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Health Risk Behaviors Among Adolescents Who Do and Do Not Attend School -- United States, 1992

High proportions of U.S. high school students engage in behaviors that place them at increased risk for the leading causes of death and morbidity (e.g., motor-vehicle crashes and other unintentional injuries, homicide, suicide, heart disease, and cancer {1}), unintended pregnancy, and infection with human immunodeficiency virus (HIV) and other sexually transmitted diseases (2). Because efforts to measure health-risk behaviors among adolescents throughout the United States have not included those who do not attend school, the prevalences of those behaviors are probably underestimated for the total adolescent population. To characterize more accurately the prevalence of selected health-risk behaviors among adolescents aged 12-19 years who do and do not attend school, CDC analyzed self-reported national data from the Youth Risk Behavior Survey (YRBS), conducted as part of the 1992 National Health Interview Survey (NHIS). This report summarizes the results of the analysis.

The 1992 NHIS was conducted among a representative sample of the civilian noninstitutionalized U.S. population using a multistage cluster-area probability design of approximately 120,000 persons representing approximately 49,000 households. The YRBS was conducted as a followback survey to the NHIS among a representative sample of adolescents in the sampled households. In each household with at least one person aged 12-21 years, the current school enrollment status of each adolescent was determined as either "in-school" (i.e., attending school or on vacation from school at the time of the interview) or "out-of-school" (i.e., not attending school and had not graduated from high school or attained General Educational Development credentials at the time of the interview). Out-of-school adolescents were over-sampled. During April 1992- March 1993, adolescent respondents listened to a tape recording of the questionnaire and recorded their responses on a standardized answer sheet. Questionnaires were completed by 10,645 (77.2%) eligible adolescents. Information was analyzed for the 6969 respondents who were aged 12-19 years and had not completed high school. Among these respondents, 91% were classified as in-school and 9% as out-of-school. Results were standardized by age by using the age distribution of the total population participating in the YRBS. SUDAAN was used to compute all standard errors for the estimates and for differences between the estimates (3). All estimates were based on weighted data.

In-school adolescents were significantly more likely than out-of-school adolescents to have reported "always" using safety belts when riding in a car or truck as a passenger (33.2% versus 23.2%) and were significantly less likely to have reported riding during the 30 days preceding the survey with a driver who had been drinking alcohol (18.9% versus 28.4%), having been involved in a physical fight during the 12 months preceding the survey (44.2% versus 51.0%), and having carried a weapon (e.g., gun, knife, or club) during the 30 days preceding the survey (15.5% versus 22.9%) (Table_1). Use of motorcycle helmets did not vary by school enrollment status.

Out-of-school adolescents were significantly more likely than in-school adolescents to have reported smoking cigarettes during the 30 days preceding the survey (33.7% versus 20.4%) and to have reported ever having smoked cigarettes (57.7% versus 50.9%) or used alcohol (62.9% versus 55.2%), marijuana (31.4% versus 15.9%), or cocaine (7.1% versus 2.1%) (Table 1). Use of chewing tobacco or snuff during the 30 days preceding the survey, episodic heavy drinking *, and injecting-drug use did not vary by school enrollment status.

Out-of-school adolescents aged 14-19 years were significantly more likely than in-school adolescents to have reported ever having had sexual intercourse (70.1% versus 45.4%) and to have had four or more sexual partners (36.4% versus 14.0%) (Table 1) **. Among adolescents who reported having had sexual intercourse during the 3 months preceding the survey, use of condoms at last sexual intercourse did not vary by school enrollment status.

In-school adolescents were significantly more likely than out-of-school adolescents to have reported eating five or more servings of fruits and vegetables during the day preceding the survey (14.5% versus 10.1%) (Table_1). Eating foods typically high in fat content and participating in moderate physical activity did not vary by school enrollment status.

Reported by: Div of Adolescent and School Health, National Center for Chronic Disease Prevention and Health Promotion; Div of Health Interview Statistics, National Center for Health Statistics, CDC.

Editorial Note

Editorial Note: The findings in this report indicate that out-of-school adolescents were more likely to engage in behaviors (e.g., sexual intercourse and cigarette smoking) with potentially severe adverse health outcomes than were adolescents in school. In 1991, 13% of all persons aged 16-24 years in the United States were high school dropouts (4). Some health-risk behaviors (e.g., alcohol use and other drug use and sexual intercourse resulting in unintended pregnancy) may have preceded and contributed to the decision of some adolescents to quit school, and these risk behaviors may increase after adolescents quit school (5).

Because health education can assist adolescents who remain in school to develop skills to avoid or modify health-risk behaviors, two national goals (National Education Goal 2 {4} and year 2000 national health objective 8.2 {5}) are to increase the high school graduation rate to at least 90% by the year 2000. In addition, health objective 8.4 is to increase to at least 75% the proportion of elementary and secondary schools that provide planned and sequential school health education from kindergarten through 12th grade (5).

The findings in this report are being used by public health and education officials to highlight the special needs of out-of-school adolescents and to develop innovative approaches to provide accessible prevention services to adolescents who are not in school. Such approaches may include partnerships among or between schools, health departments, voluntary health organizations, community organizations, religious organizations, families, and adolescents. In 1991, CDC expanded efforts to intensify public health and education programs among out-of-school adolescents and others in high-risk situations (e.g., runaways, homeless adolescents, juvenile offenders, and migrant youth). This initiative is assisting local health departments in Chicago, the District of Columbia, Los Angeles, and New York City to strengthen their capacity to prevent HIV infection and other health problems and to establish or strengthen existing coalitions of community-based organizations that serve youth. By providing training, improving agency referral systems, and sharing resources, these coalitions will help participating agencies increase their capacity to reach youth so that all adolescents will have better access to an integrated service-delivery system that may better meet their needs. References:

  1. Kann L, Warren W, Collins JL, Ross J, Collins B, Kolbe LJ. Results from the national school-based 1991 Youth Risk Behavior Survey and progress toward achieving related health objectives for the nation. Public Health Rep 1993;108(suppl):47-55.

  2. Morris L, Warren CW, Aral SO. Measuring adolescent sexual behaviors and related health outcomes. Public Health Rep 1993;108(suppl):31-6.

  3. Shah BV, Barnwell BG, Hunt PN, LaVange LM. SUDAAN user's manual, release 5.50. Research Triangle Park, North Carolina: Research Triangle Institute, 1991.

  4. National Education Goals Panel. The national education goals report. Washington, DC: National Education Goals Panel, 1991.

  5. Public Health Service. Healthy people 2000: national health promotion and disease prevention objectives -- full report, with commentary. Washington, DC: US Department of Health and Human Services, Public Health Service, 1991; DHHS publication no. (PHS)91-50212.

* Drinking five or more drinks of alcohol on at least one occasion during the 30 days preceding the survey. 

** 12-13-year-olds were not asked the sexual behavior questions.
Table_1
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TABLE 1. Percentage of adolescents aged 12--19 years * who engaged in selected
health-risk behaviors, by school enrollment status + -- United States, Youth Risk
Behavior Survey, National Health Interview Survey, 1992
==============================================================================================================
                                    School enrollment status    Standard
                                    ------------------------  error of the
Behavior                            In-school  Out-of-school   difference    Total
----------------------------------------------------------------------------------
Used safety belts &                   33.2         23.2           2.7 @      32.5
Used motorcycle helmets **            43.7         45.6           6.7        43.6
Rode with a drinking driver ++        18.9         28.4           2.8 @      19.6
Participated in a physical fight &&   44.2         51.0           3.2 @      44.6
Carried a weapon @@                   15.5         22.9           2.9 @      15.7
Lifetime cigarette use ***            50.9         57.7           3.2 @      51.5
Current cigarette use +++             20.4         33.7           2.9 @      21.7
Current smokeless
  tobacco use &&&                      6.8          8.4           1.7         6.9
Lifetime alcohol use @@@              55.2         62.9           3.3 @      55.6
Current episodic heavy
  drinking ****                       17.1         21.8           2.6        17.5
Lifetime marijuana
  use ++++                            15.9         31.4           2.9 @      17.2
Lifetime cocaine use &&&&              2.1          7.1           1.4 @       2.6
Ever injected drugs @@@@               0.8          3.9           1.6         1.0
Ever had sexual
  intercourse (14--19-year-olds)      45.4         70.1           4.1 @      47.5
Sexual intercourse
  with four or more
  sex partners (14--19-year-olds)     14.0         36.4           4.6 @      15.9
Condom use during most recent
  sexual intercourse
  (14--19-year-olds) *****            59.8         50.2           6.1        58.3
Ate fruits and vegetables +++++       14.5         10.1           2.0 @      14.1
Ate foods typically high
  in fat content &&&&&                65.7         70.0           3.3        66.2
Engaged in moderate
  physical activity @@@@@             29.2         31.1           3.5        29.0
----------------------------------------------------------------------------------
    * Standardized by age by using the age distribution of the total population participating in the Youth
      Risk Behavior Survey.
    + In-school = adolescents who were going to school or were on vacation from school at the time of the
      interview. Out-of-school = adolescents who were not presently attending school and had not graduated
      from high school or attained General Educational Development credentials at the time of the interview.
    & Safety belts used "always" when riding in a car or truck as a passenger.
    @ p<0.05
   ** Helmets used "always" among respondents who rode motorcycles.
   ++ Rode at least once during the 30 days preceding the survey in a car or other vehicle driven by someone
      who had been drinking alcohol.
   && Fought at least once during the 12 months preceding the survey.
   @@ Carried a gun, knife, or club at least 1 day during the 30 days preceding the survey.
  *** Ever tried cigarette smoking, even one or two puffs.
  +++ Smoked cigarettes on one or more of the 30 days preceding the survey.
  &&& Used chewing tobacco or snuff on one or more of the 30 days preceding the survey.
  @@@ Ever drank alcohol.
 **** Drank five or more drinks of alcohol on at least one occasion during the 30 dayspreceding the survey.
 ++++ Ever used marijuana.
 &&&& Ever used cocaine.
 @@@@ Respondents were classified as injecting-drug users only if they 1) reported injecting-drug use not
      prescribed by a physician and 2) answered one or more to any of these questions: "During your life,
      how many times have you used any form of cocaine including powder, crack, or freebase?"; "During
      your life, how many times have you used any other type of illegal drug such as LSD, PCP, ecstacy,
      mushrooms, speed, ice, heroin, or pills without a doctor's prescription?"; or "During your life, how
      many times have you taken steroid pills or shots without a doctor's prescription?"
***** Among respondents who had had sexual intercourse during the 3 months preceding the survey.
+++++ Ate five or more servings of fruits and vegetables (e.g., fruit, fruit juice, green salad, and cooked
      vegetables) the day preceding the survey.
&&&&& Ate no more than two servings of foods typically high in fat content (hamburger, hot dogs, or sausage;
      french fries or potato chips; and cookies, doughnuts, pie, or cake) the day preceding the survey.
@@@@@ Walked or rode a bicycle at least 30 minutes at a time during 5 or more of the 7 days preceding the
      survey.
==============================================================================================================

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