(CYD) estimates that for every $1 spent on
adolescent development programming the
potential return is approximately $11.116 This
estimate is based on the assumption of an average
salary for a high school graduate working for
40 years. The CYD did not attempt to incorporate
the costs of prevented injury, substance use, teen
pregnancy, unemployment and associated health
outcomes into its calculation.117
Chapter 5: Creating Environments and Opportunities for Healthy Adolescent Development
Table 1
Examples of
Evaluated
Adolescent
Healthy
Development
Initiatives
in Canada
Program and
Location
Program Goals
and Approach
Documented
Health-Related Benefits
The Outdoor Classroom:
Gwich’n Tribal Council109
Through community involvement
and a supportive school environment, the traditional “outdoor
classroom” is used as a teaching
environment to address concerns
regarding youth crime.
• Increased parent involvement in children’s
schoolwork, improved school attendance,
self-control and classroom behaviour
• 30% reduction in the number of
RCMP files
• Improved school relations
A school-based early intervention
model that promotes an emotionally secure and physically
safe school environment in
which youth can develop feelings
of school connectedness and their
social competence skills.
• Increased non-violent responses to anger
• Improvements in attitudes toward school
• Reduced bullying and fighting
• Increased respectful behaviour, selfrespect and community connectedness
Through government, employer
and community partnerships,
assists youth in Newfoundland
and Labrador to participate in
postsecondary education and
gain career-related experience.
• 34% of participants receiving social
assistance indicated they would not
have pursued postsecondary education
without the program compared to
10% of participants not receiving
social assistance
Uses a comprehensive approach
to provide youth with opportunities to engage in pro-social
activities, improve their social
functioning, address their
behavioural challenges and
increase their resiliency to
factors putting them at risk for
engagement in criminal behaviour.
• Improvements in social functioning
(for example, less socially withdrawn)
• Reductions in both internalizing
(for example, less anxious) and
externalizing (for example, less
aggression, inattentiveness)
behaviour problems
Northwest Territories
Together We Light the Way:
Building Stronger and Safer
Communities110, 111
Ontario, Manitoba,
Nova Scotia
Student Work and Services
Program (SWASP)112
Newfoundland and Labrador
Project Early Intervention113
Ontario
61
Improving the Health of Young Canadians
1. Interventions that are comprehensive and
address common factors associated with
multiple behaviours
Research shows that youth behaviours
tend to cluster, which means that various
“problem” behaviours (such as tobacco and
alcohol use) often occur together; the same
is true of “healthy” behaviours.12 Some
suggest that this is because behaviours
are associated with common underlying
factors that can be found in the influences
of early childhood, biology, family, school,
community and peers.12, 39
Researchers who have observed the clustering
of behaviours have suggested that benefits
may be achieved by comprehensive approaches that seek to address the underlying
factors associated with multiple behaviours,12, 69
but there remains much that we do not
know about this area. Single-issue oriented
programs can also have positive outcomes.
Some programs specifically targeting risk
behaviours, such as graduated licensing
programs118 or programs to reduce
sport/recreation-related head injuries,119
for example, have had some success.
SMARTRISK
No Regrets
Project121
Using a peer leadership and peer education model
to mobilize youth to act on injury prevention and
related-risk activities, the SMARTRISK No Regrets
Project121 began in five high schools with students
from British Columbia, Alberta, Saskatchewan,
Ontario and New Brunswick and a comparison
school in Ontario.
Outcome data show gains in students’ knowledge
about injury prevention; improvements in attitudes
and beliefs associated with personal responsibility
62
Initiatives aimed at youth tobacco cessation,
injury prevention and decreasing drinking
and driving, while addressing a single risk
behaviour, can use a comprehensive intervention approach. For example, initiatives
that have been shown to be effective at
reducing the prevalence and initiation rates
of tobacco use among youth include regularly
enforced policy initiatives (for example, tax
increases), counter-marketing, prevention
efforts that jointly involve education and
community activities, youth-focused media
messages, refusal skills training, school-based
activities (for example, peer support groups)
and multiple activities that address different
factors associated with smoking behaviour.120
for responsible choices and smart risk-taking and
evidence of using strategies to address potentially
high-risk behaviours (such as wearing protective
gear while at work and having a plan to get home
from a party without riding with someone impaired).
The schools also reported benefits in terms of
enhanced reputations in their communities and
increased connections with local injury prevention
organizations and programs. The program is
currently undergoing evaluation for its long-term
health impact on reducing injuries.
Chapter 5: Creating Environments and Opportunities for Healthy Adolescent Development
2. Approaches that support healthy
youth development
While interventions that address risky behaviours can be effective, there is emerging
evidence that suggests that youth may
also benefit from approaches that focus on
supporting healthy development. Healthy
youth development initiatives, also known
as “positive youth development,” view
adolescence as a stage in which youth:
• develop a sense of identity
and competence;
• make transitions from school to
meaningful employment;
• participate in their community; and
• prepare for personal relationships
and family life.16, 58, 128
Approaching adolescent health from a
positive development perspective differs
from “problem-based” programs (such
as smoking cessation) by focusing on
providing support for youth to experience:
• a sense of belonging;
• bonding and connections to caring,
committed adults;
• age-appropriate responsibility
for decision-making and problem
solving; and
• leadership roles and activities that are
youth friendly and encourage youth
ownership and participation.57, 58, 126–128
Over the years, Canadian governments have put
a number of population-based policies, programs
and ministers into place to address various aspects
of young peoples’ lives, such as education, the
justice system, health services, injury prevention,
employment training and social-services provisions.
For example, eight of the provinces and each of
the territories have a minister devoted to youth or
ministers with portfolios that include youth.
Some research suggests that by creating
supportive environments and opportunities,
a positive youth development approach
can provide both prevention and health
promotion benefits.57, 58 Evidence from a
review of outcome-evaluated positive
youth development initiatives indicates that,
effective programs which sought to build
competence and strengthen bonding showed
improvements in relationships with parents,
school attachment and attendance, as well as
a reduction in problem behaviours such as
substance use.58 An evaluation of Job Corps, a
comprehensive vocational skills training and
support service program for disadvantaged
youth in the U.S., found increased high school
graduation rates, modestly improved employment rates, as well as a reduction in arrest
rates.100, 122–124 This evaluation also notes that,
while cost-effective, programs such as Job
Corps are limited to helping only a few,
given that they are intensive, complex and
expensive to run.100, 122
There is also some evidence that suggests
that interventions that support youth to
engage in employment and learning experiences and to develop healthy relationships,
problem solving and coping skills may be
linked to healthier transitions to adulthood.128
However, more research is needed to better
understand the effectiveness of positive
youth development approaches on longterm outcomes.58
Young persons under the age of 18 are included
under the banner of the National Children’s Agenda,
which was announced in the 1997 throne speech
as “a comprehensive strategy to improve the
well-being of Canada’s children.”125 (p. 4) To date,
most of the federal, provincial and territorial policy
focus related to the agenda has been on early
childhood development initiatives, such as the
expansion of Aboriginal Head Start (September
1997), the Early Childhood Development Accord
(September 2000) and the Multilateral Framework
on Early Learning and Childcare (March 2003).
Youth and
the National
Children’s
Agenda
63
Improving the Health of Young Canadians
3. Approaches that engage youth
A literature review by Canada’s Centre
of Excellence for Youth Engagement
demonstrates a link between youth
engagement (participation in meaningful
activities) and health.14 The review also
indicates that youth who are involved in
structured activities such as sports, music
and community work are less likely to take
part in risky behaviours such as substance
use (tobacco, alcohol, marijuana and hard
drugs), violence and crime. Youth who are
engaged in structured activities are also less
likely to drop out of high school and more
likely to get higher grades, graduate from
college and have higher self-esteem.
“
I think every youth around the world would like to be heard
about the things we have to say.
—youth66
Centre of
Excellence
for Youth
Engagement13
64
The Centre’s review notes that it is not
clear whether youth who are engaged in
structured activities have higher self-esteem
or if youth who have higher self-esteem are
more likely to participate in such activities.
This issue illustrates the need for further
research to better understand the connection
between engagement, self-esteem and
healthy youth development.
The Centre of Excellence for Youth Engagement13
(funded by the Public Health Agency of Canada)
is committed to supporting youth to become
more self-confident and able to make responsible
choices for their health. Youth are engaged
directly in planning and delivery of the Centre’s
activities in partnership with agencies, organizations and universities across Canada, including
”
HeartWood Centre for Community Youth
Development, Environmental Youth Alliance,
Children’s Hospital of Eastern Ontario/YouthNet,
Wilfred Laurier University, Brock University:
Youth Lifestyle Choices, Saskatoon Action Circle
on Youth Sexuality and Fédération de la jeunesse
canadienne-française.
Chapter 5: Creating Environments and Opportunities for Healthy Adolescent Development
Approaches
that support
healthy youth
development
Environments
that foster
positive parenting
Education that is
accepting, sets
limits and has
high expectations
Schools and
communities
that provide
opportunities
for all youth
Approaches
that engage
youth
Opportunities
for youth
to engage in
paid work
Involving
young people
in community
activities outside
school and work
Encouraging
positive peer
relationships
65
6
6
Summary and
Conclusions
Adolescence is a time when new ideas and values may be
explored and when experimentation in a range of activities
occurs. Experiences during adolescence can have multiple longterm effects, some of which can lead to negative health outcomes.2
Canada’s adolescents are a diverse group. Overall, most are in
good health.
Emerging evidence suggests that supportive relationships in the
family, as well as feelings of connectedness to school, community
and peers, are associated with successful health outcomes and
development for youth. These relationships may protect against
potentially risky behaviours and promote health-enhancing
behaviours. Although adolescence is characterized by increasing
independence from parents, families still matter.
Improving the Health of Young Canadians examines why some youth
are healthy and others are not. Our primary focus is on how links
with families, friends, school and the community are—or are not—
related to health and to risky health behaviours.
69
Improving the Health of Young Canadians
The report shows that youth with higher levels of parental
nurturance and school attachment report higher levels of health
status. In addition, the association between assets and positive health
behaviours and outcomes appear to be cumulative. Youth with more
assets are less likely to engage in risky behaviours than youth with
fewer assets and are more likely to report high levels of health status
and self-worth.
More research that assesses the health outcomes of youth-based
policies and programs may improve what is known about
effective interventions. The scarcity of evaluative research in
Canada means that few conclusions regarding the effectiveness
of the strategies discussed in the previous section can be made.
The strategies may be effective in all cases—or in only a few. And
some may be more effective than others.
The analyses and the research presented in this report suggest
that the relationships that adolescents have in their schools, their
families and their neighbourhoods, and with their friends are
important. There is a role for parents, peers, schools, communities,
employers, program developers, volunteer organizations and all
levels of government in supporting adolescents in their transition
to healthy adults.17
70
Chapter 6: Summary and Conclusions
Key Messages and Information Gaps
What do
we know?
• Overall, Canada’s youth are healthy.
• Youth who feel nurtured by their parents and engaged in their school report better
health outcomes (higher self-rated health and self-worth, and lower anxiety levels),
as well as less likelihood of engaging in risky health behaviours.
• Youth with higher levels of parental monitoring are less likely to report using
alcohol, tobacco and marijuana, but they rate their health and self-worth about
the same as other youth.
• Youth with more assets report better health and higher levels of self-worth than
youth with fewer assets. They are also less likely to engage in practices that are
potentially harmful to their health (for example, alcohol, tobacco and marijuana use).
What do we still
need to know?
• The association between positive assets and health behaviours/outcomes among
12- to 15-year-olds has been highlighted in this report. Is there also an association
among youth aged 16 to 19 years? Are some assets more important than others for
this age group?
• What is the association between positive assets and health behaviours/outcomes
among Aboriginal and immigrant youth and youth in the territories?
• What are the mechanisms through which positive assets influence behaviour and
health outcomes?
• Are aspects of health and behaviour more influenced by some positive assets
than others?
• What other positive assets promote healthy development?
• Which policies and programs are most effective in promoting healthy development
for all Canadian youth?
• Are programs designed for specific groups of adolescents associated with changes in
health disparities?
• What new risks to adolescent health are emerging?
see next page
71
Improving the Health of Young Canadians
Key Messages and Information Gaps (continued)
What’s
happening in
this area?
• The importance of Canada’s adolescents has been recognized through various
reports and initiatives, including the Federal/Provincial/Territorial Advisory
Committee on Population Health’s Opportunities of Adolescence: The Health Sector
Contribution72 and the Centre of Excellence for Youth Engagement.13
• Through provincial and pan-Canadian surveys, as well as research nodes involving
Canadian youth, Canada is seeking to better understand the factors affecting
adolescent health and development. Examples include:
- National Longitudinal Survey of Children and Youth (NLSCY, Statistics Canada)
- Canadian Community Health Survey (CCHS, Statistics Canada)
- Canadian Component of the Health Behaviours in School-Aged Children Survey
- McCreary Centre Society (British Columbia)
- Health and Learning Knowledge Centre of the Canadian Council on Learning
• CPHI has also funded a number of research projects involving youth. Some examples
of ongoing and recently completed research projects include:
- Canadian Adolescents At-Risk Research Network (CAARRN) (principal
investigator: William Boyce)
- Individual-, peer- and community-level determinants of addictions-related health
in the adolescent student population (principal investigator: Christiane Poulin)
- Vulnerable teens: A study of obesity, poor mental health and risky behaviours
among adolescents in Canada (principal investigator: Douglas Willms)
- Program of research examining the relation between the health of Aboriginal
youth and Aboriginal community efforts to preserve and promote Native culture
(co-principal investigators: Christopher Lalonde and Michael Chandler)
- How are Canadian adolescents developing in comparison with adolescents in
other wealthy countries: Time use, time pressure, emotional well-being and
health (principal investigator: Jiri Zuzanek)
72
For More Information
Improving the Health of Canadians (IHC) 20041 was the Canadian Population
Health Initiative’s first flagship report. The report was organized into four
key chapters: income, early childhood development, Aboriginal Peoples’
health and obesity. It synthesized and presented evidence about the factors
that affect the health of Canadians, ways to improve health and the implications of policy and program options. It also noted key information gaps and
recent initiatives.
After the release of IHC 2004, a decision was made to produce and disseminate
the second biennial Improving the Health of Canadians 2005–2006 as a report
series reflecting CPHI’s three current strategic themes: Healthy Transitions
to Adulthood, Healthy Weights (scheduled for release in winter 2006) and Place
and Health (scheduled for release in spring 2006). Building on earlier reports,
the Improving the Health of Canadians 2005–2006 Report Series further examines
what we know about factors that affect the health of Canadians, ways to
improve our health and relevant options for evidence-based policy choices.
The unique contribution of this first report in the new series is its focus,
within a population health framework, on the factors that facilitate healthy
youth development.
Improving the Health of Young Canadians is available in both official languages
on the CIHI Web site, at www.cihi.ca/cphi. To order additional copies of the
report, please contact:
Canadian Institute for Health Information
Order Desk
495 Richmond Road, Suite 600
Ottawa, ON K2A 4H6
Tel: (613) 241-7860
Fax: (613) 241-8120
We welcome comments and suggestions about this report and about
how to make future reports more useful and informative. For your
convenience, a feedback sheet, “It’s Your Turn,” is provided at the end
of the report. You can also email your comments to [email protected]
73
There’s More on the Web!
The PDF version of this report is only part of what you can find on our Web
site (www.cihi.ca/cphi). For additional information and a full list of available
CPHI reports, newsletters and other products please visit our Web site and
• Download a presentation of the highlights of Improving the Health
of Young Canadians
• Sign up to receive updates and information through CPHI’s
quarterly e-newsletter, Health of the Nation
• Learn about upcoming reports, including Improving the Health of Canadians
2005–2006 Report Series: Healthy Weights and Place and Health
• Learn about upcoming CPHI events
• Download copies of other reports previously published by CPHI
Reports
Previously
Published
by CPHI
Name of Report
Author and Publication Date
Healthy Transitions to Adulthood
• “You say ‘to-may-to(e)’ and I say ‘to-mah-to(e)’”:
Bridging the Communication Gap Between
Researchers and Policy-Makers
CPHI (September 2004)
Place and Health
• Developing a Healthy Community Index
Collected Papers (February 2005)
• Housing and Population Health
Brent Moloughney (June 2004)
• CPHI Workshop on Place and Health
Synthesis report (Banff)
CPHI (June 2003)
• Prairie Regional Workshop on the
Determinants of Healthy Communities
CPHI (August 2003)
Healthy Weights
• Overweight and Obesity in Canada:
A Population Health Perspective
Kim D. Raine (August 2004)
• Improving the Health of Canadians—Obesity Chapter
CPHI (February 2004)
• Obesity in Canada—Identifying Policy Priorities
CPHI and CIHR (June 2003)
Early Childhood Development
• Early Development in Vancouver: Report of
the Community Asset Mapping Project (CAMP)
Clyde Hertzman et al.
(March 2004)
• Improving the Health of Canadians—
Early Childhood Development Chapter
CPHI (February 2004)
Income
• What Have We Learned Studying Income
Inequality and Population Health?
Nancy Ross (December 2004)
• Improving the Health of Canadians—Income Chapter
CPHI (February 2004)
• Poverty and Health CPHI Collected Papers
CPHI, Shelley Phipps and
David R. Ross (September 2003)
75
Improving the Health of Young Canadians
continued
Reports
Previously
Published
by CPHI
Name of Report
Author and Publication Date
Aboriginal Peoples’ Health
• Improving the Health of Canadians—
Aboriginal Peoples’ Health Chapter
CPHI (February 2004)
• Measuring Social Capital: A Guide
for First Nations Communities
Javier Mignone (December 2003)
• Initial Directions: Proceedings of a Meeting
on Aboriginal Peoples’ Health
CPHI (June 2003)
• Urban Aboriginal Communities:
Proceedings of a Roundtable Meeting on
the Health of Urban Aboriginal People
CPHI (March 2003)
• Broadening the Lens: Proceedings of a
Roundtable on Aboriginal People’s Health
CPHI (January 2003)
Cross-Cutting Issues and Tools
76
• Select Highlights on the Public Views of the
Determinants of Health
CPHI (February 2005)
• Women’s Health Surveillance Report:
A Multidimensional Look at the Health
of Canadian Women
CPHI and Health Canada
(October 2003); Supplementary Chapters
(October 2004)
• Charting the Course Progress:
Two Years Later: How Are We Doing?
CPHI and CIHR (February 2004)
• CPHI Regional Workshop—
Atlantic Proceedings (Fredericton)
CPHI (July 2003)
• Charting the Course: A Pan-Canadian
Consultation on Population and Public
Health Priorities
CPHI and CIHR (May 2002)
• Barriers to Accessing and Analyzing Health
Information in Canada
George Kephart
(November 2002)
• Tools for Knowledge Exchange:
Best Practices for Policy Research
CPHI (October 2002)
• Partnership Meeting Report
CPHI (March 2002)
• An Environmental Scan of Research
Transfer Strategies
CPHI (February 2001)
Appendix A
Methodology
Data Sources
This report focused on the health of youth
aged 12 to 19 years. Information was obtained
from various published reports and surveys
and is referenced accordingly (for example,
Youth in Transition Survey, Adolescent Health
Survey). In addition, this report features
new analyses using data from the Canadian
Community Health Survey (CCHS 2003) and
the National Longitudinal Survey of Children
and Youth (NLSCY Cycle 4, 2000–2001).
Variables Examined in This Report
The following variables were included in the
analyses based on a review of the literature,
their relevance to the report’s objectives,
availability in the CCHS and NLSCY and
their respective psychometric properties
(that is, response rates). Scoring levels (high,
medium-low) for the variables were created
based on literature that used similar variables
and scoring strategies.56, 129
Canadian Community Health Survey
(CCHS 2.1, 2003)
The CCHS provides data on Canadians’ health
status, health determinants and health care use.
It is a bi-annual Canada-wide population survey
that was first administered in 2000–2001. The
CCHS collects responses from persons aged
12 or older living in private occupied dwellings, excluding persons living on Indian
Reserves or Crown Lands, residents of
institutions, full-time members of the
Canadian Armed Forces and residents
of certain remote regions, and thus covers
approximately 98% of the Canadian population aged 12 and over. Further details on the
CCHS can be found at the following Web site:
www.statcan.ca/english/concepts/health/
cchsinfo.htm. For the current report, all
data involving the CCHS was obtained from
the Canadian Socio-economic Information
Management System (CANSIM), custom
cross-tabulations, or the Public Use Microdata
File (PUMF, Cycle 2.1, 2003).
Sense of Belonging. Asks participants to
describe their sense of belonging to their
local community.
Response Categories:
• very strong
• somewhat strong
• somewhat weak
• very weak
• don’t know
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Self-Rated Health. Asks participants to
indicate their health status in general.
Response Categories:
• excellent
• very good
• good
• fair
• poor
• don’t know
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Income Adequacy. A derived variable that
considers the total household income and the
number of people living in the household for
computing the five income categories.
Response Categories:
• lowest income quintile
• lower-middle income quintile
• middle income quintile
• upper-middle income quintile
• highest income quintile
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
77
Improving the Health of Young Canadians
Alcohol Use. Participants who answered
“yes” to the question, “During the past
12 months, have you had a drink of beer, wine,
liquor or any other alcoholic beverage?” were
further asked to describe their frequency of
consumption of five or more drinks on one
occasion during the past 12 months.
Response Categories:
• never
• less than once a month
• once a month
• two to three times a month
• once a week
• more than once a week
• not applicable
• don’t know
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Physical Activity Index. Derived variable
using adult categories that groups participants
based on the total daily energy expenditure
values (kcal/kg/day).
Response Categories:
• active
• moderate
• inactive
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Fruits and Vegetables. Derived variable
based on responses to a number of questions
on the frequency (times per day) of consumption of various fruits, juices and vegetables.
Response Categories:
• less than 5 times per day
• 5 to 10 times per day
• more than 10 times per day
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
78
Exposure to Second-Hand Smoke at Home.
Variable based on questions about exposure
to second-hand smoke inside the home on
most days.
Response Categories:
• yes
• no
• not applicable
• don’t know
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Self-Perceived Unmet Health Care Needs.
Asks participants if there ever was a time
during the previous 12 months when they
felt that health care was needed but they
did not receive it.
Response Categories:
• yes
• no
• don’t know
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Reasons for Care Not Received. Participants
who answered “yes” to the question, “During
the past 12 months, was there ever a time
when you felt that you needed health care
but you didn’t receive it?” were asked to
agree or disagree with the following reasons
for why they did not receive care: not available
in the area; not available at time required;
waiting time too long; felt would be inadequate; cost; too busy; didn’t get around to
it/didn’t bother; didn’t know where to go;
transportation problems; language problems;
personal or family responsibilities; dislikes
doctors/afraid; decided not to seek care;
doctor didn’t think it was necessary; unable
to leave the house because of health;
problems; and other.
Response Categories:
• yes
• no
• not applicable
• don’t know
• refusal/not stated
Age Group Examined: 12- to 19-year-olds
Appendix A—Methodology
National Longitudinal Survey
of Children and Youth (NLSCY
Cycle 4, 2000–2001)
The National Longitudinal Survey of Children
and Youth (NLSCY) is a long-term study
following Canadian children from birth to early
adulthood. It was first completed in the fall
of 1994 with a cohort from a targeted population of 25,000 Canadian children aged 0 to
11 years who have been surveyed every two
years since. The information is provided by
parents, children themselves (for children
above 10 or 11 years of age), teachers and
principals. The sample excludes children
and youth living on Indian Reserves or
Crown Lands, in institutions as well as
in the territories. More information on
the NLSCY can be found at the following
Web site: http://www.statcan.ca/english/
sdds/4450.htm.
For the current report, data for youth aged
12 to 17 years old in 2001 (n = 5,580 and
representing 2,451,613 youth of the same age
in Canada) were examined. All analyses for
the NLSCY were done through Remote Data
Access. Cycle 5 longitudinal data was not
used due to the unavailability of cross-sectional
weights for youth aged 8 to 19 years. Cycle 4
data, for which cross-sectional weights are
available, is analyzed in the report.
NLSCY Assets
Parental Nurturance. Derived score based on
the following NLSCY items: My parents . . .
smile at me; praise me; make me feel appreciated; speak of the good things I do; seem
proud of the things I do; listen to my ideas and
opinions; solve a problem together with me
whenever we disagree about something.
Response Categories:
• never
• rarely
• sometimes
• often
• always
• refusal/not stated
Age Group Examined: 12- to 15-year-olds
Continuous Score Range (0 to 28):
• medium-low (0 to 20)
• high (21 to 28)
High score indicates a high degree of
parental nurturance.
Non-Response Rate: 28%
Parental Monitoring. Derived score based on
the following NLSCY items: My parents . . .
want to know exactly where I am and what
I am doing; tell me what time to be home when
I go out; let me go out any evening I want; take
an interest in where I am going and who I am
with and find out about my misbehaviour.
Response Categories:
• never
• rarely
• sometimes
• often
• always
• refusal/not stated
Age Group Examined: 12- to 15-year-olds
Continuous Score Range (0 to 20):
• medium-low (0 to 14)
• high (15 to 20)
High score indicates a high degree of
parental monitoring.
Non-Response Rate: 26%
School Engagement is a compound variable
derived by CPHI based on the degree of
importance a youth places on the following
items: getting good grades; making friends;
participating in extra-curricular activities;
getting to class on time; learning new things;
expressing one’s opinion in class; and getting
involved in the student council or other
similar groups.
Response Categories:
• very important
• somewhat important
• not very important
• not important at all
• refusal/not stated
Age Group Examined: 12- to 15-year-olds
79
Improving the Health of Young Canadians
Continuous Score Range (0 to 21):
• medium-low (0 to 13)
• high (14 to 21)
High score indicates a high level of
school engagement
Non-Response Rate: 24%
Community Engagement (Volunteerism)
is a compound variable derived by CPHI
based on the youth who indicated that
in the past 12 months they engaged in
one or more of the following activities
without pay:
• supporting a cause (food bank,
environmental group)
• fundraising (charity, school trips)
• helping in one’s community
(hospital volunteering, work
in a community organization)
• helping neighbours or relatives (cutting
grass, babysitting, shovelling snow for
a neighbour)
• doing another organized
volunteer activity
Response Categories:
• yes
• no
• not applicable
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• volunteer
• non-volunteer
Non-Response Rate: 22%
80
Peer Connectedness. Derived score based on
the following NLSCY items (“Friends” score):
• I have many friends
• I get along easily with others my age
• others my age want me to be their friend
• most others my age like me
Response Categories:
• false
• mostly false
• sometimes true/sometimes false
• mostly true
• true
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Continuous Score Range (0 to 16):
• medium-low (0 to 11)
• high (12 to 16)
High score indicates a high level of
peer connectedness.
Non-Response Rate: 24%
Labour Force Engagement—Number of Hours.
Youth aged 16 and 17 years were asked
to indicate in an average week since September 1 how many hours they worked from
Monday to Friday and how many hours they
worked on Saturday and Sunday. Youth aged
14 and 15 were asked to think of all the jobs
they do in a typical school week and indicate
how many hours in total they usually worked
Monday to Friday and Saturday and Sunday.
Response Categories:
• 1 to 60 hours (varies according
to age range and question)
• not applicable
• don’t know
• refusal/not stated
Age Group Examined:
• 14- to 15-year-olds
• 16- to 17-year-olds
Categorical Score:
• works 20 hours per week or more
• works less than 20 hours per week
Non-Response Rate: 57%
Multiple Assets. Grouping of parental
nurturance, parental monitoring, peer
connectedness, school engagement and
volunteerism assets for 12- to 15-year-olds.
Categorization is based on youth reporting a
“high” level of each asset.
CPHI-Derived Score Range:
• 0 or 1 asset
• 2 or 3 assets
• 4 or 5 assets
Age Group Examined: 12- to 15-year-olds
NLSCY Outcome Variables
Self-Rated Health. Asks youth to indicate
their health status in general.
Response Categories:
• excellent
• very good
• good
• fair
• poor
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• excellent or very good
• good
• fair or poor
Non-Response Rate: 22%
Appendix A—Methodology
Anxiety. Derived NLSCY score based on the
following items: I am unhappy or sad; I am
not as happy as other people my age; I am
too fearful or nervous; I worry a lot; I cry a lot;
I am nervous, high-strung or tense; and I have
trouble enjoying myself.
Response Categories:
• never true or not true
• sometimes or somewhat true
• often or very true
Age Group Examined: 12- to 15-year-olds
Continuous Score Range (0 to 14):
• low (0 to 7)
• medium-high (8 to 14)
Non-Response Rate: 24%
Alcohol Use. Asks youth which of the
following best describe their experience
with drinking alcohol.
Response Categories:
• I have never had a drink of alcohol
• I have only had a few sips
• I only tried once or twice (at least
one drink)
• I do not drink alcohol anymore
• a few times a year
• about once or twice a month
• about 1 or 2 days a week
• about 3 to 5 days a week
• about 6 or 7 days a week
• not applicable
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• ever had a drink
• never had a drink
Non-Response Rate: 25%
Tobacco Use. Asks youth which of the
following best describes their experience
with smoking cigarettes.
Response Categories:
• I have never smoked
• I have only had a few puffs
• I do not smoke anymore
• a few times a year
• about once or twice a month
• about 1 or 2 days a week
• about 3 to 5 days a week
• about 6 or 7 days a week
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• ever smoked
• never smoked
Non-Response Rate: 25%
Marijuana Use. Asks youth which of the
following best describes their experience
with using marijuana and cannabis products
(also known as a joint, pot, grass or hash)
during the past 12 months.
Response Categories:
• I have never done it
• I have done it but not during
the past 12 months
• a few times
• about once or twice a month
• about 1 or 2 days a week
• about 3 to 5 days a week
• about 6 or 7 days a week
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• ever used marijuana
• never used marijuana
Non-Response Rate: 24%
Self-Worth. Derived NLSCY score based on
the following items (general “self” score):
in general I like the way I am; overall I have
a lot to be proud of; a lot of things about me
are good; when I do something I do it well.
Response Categories:
• false
• mostly false
• sometimes false/sometimes true
• mostly true
• true
• refusal/not stated
Age Group Examined: 12- to 15-year-olds
Continuous Score Range (0 to 16):
• medium-low (0 to 11)
• high (12 to 16)
High score indicates positive
general self-worth.
Non-Response Rate: 24%
81
Improving the Health of Young Canadians
82
Frequency of Headaches. Asks respondents
how often in the previous six months they
had or felt a headache
Response Categories:
• seldom or never
• about once a month
• about once a week
• more than once a week
• most days
• refusal/not stated
Age Group Examined: 12- to 15-year-olds
Categorical Score: Youth who reported
headaches once a week or more were classified
as having frequent headaches.
Non-Response Rate: 25%
Contact with Peers who Commit Crimes.
Asks respondents how many of their close
friends do the following: break the law by
stealing, hurting someone or damaging property.
Response Categories:
• none
• a few
• most
• all
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• has friends who break the law
• does not have friends who break the law
Non-Response Rate: 24%
Pro-Social Behaviours. Derived NLSCY score
based on the following items (“pro-social” score):
I show sympathy to (I feel sorry for) someone
who has made a mistake; I try to help someone
who has been hurt; I offer to help clear up a
mess someone else has made; if there is an
argument, I try to stop it; I offer to help other
young people (friend, brother or sister) who
are having difficulty with a task; I comfort
another young person (friend, brother or sister)
who is crying or upset; I help to pick up things
which another young person has dropped;
when I am playing with others, I invite
bystanders to join in a game; I help other
people my age (friends, brother or sister)
who are feeling sick; and I encourage other
people my age who cannot do things as well
as I can.
Response Categories:
• never or not true
• sometimes or somewhat true
• often or very true
• refusal/not stated
Age Group Examined: 12- to 15-year-olds
Continuous Score Range (0 to 20):
• low (0 to 10)
• high (11 to 20)
Low score indicates a lack of engagement in
pro-social behaviours.
Non-Response Rate: 25%
Injuries. Asks respondents whether they
were injured in the past 12 months.
Response Categories:
• yes
• no
• not applicable
• don’t know
• refusal/not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• youth who reported having
been injured
• youth who reported having not
been injured
Non-Response Rate: 3%
Bullying is a compound variable derived by
CPHI based on the following experiences
during the past 12 months: number of times
someone said something personal about the
youth that made him or her feel uncomfortable
while at school or on a school bus; number
of times someone said something personal
about the youth that made him or her feel
uncomfortable elsewhere (including at
home); number of times someone threatened
to hurt the youth badly, but did not actually
hurt him or her while at school or on a school
bus; number of times someone threatened
to hurt the youth, but did not actually hurt
him or her elsewhere (including at home);
number of times someone physically attacked
or assaulted the youth while at school or on a
school bus; and number of times someone
physically attacked or assaulted the youth
elsewhere (including at home).
Appendix A—Methodology
Response Categories:
• never
• once or twice
• three or four times
• five times or more
• not applicable
• don’t know
• refusal
• not stated
Age Group Examined: 12- to 17-year-olds
Categorical Score:
• never
• one or more times
Income Adequacy. A derived variable that
considers the total household income and the
number of people living in the household for
computing five income categories.
Response Categories:
• lowest income quintile
• lower-middle income quintile
• middle income quintile
• upper-middle income quintile
• highest income quintile
Age Group Examined: 12- to 15-year-olds
Household Education Level. A grouped
variable that considers the highest level of
educational attainment within a household.
Response Categories:
• less than secondary school graduation
• secondary school graduation
• some postsecondary education
(college or university)
• postsecondary graduation
(college or university)
Age Group Examined: 12- to 15-year-olds
Statistical Analyses
Cross-tabulations were used to estimate the
prevalence of various health indicators in
the CCHS among youth aged 12 to 19 years.
Bootstrapping techniques were used by Statistics
Canada in its analysis of the variables
presented in the custom tabulations.
Cross-tabulations were also used with the
NLSCY to estimate the prevalence of various
assets and health behaviours among youth
aged 12 to 15, and for some variables, 12 to
17 years. The bootstrap weights method for
variance estimation was used to account for
the complexity of the NLSCY (that is, complex
sample design, non-response adjustment
and post-stratification). NLSCY cycle 4 crosssectional weights were used. Only those
who responded to the relevant questions
were included in the analyses. Comparisons
between respondents and non-respondents
for the noted outcomes and independent
variables were conducted, as were nonresponse analyses by gender, household
income and household education; these values
are available upon request at [email protected]
Multiple logistic regression was used to model
associations between health behaviours and
outcomes (that is, self-worth, self-rated health,
use of alcohol, tobacco and marijuana), assets
(parental nurturance, peer connectedness,
school engagement, volunteerism) and
socio-demographic characteristics (gender,
household income, household education).
For the purposes of this report, due to small
sample size for the low category (and hence
high variability), the medium and low categories
for most NSLCY-specific variables have been
combined. Consequently, all analyses in this
report were of acceptable quality, according
to Statistics Canada’s quality level guidelines:
Quality Level Requirements
Acceptable
n is equal or greater than 30
and coefficient of variation is
between 0 and 16.5%
Marginal
n is equal or greater than 30
and coefficient of variation is
between 16.5% and 33.33%
Warning: High level of error
associated with the estimate
Unacceptable
n is less than 30 or coefficient of
variation is greater than 33.33%
The estimate should not
be released.
83
Improving the Health of Young Canadians
Data Sources for Just the Facts #1, #2 and #3
Data Source for Exposure to Second-Hand Smoke:
1
Table 105-0256: “Exposure to second-hand smoke at home, by age group and sex, non-smoking
household population aged 12 and over, Canada, provinces, territories, health regions (June 2003
boundaries) and peer groups, every 2 years (224448 series),” from the Statistics Canada CANSIM
database at <http://cansim2.statcan.ca>; date accessed: May 5, 2005.
Data Source for Self-Rated Health:
2
Table 105-0222: “Self-rated health, by age group and sex, household population aged 12 and over,
Canada, provinces, territories, health regions (June 2003 boundaries) and peer groups, every 2 years
(392784 series),” from the Statistics Canada CANSIM database at <http://cansim2.statcan.ca>; date
accessed: May 9, 2005.
Percentage of Youth (12 to 19 Years) Reporting Excellent or Very Good
Health Status—Health Regions Significantly Different from Canadian Average
Canada’s Health Regions
Percentage
of Youth
66.9%
CANADIAN AVERAGE
Significantly Higher Than Canadian Average
Ontario
Perth District Health Unit
78.6%
Ontario
Waterloo Health Unit
76.0%
Alberta
Capital Health
76.7%
British Columbia
Central Vancouver Island Health Service Delivery Area
80.3%
Significantly Lower Than Canadian Average
Nova Scotia
Zone 3
51.9%
Quebec
Région des Terres-Cries-de-la-Baie-James
46.7%
Ontario
Leeds, Grenville and Lanark District Health Unit
55.2%
Ontario
Renfrew County and District Health Unit
51.4%
Ontario
Windsor–Essex County Health Unit
53.9%
Manitoba
Burntwood/Churchill*
40.8%
Saskatchewan
Mamawetan/Keewatin/Athabasca
50.6%
Alberta
Northern Lights Health Region
56.6%
Northwest Territories
56.3%
Note: All other health regions not significantly different from Canadian average at p <.05.
* Data of marginal quality. Use with caution.
Data Sources for Leisure Time Physical Activity
and Dietary Practices:
84
3
Table 105-0233: “Leisure-time physical activity, by age group and sex, household population aged 12
and over, Canada, provinces, territories, health regions (June 2003 boundaries) and peer groups, every
2 years (336672 series),” from the Statistics Canada CANSIM database at <http://cansim2.statcan.ca>;
date accessed: May 5, 2005.
4
Table 105-0249: “Dietary practices, by age group and sex, household population aged 12 and over,
Canada, provinces, territories, health regions (June 2003 boundaries) and peer groups, every 2 years
(336672 series),” from the Statistics Canada CANSIM database at <http://cansim2.statcan.ca>; date
accessed: May 9, 2005.
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103 S. G. Forman and J. Kalafat, “Substance Abuse and Suicide: Promoting Resilience Against SelfDestructive Behavior in Youth,” School Psychology Review 27, 3 (1998): pp. 398–406.
104 M. S. Gould et al., “Youth Suicide Risk and Preventive Interventions: A Review of the Past 10 Years,”
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Improving the Health of Young Canadians
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91
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