Chapter 11: Implications

The main purpose of this report was to present trends in the health of Canadian youth based on three HBSC surveys conducted in 1989-90,1993-94 and 1997-98. The majority of Canadian youth aged 11 to 15 appear to be well-adjusted in terms of their physical and mental health, their relationships with their parents, peers and school, and their health behaviours. However, particular areas of concern have been identified and in this chapter they have been summarized and directions for programs and policies suggested.

As noted in the introduction, population health focuses on the interrelated conditions and factors that influence the health of populations over the life course, identifies systematic variations in the patterns of occurrence, and applies the resulting knowledge to develop and facilitate the implementation of policies and actions to improve the health and well-being of these populations. This research report focuses on the psychosocial environments of the home and family, school and peer culture settings, the individual capacity and coping skills and personal health behaviours of the young people themselves. The information should be of use to health, education, social service and recreation professionals working directly or indirectly with youth and youth-serving organizations, but it also has implications for the federal, provincial and territorial governments which have the responsibility for initiating major policies and programs.

The Family

The findings from the three surveys reinforce the importance of a supportive home life to the physical and mental health of youth. Most young people who have good relationships with their parents, based on effective communication, trust and understanding, are far more likely to be well adjusted in all aspects of their life than those who do not. Young people who do not have good relationships at home are far more likely to engage in health-risk behaviours, such as smoking and drug use, to experience adjustment problems at school and to suffer from health problems. There are many homes in which children feel burdened by unrealistic expectations and an absence of trust and understanding. Given these findings, it is especially disturbing to find that from the children's' perspective fathers' capacity to communicate with their children, and especially their daughters, weakens as young people move into their middle teens.

Although nearly three-quarters of the 1998 survey respondents lived with both parents, there was evidence of strains in families, especially in single-parent and blended family homes. The common pattern of two parents fully engaged in the labour market increases the pressure on them to be responsive to their children. Parents need information about effective parenting and about the implications of ineffective parenting on the lives of their children. The home is the optimum setting for the modeling and development of sound values, social skills and personal health practices. Young people learn about healthy eating, the benefits of physical activity and the value of good relationships primarily from the example set by their parents. In order to be responsive to their childrens' needs as they progress through school, parents need to maintain regular communication with teachers and develop realistic expectations for achievement in order for their children to feel accepted and supported. Even through the challenging adolescent years, parents must sustain their capacity to communicate with their children and to encourage discussion of the most sensitive issues, such as sexuality and relationships. Children are also influenced by the media, their peers and their communities; parents need programs and resources to help them in their roles as guides and mentors as they help their children develop into healthy adults.

The School

School does make a difference to the health of youth. It is the basic arena in which they develop social and life skills. Students who are unhappy at school because of lower-than-expected achievement, adjustment problems and poor relationships with teachers and other students tend to disengage from school. They often become friends with other young people who have had similar experiences and share negative views of school. Together they engage in health-risk behaviours, such as skipping classes, smoking and drug use. It is difficult for teachers to make all their students feel accepted and respected for their individuality when they must differentiate among them using marks. However, if students do not feel that they belong at school and that school is not meeting their needs, the costs to both the students and society can be substantial.

Compared to students from other countries, Canadian students continue to be generally happy with their school experience. However, the HBSC survey shows that there are emerging and ongoing problems: a large number of students skip classes; bullying behaviour by both boys and girls is commonplace; the victims of bullies tend to be isolated and to have emotional problems; a small but significant number of students do not feel safe at school; and, there is a small number of male students who carry weapons. Schools play an important role in the social development of youth: young people must feel accepted and supported, not threatened and isolated.

A number of approaches to the improvement of the school as a safe, secure and supportive setting contributing to promoting the health of young people have been developed in the last decade. In Europe, the World Health Organization, Council of Europe and European Union have worked together to develop and promote the European Network of Health Promoting Schools (ENHPS). The ENHPS Program is a process by which a school community undertakes a community needs assessment to identify and set priorities among the identified health problems. The specific program that is subsequently planned varies from school to school and from community to community. One school community may focus on reducing smoking while another may focus on building self-esteem.

In Canada, the Canadian Association for School Health in collaboration with Health Canada and approximately 30 national health and education sector organizations, developed the Comprehensive School Health Model. This model was based on the idea that health is a prerequisite for learning and consists of four components: instruction for all students for and about health so that they have the knowledge and skills to maintain and improve their own health; a healthy, safe, violence-free physical environment in which to grow and develop; a healthy, safe and supportive psychosocial environment in which to develop social skills and the skills needed to live in a civic society; and support services of various kinds for those young people and their families who live in conditions of risk or who already have difficulties. The programs developed evolve from the needs identified in the specific school community and depend on the collaborative action of many sectors (e.g., public health, recreation, social services, justice) as well as education.

Both of these models focus on the processes of becoming a more health promoting setting that is supportive of the development of the students and teachers within it. Both of these models are based on the principle that all sectors within a school community, including the students, will be involved in identifying the problems and needs and developing the solutions. They are also both based on the principle that policies and programs and best practices are necessary to respond to student needs for support, acceptance and recognition; opportunities to develop and maintain social skills and relationships; opportunities for physical and leisure-time activities; and a school climate emphasizing respect and tolerance of all school community members.

The Peer Group

The mental health of young people and the degree to which they engage in health-risk behaviours are strongly associated with the relationships they have with their peers. Youth who are well integrated socially are far less likely to experience emotional problems than youth who have few friends and feel isolated. Having difficulty relating to peers is strongly associated with feeling helpless and suffering periods of depression and sleeplessness. Young people who feel included and accepted develop positive self-esteem; those who feel rejected and ridiculed rarely do. Ironically, some students who are socially integrated but who spend a great deal of time with their friends in the evenings are likely to engage in health-risk behaviours, such as smoking, alcohol and drug use. Young people typically engage in these behaviours in the company of friends who also smoke, drink or use drugs. Smoking in particular is almost exclusively done with other smokers in settings that reinforce its social and health-related irresponsibility. Youth who smoke and adopt other risk behaviours, at least in part, appear to be seeking peer-group approval and acceptance not available to them from other sources.

A core group of young smokers do not respond to the warnings in educational programs and on cigarette packages; 17 percent of Grade 10 boys and 23 percent of Grade 10 girls are daily smokers. It was not new or surprising to find that young people who engaged in one risk behaviour were more likely to engage in others. For example, 90 percent of Grade 10 daily smokers had also used marijuana.

Most interventions specifically targeted at individual risk behaviours have had little or short-term success. An integrated and systematic approach that recognizes the role of the home, the school, the peer group and the community is required. Schools can encourage teachers to use teaching/learning methods that enable social interaction and skill development. The constantly changing secondary school class makeup associated with individual student timetables that appears to contribute to the social isolation of some students can be countered with a wide and varied extracurricular program designed to respond to the interests of students, stable homeroom groupings and mentoring programs. Parents can provide opportunities at home for young people to get together with friends in activities that are enjoyable, healthy and that support positive peer-group relationships. The community can provide programs, space and resources to help young people use their time in ways that enhance their physical, social and emotional health.

Gender Issues

While today's young women continue to be better adjusted at school than young men, to attain higher levels of school achievement and to be more likely to aspire to and to participate in post-secondary education, they also show evidence of higher levels of stress. For example, girls are far more likely to be concerned about their appearance; to diet; to take medication; to have headaches, backaches and stomachaches; to lack confidence and to suffer periods of depression. They are closing in on boys in the proportion who use drugs and alcohol and are well ahead of boys in the proportion who smoke. On many of these measures there has been an increase through the 1990s.

How they appear to others has become even more important for young women who view their appearance as a fundamental component of a successful career. Concerns about marriage, family and career must seem almost overwhelming for young women today. The stress of competing at school is so great for some that they may disengage from school and, sooner or later, may associate with others who have had similar experiences. Health-risk behaviours, such as smoking and drug use, become the norm for these young women. A sensitive, caring support system involving the school, the home and the community must be available to help both boys and girls through the difficult transitions of the teen years.

Unintentional Injuries

The number of young people in Canada who receive injuries that require medical treatment is disturbingly high, especially by international standards. In spite of our efforts to make sporting activities safer, injuries in both organized and unorganized sport continue to be a serious problem. The playground is also a major source of injury. Legislation regarding seatbelt use does not seem to have had the desired effect on youth: Germany, France and Sweden all have better compliance records. The vast majority of older adolescent bicyclists do not wear helmets. Although Canada prides itself on its safety legislation, safe equipment and appropriate supervision, more effort is required to reduce the injury rates noted in this report.

Concluding Comments

Perhaps the most important theme to arise from this trends analysis is the increase or continuance of health-risk behaviours in youth in spite of educational programs and legislation that have been directed toward reducing the behaviours. Part of this resistance appears to be related to the marginalization of some youth that encourages them to reject much of what they see in school and society and to establish their own norms and values which may include smoking and substance abuse. Health and social problems associated with youth alienation require prevention programs directed at our basic institutions of the family and the school. Addressing the root causes of poor health among youth requires working collaboratively across government and non government organizations to ensure a comprehensive approach to promoting their health where they live, learn, work and play. Increasing young people's access to protective factors for their health and well-being in the environment, such as social support, safe communities, positive parenting and increased health literacy and coping skills can help improve some of the inequities in health attitudes and behaviours observed through this study.

Prevention is fundamental, but what can be done to re-engage the already disengaged? Some success has been achieved with "secondary school retrieval programs" designed to upgrade basic skills, provide supervised work experiences and enable graduation.

Community recreation initiatives that provide space and stimulating activities to youth have also been successful. Interventions such as these must recognize the significance of the peer group in meeting basic social and emotional needs if they are to be viable.

The primary purpose of this report is to provide information on trends in the health of Canadian youth. Some analyses have been presented to identify factors associated with particular health problems and to illustrate the strong relationships among risk behaviours; the policy implications of the findings are stated in very general terms. Obviously more analysis of the data and more effort to develop specific policy is required. The HBSC surveys provide a wealth of useful information about the health behaviours of youth from both a national and cross-national perspective. More policy-directed research on the role of the family, school and peer group in the health of youth is clearly required.