HEALTH EDUCATION RESEARCH
Theory & Practice
Vol.12 no. 1 1997
Pages 37-52
Psychosocial correlates of health compromising
behaviors among adolescents
Dianne Neumark-Sztainer, Mary Story, Simone A. French and
Michael D. Resnick1
Abstract
The objective of the present study was to
examine psychosocial correlates of diverse
health-compromising behaviors among adolescents of different ages. The study population
included 123 132 adolescents in sixth, ninth and
12th grades. Psychosocial correlates of substance abuse, delinquency, suicide risk, sexual
activity and unhealthy weight loss behaviors
were examined. Risk-taking disposition was
significantly associated with nearly every
behavior across age and gender groups. Other
consistent correlates included sexual abuse and
family connectedness. Correlates of healthcompromising behaviors tended to be consistent across age groups. However, stronger
associations were noted between sexual abuse
and substance use for younger adolescents, and
risk-taking disposition and school achievement
were stronger correlates for older youth. The
results suggest the presence of both common and
unique etiological factors for different healthcompromising behaviors among youth. The
results emphasize the importance of focusing
on positive 'risk-taking' experiences for youth in
prevention programs; being sensitive to possible
sexual abuse experiences among both female
and male adolescents in health-care consulta-
Diviskm of Epidemiology, School of Public Health,
University of Minnesota, Minneapolis, MN 55454-1015,
and 'Division of Health Management and Policy, School
of Public Health, and Division of General Pediatrics and
Adolescent Health, School or Medicine, University of
Minnesota, Minneapolis, MN 55455, USA
© Oxford University Press
tions; integrating strategies for improved family
connectedness into health promotion efforts;
and making school relevant for all adolescents.
Introduction
The major causes of adolescent mortality are not
diseases, but are primarily related to preventable
social, environmental and behavioral factors (Irwin
and Millstein, 1986; Millstein, 1989). The three
primary causes of mortality during adolescence are
injuries, homicide and suicide; together they are
responsible for 75% of all adolescent deaths
(Millstein et al, 1993). Major sources of morbidity
include injury and disability associated with the
use of motor or recreational vehicles, pregnancy
complications, sexually transmitted diseases and
consequences of substance abuse (Millstein et al.,
1993). Among adolescent females, eating disorders
are another significant source of morbidity, and
the use of unhealthy weight loss methods may
have numerous psychological and physical health
consequences (Nylander, 1971; Pugliese et al.,
1983; French and Jeffery, 1994; Neumark-Sztainer,
1995). To improve adolescent health it is essential
to reduce the frequency, delay the onset and aim
towards the prevention of behaviors associated
with morbidity and mortality among youth. Following the identification of health-compromising
behaviors to be targeted for intervention, the next
step in building effective prevention programs is
to understand the factors associated with these
behaviors among adolescents at different stages of
development.
Numerous studies on health-compromising
behaviors among adolescents indicate that these
37
D. Neumark-Sztainer et al.
behaviors tend to co-occur, leading to a healthcompromising life-style (Donovan and Jessor,
1985; Donovan et al., 1988, 1991; Osgood, 1991;
Neumark-Sztainer et al., 1996). Research on
Problem Behavior Theory suggests that alcohol and
marijuana use, delinquent behaviors, and sexual
intercourse may constitute a 'syndrome' of
problem behavior in adolescence (Jessor and
Jessor, 1977; Donovan and Jessor, 1985;
Donovan, Jessor et al,
1988). However,
strengths of associations between health-compromising behaviors differ, suggesting that there
may be greater shared etiologic factors for certain
sets of behaviors than for others (Osgood, 1991;
Elliot, 1993). Studies on covariations of healthcompromising behaviors provide information for
hypothesis generation about common underlying
factors leading to the clustering of behaviors.
However, these hypotheses need to be tested
through the comparison of associations between
potential etiologic factors and different healthcompromising behaviors. In a previous study on
the covariations of diverse health-compromising
behaviors, strong associations were found between
substance abuse and delinquency (r = 0.43);
modest associations between both of these
behaviors and suicide risk (correlations ranged
from 0.26 to 0.33); and weak associations between
all of these behaviors and unhealthy weight loss
and sexual activity (correlations ranged from 0.05
to 0.23) (Neumark-Sztainer et al., 1996). It was
hypothesized that those behaviors strongly associated with each other shared common etiologic
or underlying factors; those with modest associations had both common and unique underlying
factors; and those weakly associated with each
other had mainly unique underlying factors. The
present study aims to test these hypotheses through
the examination and comparison of associations
between these behaviors and an array of psychosocial factors. While numerous studies have examined correlates of health-compromising behaviors
(Robbing et al., 1985; Kraft, 1991; Story et al.,
1991; Swanson et al., 1992; Vega et al. 1993;
Walter et al. 1993; Nagy et al., 1994; Velez and
Ungemack, 1995), few studies examine correlates
38
across diverse behaviors (Donovan et al., 1991).
While it is possible to compare correlates of diverse
health-compromising behaviors across studies,
complications may arise due to different methodologies and study populations. The identification of
etiologic factors common to an array of healthcompromising behaviors may foster the design
of more effective and cost-efficient prevention
programs.
Social Cognitive Theory (SCT) discusses the
importance of personal, socio-environmental and
behavioral factors on behavior and the reciprocal
relations between all of these factors (Bandura,
1977, 1986). SCT has particular relevance for
explaining involvement in health-compromising
behaviors among youth. Jessor has developed a
model specifically aimed at explaining adolescent
risk behavior/lifestyle which incorporates a number of principles similar to those in SCT (Jessor,
1991, 1992, 1993). Personal, socio-environmental
and behavioral factors are shown to influence
adolescent risk behavior with reciprocal relationships among all of the factors. However, personal
factors are separated into biological and personality domains while the social environmental
factors are divided into actual and perceived
domains. Jessor indicates that both risk factors
and protective factors may exist within each
domain. Both of these models were used as a
guide in developing a theoretical framework for
the present study and in selecting variables
whose associations with health-compromising
behaviors were to be examined (see Figure
1). Personal factors include those from the
psychological domain: self-esteem, emotional
well-being and risk-taking disposition. Socioenvironmental factors include both actual and
perceived components such as family structure
and family connectedness, school connectedness,
and stressful life experiences such as past physical
and sexual abuse. Behavioral factors include
school achievement, involvement in extracurricular activities and attendance at religious services.
It should be noted that the placement of these
variables into these larger categories is not clearcut as most of these variables have personal,
Health-compromising behaviors
School achievement
Extra cumcular activities
Physical abuse
Religiosity
Sexual abuse
Family structure
RiiV-taking
disposition
Youth
Involvement in
Health
Compromising
Behaviors
School connectedness
Family connectedness
N
,
Number of concerns
Fig. 1. A framework for understanding factors influencing youth involvement in health-compromising behaviors
socio-environmental and behavioral components
(e.g. school connectedness and achievement,
religiosity and physical and sexual abuse). However, the purpose of this study was to compare
associations with specific variables across an
array of behaviors, and not with domains, thus
their unique placement into domains is of
less concern.
The objective of the present study was to
examine global psychosocial correlates of diverse
health-compromising behaviors in a large population of adolescents. Health-compromising behaviors studied are those that have been shown to
make substantial contributions to morbidity and
mortality among adolescents, including substance
abuse, suicide risk, delinquency, unhealthy weight
loss and high-risk sexual activity. This study
expands upon previous research on risk factors
for health-compromising behaviors in that correlates of an array of behaviors are examined.
Furthermore, the large study population allows
for analyses of associations among males and
females in early, middle and late adolescence.
Methods
Study population and study design
The study population included 123 132 sixth, ninth
and 12th grade adolescents in Minnesota who
completed the Minnesota Student Survey in 1992.
This statewide classroom administered survey was
prepared by the Prevention and Risk Reduction
Unit of the Minnesota Department of Education
and distributed in all but one of the 411 school
districts within Minnesota. In most districts, the
entire student population in these grades participated in the study; however, within a few of the
larger school districts, representative sampling was
undertaken. The study population includes
approximately 73% of the actual student enrollment for these three grades in 1992. Details on
sampling, instrumentation, psychometrics, consent
procedures and data cleaning have been described
elsewhere (Minnesota Student Survey, 1992;
Harrison and Luxenberg, 1995). The study population included 50.1% males and 49.9% females.
39
D. Neumark-Sztainer et al.
Adolescents ranged in age from 11 to 21 years
(mean = 14.3, SD = 2.4) with 37.2% in sixth
grade, 36.0% in ninth grade and 26.9% in 12th
grade. Ethnic breakdown was as follows: 1.3%
American Indian, 1.4% African American, 1.1%
Hispanic, 2.4% Asian American, 87.0% white and
6.4% other/mixed/unknown.
Measures
The Minnesota Student Survey focuses on highrisk behaviors and associated factors. Questions
were mainly based on items used in the Adolescent
Health Survey (see Resnick et al, 1993; Saunders
et al, 1994), the National Institute on Drug Abuse
Monitoring the Future Survey (Johnston et al.,
1986) and the National Youth Risk Behavior
Survey (Kann et al., 1995). The present study
focuses on items and scales assessing healthcompromising behaviors and psychosocial factors.
Global psychological, familial and social factors
reported by others to be associated with healthcompromising behaviors were chosen for inclusion
in the present study (Resnick et al, 1993; Benson
et al, 1995). The questions had also been used in
a previous version of the Minnesota Student Survey
in 1989 and minor modifications had been made.
Descriptive data for all of the scales are presented
in Table I.
Health-compromising behaviors
Unhealthy weight loss behaviors
Respondents indicated involvement in any of the
following behaviors for weight control purposes:
laxative use, water pills (diuretics), diet pills and
vomiting. Internal consistency as measured by
Cronbach's a was 0.60. Scores ranged from 0 to
4, for the number of methods used.
Substance abuse behaviors
Respondents indicated frequency and quantity of
consumption for cigarettes, alcohol and marijuana.
Responses to six questions were summed (a =
0.81).
Delinquent behaviors
Adolescents reported the frequency with which
they had damaged or destroyed property; hit or
40
beat up another person; or taken something from
a store without paying for it, over the past 12
months. Responses were summed (a = 0.84).
Sexual activity
Adolescents in the ninth and 12th grades indicated:
whether they ever had sexual intercourse, number
of opposite gender partners over the past 12 months
and frequency of birth control use. Responses were
summed with higher scores indicating higher risk
sexual activity (more partners and less use of birth
control) (a = 0.98). Data on sexual behaviors
were not collected on sixth graders.
Suicide attempts
Adolescents completed two questions regarding
suicidal ideation and behaviors, and indicated
whether they had thought about, or attempted
suicide, over a year ago, during the past year, both
or never. Responses were summed with higher
scores indicating increased suicidal risk (a = 0.54).
Psychosocial variables
Emotional well being
Emotional well being was assessed with six questions regarding mood, stress, sadness, hopelessness,
nervousness and personal satisfaction over the
past month. Each question had five categories
of response which were summed. Higher scores
indicated more positive emotional well being
(a = 0.82).
Self-esteem
This scale included seven items tapping personal
satisfaction, pride, worthiness, abilities and
feelings about oneself. Respondents indicated how
strongly they agreed with each statement with four
categories of response. Responses were summed
with higher scores indicating a higher self-esteem
(a = 0.85).
Risk-taking disposition
Adolescents indicated whether they 'get a real kick
out of doing things that are a little dangerous' on
a four-point scale ranging from 'not at all' to
'very much'.
Health-compromising behaviors
Table I. Health-compromising behaviors and psychosocial variables: descriptive data
Scale
Health behaviors
unhealthy weight loss
substance abuse
delinquent behaviors
sexual activity (males)
sexual activity (females)
Psychological variables
emotional well-being
self-esteem
risk-taking disposition
no. of concerns
extracurricular activities
religiosity
school connectedness
school achievement
physical abuse
sexual abuse
family connectedness
family structure
Mean
SD
0.05
1.49
1.54
2.90
2.86
0.30
0.82
0.74
0.69
0.53
2.31
3.27
2.33
25.77
24.14
5.60
3.38
2.89
2.25
2.10
3.83
3.60
0.51
0.65
0.97
4.22
9.21
1.83
1.05
0.77
0.58
0.36
0.99
0.64
Range
n
Cronbach's a
0-4.00
1.00-6.67
1.00-5.00
1.00-6 50
1.00-6.00
123131
121615
121919
35584
35831
0.60
0.81
0.84
0.98
0.98
0.50-3.33
1.CXM.00
1.00-4.00
20.00-40.00
10.00-70.00
2.00-8.00
1.00-5.00
0-4.00
2.00-4.00
2.00-4.00
1.00-5.00
1.00-4.00
122142
121999
120193
123078
98478
120772
122229
117765
119480
119582
120053
121291
0.82
0.85
—
0.84
0.82
0.72
—
—
0.70
0.53
0.92
—
Number of concerns
School connectedness
Adolescents were asked to indicate which of 20
items they worried about very much. Items included
personal issues such as having friends, appearance,
weight, pregnancy, death, and social issues such
as pollution, nuclear war and racial discrimination.
The number of items for which they expressed
concern was computed (a = 0.84).
Adolescents indicated how they felt about going
to school. Five categories of response ranged from
'I like school very much' to 'I hate school'
with higher scores indicative of greater school
connectedness.
Involvement in extracurricular activities
Adolescents reported how many hours in a typical
week they engaged in each of 10 extracurricular
activities such as school sports, reading, creative
activities, clubs, volunteer work and work for pay.
Responses were scored on a seven-point scale and
summed (a = 0.82).
Religiosity
Adolescents reported on the frequency of attending
religious services and the importance of religion
in their lives. Both questions had four categories
of response which were summed together with
higher scores indicative of higher levels of religiosity (a = 0.72).
School achievement
Adolescents reported the two grades which they
received most frequently and a modified grade
point average, ranging from 0 to 4.0, based on
these two scores was calculated.
Physical abuse
Physical abuse was assessed with two questions
on whether anyone in their household (or family)
had hit them (or anyone else in the family) so hard
or so often that they had marks or were afraid of
that person (a = 0.70).
Sexual abuse
Sexual abuse was assessed with the following two
questions: 'Has any adult or older person outside
the family ever touched you sexually against your
41
D. Neumark-Sztainer et al.
wishes or forced you to touch them sexually?' and
'Has any older or stronger member of your family
ever touched you sexually or had you touch them
sexually?' Responses to each question were coded
as 0 and 1 and were summed (a = 0.53).
Family connectedness
Family connectedness was assessed with a fiveitem scale assessing adolescents' perceptions of
how much their family cared about them and their
feelings, respected their privacy, understood them,
and had fun together. The five categories of
response, which ranged from 'not at all' to 'very
much', were summed, with higher scores indicative
of greater family connectedness (a = 0.92).
Family structure
Adolescents reported adults with whom they lived
and responses were coded in descending order as:
living with two adults, living in a single parent
household, living with others or living alone.
Data analysis
Strength of association between psychosocial variables and health-compromising behaviors were
examined with Pearson's correlation coefficients
separately among males and females. Associations between psychosocial variables were also
examined using Pearson's correlation coefficients. Multiple stepwise linear regressions were
employed in analyzing associations between
psychosocial variables and health-compromising
behaviors. Health-compromising behaviors were
the dependent variables, and separate regressions
were run on each behavior for the different age
and gender groups. The contribution of each
psychosocial variable to the total explained variance in the behaviors and the total percent of
variance explained by all of the psychosocial
variables included in the analyses was determined.
Listwise deletion of variables was done in the
multiple regression analyses. Therefore, respondents with missing values for any of the psychosocial variables included in the analyses were
excluded (14.9%, n = 18 346). These students
were compared with the other students with regard
42
to gender, age, ethnicity and involvement in healthcompromising behaviors. Students with missing
data were more likely to be male, younger and
non-white (with the highest rates among American
Indians and those indicating mixed/other/don't
know for ethnic background). Differences in
health-compromising behaviors were not substantial.
Results
Unadjusted associations between psychosocial
variables and health-compromising behaviors
among males and females are presented in Tables
II and in, respectively. Due to the large sample
size, all of the correlations were statistically significant {P < 0.001), except for the correlations
with extracurricular activities and with number
of concerns. Inverse associations were found with
all protective factors (i.e. stronger emotional well
being, higher self-esteem, religiosity, school connectedness and achievement, family connectedness, and more conventional family structure).
Adolescents who indicated that they liked to take
risks, had more concerns and had experienced
physical or sexual abuse were more likely to
engage in all of the health-compromising
behaviors. Similar patterns of association were
found among males and females. Well being, selfesteem and, to a lesser extent, family connectedness
were strongly associated with suicide risk. Risktaking disposition was a strong predictor of substance abuse and delinquency. The associations
between psychosocial factors and suicide risk,
substance abuse and delinquency were considerably stronger than associations with unhealthy
weight loss behaviors and sexual activity, which
were quite small. Due to the weak associations
found between reported health-compromising
behaviors and number of concerns and extracurricular involvement (and the large number of
missing values for extracurricular involvement, see
Table I), these two variables were excluded from
multiple regression analyses.
Associations between the 10 psychosocial variables were examined prior to their inclusion in
Health-compromising behaviors
Table II. Associations between psychosocial variables and health-compromising behaviors among adolescent males: Pearson's
correlation coefficients
Variables'
Suicide
risk
Substance
abuse
Delinquency
Unhealthy
weight loss
Sexual
activity
Emotional well being (high)
Self-esteem (high)
Risk-taking disposition
No. of concerns
Extracurricular activities
Religiosity (high)
School connectedness (high)
School achievement (high)
Physical abuse
Sexual abuse
Family connectedness (high)
Family structure (conventional)
-0.44
-0.43
0.21
0.06
0.00
-0.12
-0.20
-0.20
0.28
0.27
-0.35
-0.12
-0.21
-0.17
0.34
-0.04
-0.12
-0.26
-0.25
-0.32
0.16
0.20
-0.30
-0.13
-0.25
-0.22
0.41
0.05
0.00
-0.17
-0.29
-0.25
0.25
0.20
-0.31
-0.12
-0.11
-0.12
0.08
0.02
0.00
-0.03
-0.09
-0.09
0.11
0.21
-0.11
-0.07
-0.05
-0.02
0.18
0.03
0.00
-0.12
-0.10
-0.09
0.08
0.10
-0.10
-0.07
"Due to the large sample size, all correlates are significant (P < 0.001), except for those between extracurricular activities and
suicide risk, delinquency, unhealthy weight loss and sexual activity.
Table m . Associations between psychosocial variables and health-compromising behaviors among adolescent females: Pearson's
correlation coefficients
Variables'
Suicide
risk
Substance
abuse
Delinquency
Unhealthy
weight loss
Sexual
activity
Emotional well being (high)
Self-esteem (high)
Risk-taking disposition
No. of concerns
Extracurricular activities
Religiosity (high)
School connectedness (high)
School achievement (high)
Physical abuse
Sexual abuse
Family connectedness (high)
Family structure (conventional)
-0.50
-0.49
0.28
0.15
-0.03
-0.16
-0.23
-0.25
0.32
0.27
-0.44
-0.12
-0.27
-0.26
0.38
0.04
-0.15
-0.28
-0.30
-0.33
0.22
0.24
-0.31
-0.15
-0.26
-0.26
0.37
0.11
-0.03
-0.18
-0.25
-0.23
0.28
0.18
-0.32
-0.11
-0.21
-0.23
0.17
0.07
-0.02
-0.08
-0.11
-0.12
0.15
0.15
-0.19
-0.06
-0.06
-0.05
0.13
0.03
-0.04
-0.16
-0.11
-0.08
0.08
0.12
-0.08
-0.09
'Due to the large sample size, all correlates are significant (P < 0.001).
multiple analyses, in order to avoid problems in
interpretation resulting from collinearity (data not
shown in tables). Among the boys, correlation
coefficients ranged from -0.31 (between physical
abuse and family connectedness) to 0.62 (between
self-esteem and emotional well being). Other relatively strong associations were found between selfesteem and family connectedness (r = 0.48),
between emotional well being and family connect-
edness (r = 0.47), and between school
connectedness and school achievement (r = 0.31).
Similar patterns were found among the girls, with
correlation coefficients ranging from -0.38
(between physical abuse and family connectedness)
to 0.65 (between self-esteem and emotional well
being). Other relatively strong associations were
found between self-esteem and family connectedness (r = 0.55), between emotional well being
43
D. Neumark-Sztainer et al.
and family connectedness (r = 0.53), and between
self-esteem and school connectedness (r = 0.34).
All other associations fell between -0.30 and 0.30.
These associations were not strong enough to
suggest that similar concepts were being measured,
with the possible exception of self-esteem and
emotional well being.
The percent of variance in the health-compromising behaviors explained by psychosocial variables
assessed in the present study are shown in Table
IV for males and Table V for females in sixth,
ninth and 12th grades. Among all gender and
age groups, psychosocial variables explained the
largest percent of the variance for suicidal risk
behaviors (28.3-40.0%) followed by substance
abuse (17.0-39.2%) and delinquent behaviors
(17.9-31.4%). The psychosocial variables did not
explain a large percent of the variance in either
unhealthy weight loss behaviors (3.2-9.8%) or
sexual activity (3.5-6.8%).
The strongest correlates of suicide risk included
poor emotional well being and low self-esteem.
Other correlates included physical abuse, sexual
abuse, risk-taking disposition and low family connectedness. Consistent patterns were found across
gender and age groups. Substance abuse was
associated with a risk-taking disposition, poor
school achievement and low school connectedness
across most gender and age groups. Sexual abuse
was the strongest predictor of substance use among
young males with a decreasing association among
the older adolescents. Low family connectedness
and lower levels of religiosity were also predictors
of substance use; however, associations among
males and females in the different age groups were
not consistent. Delinquency was correlated with
risk-taking disposition, physical abuse, and low
family and school connectedness across gender
and age groups. In addition, sexual abuse was a
consistent predictor of delinquency among males
across age groups. Low family connectedness was
also a strong predictor of delinquency in all groups
except the sixth grade males, for whom poor
emotional well being was a strong predictor. Sexual
abuse was a consistent predictor of unhealthy
weight loss behaviors among males with self-
44
esteem and emotional well being making minor
contributions. Among the females, across the different age groups, self-esteem was the strongest
predictor of unhealthy weight loss with risk-taking
disposition and sexual abuse making weaker contributions. The psychosocial predictors assessed in
the present study explained very little of the
variance in sexual activity, with the strongest
predictors including risk-taking disposition among
all groups and low religiosity among 12th grade
males and females.
Discussion
An important aim of this analysis was to determine
why health-compromising behaviors tend to cooccur and why strengths of association between
behaviors differ. In a previous study we found that
substance abuse and delinquency were strongly
associated with each other; both substance abuse
and delinquency were modestly associated with
suicide risk; and all of these behaviors were weakly
associated with unhealthy weight loss and highrisk sexual activity (Neumark-Sztainer et at,
1996). These findings suggested that while healthcompromising behaviors tend to co-occur they
may not all belong to a similar syndrome. We
hypothesized that behaviors strongly associated
with each other would share more underlying or
etiologic factors, those modestly associated with
each other would have both common and unique
etiologic factors, and those with weak associations
would be explained mainly by unique underlying
factors. While the present study is cross-sectional,
making inferences regarding causality tenuous, the
findings support this hypothesis.
Strong correlates of both substance abuse and
delinquency included a risk-taking disposition
while school connectedness and school achievement were also associated with these behaviors for
most subgroups. In contrast, suicide risk was
strongly correlated with emotional well being and
self-esteem, which were not strong correlates of
either substance abuse or delinquency for most
subgroups. However, weaker and less consistent
correlates of suicide risk included a risk-taking
Health-compromising behaviors
Table IV. Psychosocial predictors of health compromising behavion among adolescent males in early, middle and late adolescence: multiple
regression analyses
Behaviors
Grade
9
6
Predictors1
Suicide risk
Substance abuse
Delinquency
^XlOO
(n = 16634)
28.3%
Well being
Self-esteem
Physical abuse
Risk-taking
Sexual abuse
Family conn.
School conn
School achiev.
Religiosity
(n = 16577)
17.0%
Sexual abuse
Risk-taking
Family conn.
School conn.
School achiev.
Physical abuse
Religiosity
Well being
Family structure
Self-esteem
(n = 16659)
28.0%
Risk-taking
Well being
Physical abuse
School conn.
Sexual abuse
Family conn.
Religiosity
School achiev.
Unhealthy weight loss (n = 16694)
3.2%
Sexual abuse
Self-esteem
School conn.
School achiev.
Family structure
Risk-taking
Sexual activity
P
-0.43
-0.26
0.12
0.11
-0.11
-0.04
-0.03
-0.02
0.25
0.23
-0.16
-0.13
-0.10
008
-0.04
-0.04
- 0 03
-0.02
0.39
-0.24
0.17
-16
0.10
-0.09
-0.06
-0.05
0.14
-0.09
-0.05
-0.04
-0.02
0.02
Predictors1
(n = 19945)
Well being
Sexual abuse
Self-esteem
Risk-taking
Physical abuse
Family conn.
School achiev.
Family structure
Religiosity
(n = 19885)
School achiev.
Risk-taking
Sexual abuse
School conn.
School conn.
Physical abuse
Religiosity
Family conn.
Family structure
Well being
(n = 19958)
Risk-taking
Family conn.
School achiev.
Sexual abuse
Physical abuse
School conn.
Religiosity
Well being
Family structure
(n = 19973)
Sexual abuse
Well being
School conn
Family structure
Risk-taking
Physical abuse
Self-esteem
Religiosity
(n = 17730)
Risk-taking
Sexual abuse
School conn.
Family structure
Religiosity
Physical abuse
Self-esteem
Family conn.
School achiev.
12
tf'xiOO
P
32.44%
-0.45
0.22
-0.24
0.13
0.11
-0.07
-0.06
-0.04
-0.03
32.2%
-0.38
0.31
0.20
-0.15
-0.15
0.11
-0.10
-0.08
-0.05
-0.05
31.4%
0.44
-0.24
-0.16
0.13
0.11
-0.11
-0.07
-0.06
-0.03
8.8%
0.26
-0.10
-0.06
-0.05
0.05
0.04
-0.04
0.01
4.9%
0.15
0.12
-0.06
-0.05
-0.04
0.03
0.03
-0.05
-0.02
Predictors1
/^XlOO
(n = 15442)
31.0%
Well being
Sexual abuse
Self-esteem
Risk-taking
Physical abuse
Family conn.
School achiev.
Family structure
Religiosity
(n = 15412)
26.9%
School achiev.
Risk-taking
School conn.
Religiosity
Sexual abuse
Family structure
Physical abuse
Family conn.
Self-esteem
(n = 15443)
24.0%
Risk-taking
Family conn.
Sexual abuse
School conn.
Physical abuse
School achiev.
Religiosity
WeU being
(n = 15452)
5.2%
Sexual abuse
Physical abuse
School conn.
Risk-taking
Family conn.
Self-esteem
Family structure
School achiev.
Religiosity
(n = 14379)
6.8%
Risk-taking
Religiosity
School achiev.
Self-esteem
Sexual abuse
School conn.
Family structure
Physical abuse
Family conn.
P
-0.44
0.23
-0.24
0.12
0.10
-0.08
-0.04
-0.04
-0.03
-0.34
0.29
-0.18
-0.15
0.11
-0.06
0.05
0.04
0.02
0.38
-0.20
0.15
-0.13
0.11
-0.09
-0.06
-0.04
0.19
0.08
-0.07
0.05
-0.04
-0.03
-0.02
-0.02
0.02
0.20
-0.12
-0.07
0.05
0.05
-0.05
-0.04
0.03
-0.03
The contributions of all of the predictor variables to the explained variance in the behaviors were of statistical significance (P < 0.0001).
45
D. Neumark-Sztainer et al.
Table V. Psychosoaal predictors of health compromising behaviors among adolescent females in early, middle and late adolescence: multiple
regression analyses
Behaviors
Grade
6
Predictors1
Suicide risk
Substance abuse
Delinquency
^XlOO
(n = 17132)
31.4%
Well being
Self-esteem
Physical abuse
Risk taking
Sexual abuse
Family conn.
School achiev.
Religiosity
(n = 17111)
17.5%
Risk-taking
Family conn.
Sexual abuse
School achiev.
Physical abuse
School conn.
Religiosity
Well being
Family structure
Self-esteem
(n = 17159)
21.3%
Risk-taking
Family conn.
Physical abuse
School conn.
Sexual abuse
WeU being
Religiosity
Family structure
Unhealthy weight loss (n = 17176)
4.6%
Self-esteem
Sexual abuse
Risk-taking
Physical abuse
Family conn.
School achiev.
Sexual activity
12
9
P
Predictors1
/r'xlOO
(n = 20779)
Well being
Self-esteem
Risk-taking
Sexual abuse
Family conn.
Physical abuse
School achiev.
Religiosity
Family structure
40.9%
-0.45
-0.25
0.18
0.13
0.12
-0.11
-0.03
-0.02
(n = 20753)
Risk-taking
School achiev.
School conn.
Religiosity
Sexual abuse
Physical abuse
Family conn.
Family structure
Well being
39.2%
(n = 20790)
Risk-taking
Family conn.
School achiev.
Physical abuse
School conn.
Religiosity
Sexual abuse
Well being
Family structure
Self-esteem
(n = 20795)
Self-esteem
Risk-taking
Sexual abuse
Physical abuse
Well being
Religiosity
Family structure
Family conn.
(n = 19042)
Risk-taking
Sexual abuse
School achiev.
School conn.
Family structure
Religiosity
Physical abuse
Self-esteem
Family conn.
30.0%
0.28
-0.21
0.17
-0.11
0.09
-0.07
-0.05
-0.04
-0.03
-0.02
0.32
-0.26
0.17
-010
009
-0.09
-0.04
-0.03
-0.17
0.09
0.07
0.06
-0.05
-0.03
P
-034
-0.30
0.17
0.14
-0.14
0.09
0.07
-0.03
-0.01
0.44
-0.35
-0.17
-0.14
0.13
0.10
-0.07
-005
-0.03
0.42
-0.25
-0.19
0.14
-0.10
-0.08
0.05
-0.03
-0.02
0.03
9.8%
-0.25
0.14
0.10
0.06
-0.05
-0.03
-0.02
-0.02
3.5%
0.09
-0.06
-0.06
-0.04
-0.03
0.03
0.02
-0.03
Predictors1
/^XlOO
(n = 15708)
32.9%
Well being
Self-esteem
Sexual abuse
Family conn.
Risk taking
Physical abuse
School achiev.
Family structure
School conn.
Religiosity
(n = 15696)
283%
Risk-taking
School achiev.
Religiosity
School conn
Sexual abuse
Physical abuse
Family structure
Self-esteem
-0.48
-0.27
0.15
-012
0.09
008
-0.06
-0.02
0.02
-0.02
0.35
-0.29
-0.21
-0.16
0.09
0.07
-0.05
-0.03
(n = 15717)
17.9%
Risk-taking
Family conn.
Physical abuse
School conn.
Religiosity
School achiev.
Sexual abuse
Well being
0.31
-0.19
0.13
-0.11
-009
-0.06
0.04
-0.03
(n = 15718)
7.8%
Self-esteem
Risk-taking
Physical abuse
Sexual abuse
Well being
School achiev.
-0.23
0.11
0.08
0.06
-0.05
-0.03
(n = 14974)
6.8%
Religiosity
Risk-taking
Sexual abuse
School conn.
Family structure
School achiev.
Well being
Physical abuse
-0.19
0.13
0.08
-0.07
-0.06
-0.04
0.03
0.03
T h e contributions of all of the predictor variables to the explained variance in the behaviors were statistically significant (P < 0.0001).
46
P
Health-compromising behaviors
disposition, sexual abuse, physical abuse and
family connectedness, which were also associated
with substance abuse and/or delinquent behaviors
among certain subgroups.
The global psychosocial predictors assessed in
the present study were not strongly correlated with
either unhealthy weight loss behaviors or sexual
activity, suggesting unique domain-specific etiologic factors for these behaviors. Previous research
has suggested that the strongest predictor of excessive weight loss behaviors is body dissatisfaction
(Artie and Brooks-Gunn, 1989; Story et al, 1991;
Neumark-Sztainer, 1995). Although body dissatisfaction may be associated with self-esteem, which
was a correlate of disordered eating among females
in the present study, it is a more domain-specific
measure than self-esteem. In a review of healthcompromising lifestyles among adolescents, Elliot
(1993) stated that while the size and consistency
of the covariations between problem behaviors are
too great to allow a pure coincidence explanation,
the level of covariation is too weak to support
a single etiologic explanation. Rather, the most
plausible explanation involves a partial commonality in etiology as well as some unique causal
factors linked to specific types of problem
behaviors. The findings in the present study lend
empirical support to this theory. Nevertheless, it is
important to note that methodological issues may,
in part, explain the differences in associations
between psychosocial variables and health-compromising behaviors, as correlation and regression
coefficients are influenced by numerous factors
such as the variance of the behavior in the population and the reliability of the scales assessing
psychosocial concerns.
Psychosocial correlates of health-compromising
behaviors were examined across age groups of
adolescents and by gender, and the consistencies
found are striking. The main difference among age
groups is the relatively strong association between
sexual abuse and substance use among sixth grade
males, and to a lesser extent among females, as
compared to older adolescents for whom risktaking disposition and school achievement were
stronger correlates. This is not surprising as sub-
stance use in the sixth grade is less normative
and may be due to more distressful life events.
Consistencies were also found between males and
females with the exception of unhealthy weight
loss behaviors. While self-esteem was the strongest
correlate of unhealthy weight loss among the
females, sexual abuse was the strongest correlate
among the males, suggesting that unhealthy weight
loss among males is more likely to be due to
stressful life events than due to issues of body and
self image. Thus, while a few gender and agespecific differences in psychosocial correlates were
noted, the overall picture was one of consistency.
Adolescents who reported physical or sexual
abuse were more likely to engage in health-compromising behaviors. These findings are similar
to other studies that have shown that abusive
experiences may predispose adolescents to
behavioral and emotional problems (Hibbard et al,
1988, 1990; Kendall-Tackett et al, 1993).
Behavioral manifestations of adolescent abuse
commonly cited include drug and alcohol use,
acting-out sexually, poor school performance, eating disorders, and suicidal ideation (Elster and
Kuznets, 1994).
Several factors were not found to be associated
with health-compromising behaviors. Although
popular portrayals emphasize the difficulties faced
by children in single-parent homes, after controlling for such factors as family connectedness,
family structure was only weakly associated with
involvement in health-compromising behaviors.
Other studies have also shown that relations within
the family have a greater impact on adolescent
health and well-being than does actual family
composition (Resnick et al, 1993). It was somewhat surprising that level of involvement in extracurricular activities was not associated with
engagement in any of the health-compromising
behaviors. This may, at least in part, be due to
the inclusion of a wide range of extracurricular
activities included in this variable (e.g. homework, reading, sports, choices at home and work
for pay). While others have reported that structured
use of time in activities such as music involvement
and participation in community organizations is a
47
D. Neumark-Sztainer et al.
protective factor against involvement in healthcompromising behaviors, the impact of such participation after controlling for other psychosocial
variables has not been reported (Benson et al,
1995). It would be valuable to study this relationship, focusing on the effects of different types and
amounts of extracurricular activities, and examining whether extracurricular involvement is associated with increased or decreased parent supervision
and contact. Religiosity was a relatively weak
correlate of health-compromising behaviors. A
number of difficulties in interpretation arise in
assessing the effect of religiosity in the present
study, and in other large surveys, in which only
one or two questions are asked. The relatively
weak associations with religiosity in the present
study, after controlling for other psychosocial variables, suggests that there may be overlap between
these measures and that the positive effect of
'religiosity' may indeed be due to family connectedness or conventionality (proxy measures in the
present study include school achievement and
school connectedness). An exception to this pattern
was the relatively strong associations found
between religiosity and high-risk sexual activity,
particularly among the older girls, and the weak
associations found between sexual activity and
family connectedness. These findings suggest that
personal religious beliefs may be influencing sexual
involvement Other studies have also found low
religiosity to be a modest predictor of greater
sexual activity (Kraft, 1991; Walter et al., 1993).
In drawing conclusions from the study, a number
of limitations need to be taken into account. As
in all survey data, the question of validity and
reliability arises, although the validity of selfreported health-compromising behaviors has been
found to be quite high (O'Malley et al, 1983;
Winters etal, 1990-91). The internal consistencies
of scales assessing suicide risk and unhealthy
weight loss behaviors were low, probably due to
the small number of items in each scale and the
fact that items were not measuring the same
concept (i.e. different weight loss behaviors were
being examined and thoughts on suicide are not
the same). Risk-taking disposition was assessed
48
with only one question, raising some questions
about this measure. As risk-taking disposition was
consistently correlated with most health-compromising behaviors future research should develop
comprehensive scales to assess risk-taking disposition.
Another limitation of the study was that questions on socio-economic status were not included
in the survey, thus limiting the amount of explained
variance in health-compromising behaviors and
limiting the ability to control for socio-economic
status in analyzing other associations. Finally,
inferences to adolescent populations outside of
Minnesota need to be done cautiously. Factors to
be taken into account in generalizing to other
populations include the geographic location of
Minnesota, its ethnic composition which is predominantly white and its relatively low rates of
youth mortality (ranked 48th as compared to other
states; Centers for Disease Control and Prevention, 1993). Nevertheless, the study is unique and
expands upon the literature on health-compromising behaviors in that few studies have examined
correlates of such diverse health behaviors among
such a large study population.
Conclusions
The results have a number of important practical
implications for the prevention of healthcompromising behaviors among adolescents.
Schools and communities provide an important
avenue for health promotion efforts (see Figure 2).
The finding that risk-taking disposition is a
consistent correlate of these behaviors has been
discussed by others (Irwin and Millstein, 1986)
and has a number of practical implications with
regard to program development. While there is a
tendency to view risk-taking during adolescence
in a negative light, it is actually an important
part of development. Others have discussed the
importance of distinguishing between negative
risk-taking behaviors and 'exploratory behaviors'
or constructive risk taking, which would include
acts associated with positive consequences (Irwin,
1987; Irwin and Vaughan, 1988). It seems import-
Health-compromising behaviors
Health education programs
aimed at the prevention and
reduction of health-compromising
behaviors and a healthy lifestyle
Promotion of a positive
school environment for all
students: including those who
are not succeeding academically
Implementation of school policies and teaching
strategies which promote positive self esteem
and emotional well being among students
Decrease Youth
Involvement in
Health-Compromising
Outreach to families:
-services for disconnected families
-involvement of parents in school activities
-development of family activities within the community
Social and psychological
services within school-based
clinics and the community
Affordable and accessible
opportunities within the school
or community for youth to participate
in positive exploratory activities,
(e.g. sports, dance, or camping)
Fig. 2. Suggested areas of focus for schools and communities to decrease youth involvement
ant to find positive ways for adolescents to engage
in risk-taking such as through sports, arts and
wilderness exploration, providing positive experiences for young people instead of solely placing
the emphasis on education as to the dangers of
these behaviors. Approaches emphasizing youth
development (Pittman and Cahill, 1991; MacDonald et at, 1994) may be effective in the prevention
of health-compromising behaviors in that they
provide venues for young people to engage in
positive exploratory behaviors. Schools need to
work together with other community groups to
provide such opportunities for youth and to encourage their participation.
The finding that sexual abuse was a consistent
predictor of health behaviors, in particular among
males, emphasizes the importance of providing
accessible counseling services for youth where
there is an open and accepting environment for
discussing such sensitive issues. This could be
integrated into school-based clinics or provided
within the community in settings which are
affordable and easily accessible to youth. Further-
more, when health-compromising behaviors are
present, screening for sexual abuse is of particular importance. The health care system must
allow time for health care professionals to interact
with adolescents and explore and discuss issues
which may be leading to involvement in healthcompromising behaviors. This recommendation is
consistent with the American Medical Associations' Guidelines for Adolescent Preventive Services (GAPS) which provide a framework an
vehicle for psychosocial assessment of the adolescent during routine periodic health care visits
(Elster and Kuznets, 1994).
The importance of family connectedness as a
correlate of health-compromising behaviors has
also been reported previously (Resnick et al.,
1993). Crockett and Peterson (1993) suggest that
health promotion efforts should seek to strengthen
parent-adolescent relationships and facilitate
authoritative parenting whose central components
include emotional warmth, democratic decision
making, appropriate monitoring and clear standards
for behavior. Our results further suggest that while
49
D. Neumark-Sztainer et al.
school-based programs are important, their effectiveness is bound to be limited without parental or
other adult involvement, in particular for those
adolescents who do not have a high level of family
connectedness. Practical methods for increasing
family connectedness and effective functioning
need to be viewed as part of strategies for adolescent health promotion and risk reduction (Schorr
and Schorr, 1988).
The results stress the importance of a positive
school experience for all youth, as substance abuse
and delinquency were both associated with whether
or not adolescents indicated that they enjoyed
going to school. Previous research has shown that
students who are not achieving in school are at
highest risk for many health-compromising
behaviors that may compound and exacerbate their
problems with school performance (Blum, 1987).
A challenge that remains is how more supportive and positive environments can be promoted in schools. A key element in making a
school a positive learning environment appears to
be a personal environment that explicitly supports
a students' physical, emotional and social wellbeing in addition to their academic achievement.
Perry et al. (1993) stress that adolescent health
promotion efforts should not be concerned with
the development of programs for specific health
behaviors, but should also consider the total school
environment. Finally, the overall pattern of consistency in risk factors across age groups imply that
while educational programs need to be age and
developmentally appropriate in the level of material
and in the type of approach, for most behaviors
the major themes need not differ greatly.
The findings clearly illustrate the complexity of
youth involvement in health-compromising
behaviors as numerous factors are associated with
these behaviors. Elliot (1993) stresses the need for
further research and notes that our present system,
which focuses narrowly on particular behavioral
domains, is poorly equipped to address the adolescent lifestyle as a coherent set of interrelated
behaviors. Research efforts should continue to
examine the common and unique factors leading
to involvement in diverse health-compromising
50
behaviors among youth. Research is also needed
to examine these relationships in youth from varied
racial and socioeconomic backgrounds. A better
understanding of these issues will lead to the
development of more effective interventions.
Acknowledgements
The authors would like to acknowledge the Prevention and Risk Reduction Team at the Department
of Children, Families and Learning for conducting
the study and in preparation of the data for analysis.
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Received August 16, 1995; accepted March 16, 1996