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This is to certify that the

thesis entitled

HEALTH RISK BEHAVIORS AMONG ELEVENTH GRADE

STUDENTS ATTENDING A RURAL PUBLIC HIGH SCHOOL
presented by

Marilyn Ledvina Rosi

has been accepted towards fulfillment
of the requirements for

M. S . degree in Nursing

 

 

Major professor

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MSU In An Affirmative Action/Equal Opponunity Institution
W

HEALTH RISK BEHAVIORS AMONG ELEVENTH GRADE
STUDENTS ATTENDING A RURAL PUBLIC HIGH SCHOOL

By
Marilyn Ledvina Rosi

A THESIS
Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1995

ABSTRACT

HEALTH RISK BEHAVIORS AMONG ELEVENTH GRADE
STUDENTS ATTENDING A RURAL PUBLIC HIGH SCHOOL

By

Marilyn Ledvina Rosi

Adolescents face increasingly serious health threats that are primarily
behavioral in origin. Sexual behaviors, tobacco, alcohol and drug use, suicide, and
accidental injury place adolescents at risk for significant morbidity and mortality.
This descriptive study examined health risk behaviors of rural adolescents and the
relationship of gender to selected health risk behaviors using descriptive statistics and
chi-square analysis.

The sample consisted of 51 adolescents enrolled in eleventh grade at a rural
public high school in northern Michigan. The Youth Risk Behavior Survey was
utilized to obtain data. The findings suggested that rural adolescents are engaging in
health risk behaviors that may place them at risk for significant morbidity and

mortality.

ACKNOWLEDGMENTS

I offer thanks to my thesis chairperson, Carla L. Barnes, and to my committee
members, George Allen, Patricia Peck, and Linda Spence. Their knowledge and
guidance were invaluable to me in preparing this manuscript. Special thanks is
extended to the administration of the rural school district where the study was

conducted. Their support and cooperation made this project possible.

iii

TABLE OF CONTENTS

LIST OF TABLES ...................................... vi
LIST OF FIGURES ...................................... vii
Introduction ............................................ 1
Statement of the Problem .................................... 4
Conceptual Definition of the Variables. ..... ' ...................... 5
Health Risk Behaviors .................................. 5
Adolescence. ....................................... 6
Gender. .......................................... 7
Theoretical Model ......................................... 7
Review of the Literature. .................................... 9
Sexual Risk Behaviors ................................. 11
Tobacco, Alcohol, Illicit Drug Use. ........................ 12
Depression, Suicide Ideation, and Suicide . ................... 16
Unintentional Injury. ................................. 18
Summary ........................................ 18
Methods. ............................................ 20
Research Design .................................... 20
Sample ......................................... 20
Operational Definitions of the Variables ..................... 21
Instrumentation .................................... 21
Procedures ....................................... 23

. Data Analysis ..................................... 24
Procedure for Protection of Human Subjects ................... 24
Research Assumptions ................................ 25
Research Limitations ................................. 25
Results .............................................. 26
Description of the Sample .............................. 26
Answers to Research Questions ........................... 28

Frequency of Sexual Risk Behaviors That May Put the Adolescent at

iv

Risk for Sexually Transmitted Disease (STD), Human

Immunodeficiency Virus Infection (HIV), and Pregnancy ...... 28
Frequency of Tobacco Use ......................... 29
Frequency of Alcohol Use ......................... 29
Frequency of Other Drug Use ....................... 30

Frequency of Feelings of Depression, Suicide Ideation, and Suicide
Attempts .................................... 30
Frequency of Behaviors That May Result in Unintentional Injuries . 31
Risk Behavior and Gender ......................... 31
Discussion ............................................ 4O
Interpretation of Results ............................... 40
Sexual Behaviors ............................... 45
Tobacco Use ................................. 46
Alcohol Use .................................. 47
Illicit Drug Use ................................ 47
Suicide Ideation and Suicide Attempts .................. 48
Unintentional Injuries Related to Motor Vehicle Use ......... 49
Unintentional Injuries Related to Weapons and Fighting ....... 50
Risk Behaviors and Gender ......................... 50
Discussion of Results With the Conceptual Model ............... 53
Discussion of Methodological Assumptions and Limitations .......... 54
Implications for Advanced Nursing Practice in Primary Care ......... 54
Recommendations for Further Research ...................... 60
Summary ............................................ 61
REFERENCES ......................................... 62
APPENDIX A. YOUTH RISK BEHAVIOR SURVEY ................ 67
APPENDIX B. FACT SHEET FOR PARENTS .................... 78
APPENDIX C. SURVEY ADMINISTRATION GUIDELINES ........... 81
APPENDIX D. CONSENT FORMS ........................... 83
APPENDIX E. ‘UCRIHS .................................. 85

Table 1.
Table 2.
Table 3.
Table 4.
Table 5.
Table 6.
Table 7.
Table 8.

Table 9.

Table 10.

Table 11.

Table 12.

LIST OF TABLES

Frequencies of Selected Demographic Variables ............. 27
Sexual Health Risk Behavior ......................... 32
Tobacco Use Health Risk Behavior ..................... 33
Alcohol Related Health Risk Behavior ................... 34
Illicit Drug Related Health Risk Behavior ................. 35
Depression, Suicide Ideation, Suicide Attempts .............. 36
Unintentional Injuries Related to Motor Vehicle Use ........... 37
Unintentional Injuries Related to Weapons, Fighting ........... 38

Cross Tabulations and Chi-Square Analysis of Sexual Health Risk
Behavior and Gender ............................. 41

Cross Tabulations and Chi-Square Analysis of Tobacco and Alcohol
UseandGender ...... 41

Cross Tabulations and Chi-Square Analysis of Illicit Drug Use and
Gender ...................................... 42

Cross Tabulations and Chi-Square Analysis of Intentional and
Unintentional Injury and Gender ...................... 43

vi

LIST OF FIGURES

Figure 1. Conceptual Model Adapted From Health Belief Model ......... 10

vii

Introduction

The health of adolescents is a topic of concern among health care
professionals. The extent of the problem and the reasons for concern are well
documented. Adolescents face increasingly serious health threats that are primarily
behavioral in origin. Sexual behavior, tobacco, alcohol and drug use, suicide, and
accidental injury place adolescents at risk for significant morbidity and mortality.

Lavin, Shapiro and Weill (1992) write that by age 15, approximately 27% of
girls and 33% of boys engage in sexual intercourse. By age 17 the proportions rise to
50% of girls and 66% of boys. While the majority of the polled sexually active
students indicate one partner, 19% report 4 or more lifetime partners, and 35% report
2 or more lifetime sex partners.

Data on adolescent childbearing in 1990 from Child Trends, Incorporated
(1993) show that for the fourth consecutive year there has been an increase in both
the teen pregnancy rate and the actual number of births. In 1990, 6% of females
aged 15 to 19 had a birth and 68% of these births were outside of marriage. Teens
accounted for 533,483 of the total 4,158,212 births in 1990 or 13% of all births. For
first births, which are particularly important because they start a new family, teens
accounted for 401,900 of the 1,689,118 births or 24% of all first births.

In addition to the problem of teenage pregnancy, early sexual behavior

contributes to the problem of sexually transmitted disease including human

2

immunodeficiency virus (HIV) infection. Koble (1992) estimated that an average 3
million United States teenagers are infected with a sexually transmitted disease each
year. Depending on the adolescent population studied, 8 % to 25 % of sexually active
adolescent girls have endoccrvical infection with Chlamydia trachomatis, and 0.4% to
12 % have endoccrvical infection with Neisseria gonorrhoea. Human papilloma virus
(HPV) infection of the cervix is found in 15 % to 38% of sexually active adolescent
girls and has been associated with anogenital neoplasm.

Given the prevalence of sexually transmitted disease in adolescent females, the
spread of HIV is of particular concern. Although less than 1% (3,058) of teens in the
UnitedStatesare infected withtthIVvirus, themmberhasrisenby 77% inthe
last 2 years (Hein, 1993). In this age group roughly half of the transmission of the
virus occurs through heterosexual intercourse. It is estimated that 50% of all HIV
infections have occurred in 15 to 24 year olds since the beginning of the epidemic
(Hein, 1993). Acquired Immunodeficiency Disease Syndrome (AIDS) resulting from
HIV infection is the sixth leading cause of death for 15 to 24 year olds (Morris,
Warren, & Aral, 1993).

Gans, Blyth, Elster, & Gaveras (1990) report that more than 8.5 million
adolescents (42%) between the ages. of 12 and 17 have ever smoked cigarettes. Over
3 million (15%) 12 to 17 year olds have used smokeless tobacco, and 4% are current
users. About 10% of 8th and 10th grade boys and 1% of 8th and 10th grade girls
reported that they currently chew tobacco. Cigarette smoking is linked to cancer,
emphysema, and heart disease and is the single most avoidable cause of death in the

United States. Smoking accounts for nearly one third of all cancer deaths among

3
adults and can lead to health problems such as bronchitis, diminished athletic

performance, stained teeth, and bad breath (Gans et al., 1990).

The prevalence of alcohol use remains high, and alcohol use begins at younger
ages. According to Lavin et a1. (1992) more than 77% of eighth grade students and
88% of ninth grade students report having consumed alcohol. Twenty six percent of
eighth grade students and 38% of 10th grade students reported consuming more than
5 drinks on one occasion in the past 2 weeks. Among 15 to 17 year olds involved in
fatal motor vehicles crashes in 1989, 19% had been using alcohol at the time of or
shortly before the crash (Blanken, 1993).

According to Gans et a1. (1990), marijuana is the most widely used illicit drug
among adolescents. More than 3.5 million (17%) 12 to 17 year olds have tried
marijuana and 6% are current users. Results from the National Adolescent Student
Health Survey (1989) reveal that more than one out of every 20 students (6%)
reportedhavingusedcocaineintheirlifetime, and3% reportedcocaineuseduring
the past month.

Data from me Centers for Disease Control published in the Morbidity and
Mortality Weekly Report (1992) cite injuries as the leading cause of death among
persons aged 15 to 19 years in the Unimd States. Of all deaths in this age group,
42% were motor vehicle related, 13% were due to homicide, 13% to suicide, and
11% to other types of injuries. As recently as 1991, approximately half of all fatal
crashes were alcohol related and 77 % of persons killed in motor vehicle crashes were
not wearing safety belts.

Suicide and suicidal behaviors have become an all too frequent occurrence

among American youth. Suicide is the second leading cause of death among white

4

adolescents and occurs five times more frequently among boys than girls (Lamb &
Pusker, 1991). Suicide among persons between the ages of 15 to 24 years has
increased nearly 300% over the past three decades (Reynolds, 1991). Attempts
among females greatly outnumber those by males (Grossman & Rivara, 1992).

Although many health threats potentially affect all adolescents, adolescent
males are at greater risk than females for morbidity and mortality associated with
health risk behaviors. Gans et al. (1990) report that by age 15, males are more than
twice as likely as females to have had sexual intercourse. In general, male students
use substances of all kinds more than female students (O’Malley, Johnston, &
Bachman, 1995). Gans et al. (1990) note that adolescent females are 5 times more
likely than males to attempt suicide, but adolescent males are 4 times more likely to
actually commit suicide. Among 15 to 19 year olds, males are 4 times more likely
than females to die of suicide, 3 times more likely to die of homicide, and 2.5 times
more likely to die of motor vehicle injuries (Gans et a1. , 1990).

Statement of the Problem

Thepurposeofthisstudy wastodcterminethefrequencyofhealthrisk
behaviors among 11th grade adolescents attending a public high school in rural
northern Michigan and compare frequencies with available national averages. The
author investigated the relationship between selected health risk behaviors and
gender. The research questions to be answered were:
(1) What is the frequency of sexual behaviors that may put the adolescent at risk for
sexually transmitted disease, human immunodeficiency virus infection, and
pregnancy?
(2) What is the frequency of tobacco, alcohol, and other drug use?

5
(3) What is the frequency of suicidal ideation and attempted suicide?
(4) What is the frequency of behaviors that may result in unintentional injuries?
(5) What is the relationship between gender and health risk behaviors related to
sexual intercourse, tobacco, alcohol, and illicit drug use, suicide ideation and suicide
attempts, and behaviors that may result in unintentional injuries?
Conceptual Definition of the Variables
1131mm

During adolescence many health related behaviors are developed and initiated
(Grunbaum & Basen-Engquist, 1993). Some behaviors enhance health while others
compromise health status. Primary causes of morbidity and mortality during
adolescence are behavioral in origin. Violence and injury produce nearly 75 % of all
adolescent deaths each year. Substance use and abuse among adolescents, including
tobacco, alcohol, and other drugs, represents a serious concern because these
substances can affect health both during adolescence and later in life.

Millstein, Irwin, Adler, Cohn, Kegeles, & Dolcini (1992) also examined
health risk behaviors among young adolescents. They examined behaviors associated
with adolescent morbidity and mortality including sexual behavior, substance use, and
injury related behaviors. Preventable behaviors and social environmental conditions
contribute substantially to morbidity among adolescents. These include injury and
disability associated with the use of motor and recreational vehicles, consequences of
sexual activity including unplanned pregnancy and sexually transmitted disease and
substance abuse. Risk behavior was described as behavior that placed adolescents at

risk for injury, disability, illness, or death.

6

Health risk behavior for the purpose of this study was defined as behavior that
places adolescents at risk for injury, disability, illness, or death and includes sexual
behaviors, tobacco, alcohol and illicit drug use, suicidal ideation and attempted
suicide, and behaviors related to unintentional injury.

Addams

Gans et al. (1990) divide adolescence into different age groups reflecting
different biopsychosocial stages of development. Early or young adolescent refers to
people between the ages of 10 and 14 years of age. Older adolescent refers to 15 to
19 year olds, and young adult refers to those who are approximately 18 to 24 years of
age. Hein (1993) defines adolescents as pe0ple 13 through 21 years old. The
Centers for Disease Control and Prevention (CDC) defines them as 13 to 19 years of
age.

Jarvis (1992) defines adolescence as a transition stage between childhood and
adulthood which begins at puberty and extends through the teenage years.
Adolescents are those youth between the ages of 12 or 13 to 19. Adolescence,
according to Riggin (1993), is the period of life in which physical and emotional
changes occur at a more accelerated rate than in any other developmental period.
Adolescence is viewed as the developmental period between 12 to 21 years; physical
changes that indicate the beginning of adolescence may begin as early as 7 years of
age and may continue into the twenties. Adolescence, for the purpose of this study,
was described as the period of life from puberty to maturity and included those youth

enrolled in the 11th grade at the time of the study.

7

(finder
Hardy and Conway (1988) define gender as a central physical attribute of all

persons, an attribute associated with species’ procreation functions. The nature of
gender is dichotomous. One is either male or female; one cannot be gender free.
For the purpose of this proposal gender was described as the attribute associated with
being male or female.
Theoretical Model

The theoretical model used in this study was the Health Belief Model. The
Health Belief Model was developed in the early 1950’s by Rosenstock, Kegeles,
Leventhal, and Hochbaum to provide a framework for exploring personal health
behaviors (Rosenstock, 1974). Rosenstock, Kegeles, Leventhal, and Hochbaum were
social psychologists who were influenced by the orientation of Kurt Lewin
(Rosenstock, 1974). Two assumptions underlying the health belief model have their
roots in Lewin’s field theory. The first assumption is that people behave on the basis
of their perceptions of situations in which they find themselves. The second
assumption is that an individual exists in a life space composed of regions, some of
which are positively valued (positive valence), others of which are negatively valued
(negative valence), and still others which are relatively neutral. Diseases would be
regions of negative valence which could be expected to exert a force moving the
person away from that region (Rosenstock, 1974).

The five major variables or concepts of the health belief model that are
considered important in explaining and predicting health related behavior are

perceived susceptibility, perceived seriousness or severity, perceived effectiveness or

8

benefits, perceived absence of barriers or impediments to taking action, and perceived
cues to action (Rosenstock, 1974).

Perceived susceptibility is the individual’s perception of his or her degree of
risk for developing a specific illness. An individual falls somewhere on a continuum
from high to low in estimating personal degree of risk for developing a specific illness
or problem related to a behavior (Pender, 1987). Perceived seriousness is the
person’s perception of the severity of the problem as compared to other problems.
Perceived seriousness or severity of a given health problem can be judged by the
degree of emotional arousal created by the thought of the disease or by the difficulties
that individuals believe a given health condition would create for them. Perceived
seriousness may include the broad implications of the illness for work, family life, or
social relationships and commitments (Pender, 1987). Perceived benefit is the
individual’s belief that the recommended course of action will be beneficial in
preventing illness or complications. Perceived barriers include cost, fear of pain or
discomfort, and reactions of significant others. Cues to action may be either external
or internal. External cues include messages from mass media, reminder postcards
from health care providers, or advice or encouragement of family and friends.
Internal cues might include uncomfortable symptoms or recall of the condition of
affected individuals (Pender, 1987).

Becker and colleagues have added ”modifying and enabling” variables to the
health belief model. These include demographic, sociopsychological, and structural
factors. Demographic variables include gender, race, socioeconomic status,

education, and age. Sociopsychological variables may include social or peer group

9

influence. Structural factors include prior contact with a health clinic and attitudes
toward the health care provider (Janz & Becker, 1984).

As shown in Figure 1, modifying factors influence the individual’s perception
of susceptibility and seriousness, cues to action, and the benefit barrier equation.
Cues to action may influence the individual’s perception of susceptibility and
seriousness and the individual’s perception of benefits and barriers. The individual’s
perception of susceptibility and seriousness, the cues to action, and perceived benefits
and barriers will all influence health behaviors.

Research questions for this project were directed at determining descriptive
data relevant to prevalence of specific risk behaviors among adolescents attending
11th grade in a rural public high school in northern Michigan. An investigation of
the relationship between health risk behaviors and gender was completed. Although
this study did not examine all the variables in the health belief model that influence
health behavior, it was a beginning point in understanding the prevalence of health
risk behavior in adolescents attending 11th grade in a rural community.

Review of Literature

Many studies have been done on health risk behavior in adolescents. Some
studies focused on a single risk behavior such as suicide (Adcock, Nagy, & Simpson,
1991; Felts, Chernier, & Barnes, 1992; Friedman, Asnis, Boeck, & DiFiore, 1987;
Garrison, McKeown, Valois, & Vincent, 1993; Riggs, Alario, & McHorney, 1990),
sexual risk taking (Cates, 1990; Sonenstein, Pleck, & Ku, 1991), anabolic steroid use
(Buckley, Yesalis, Fried], Anderson, Streit, & Wright, 1988), and substance use
(Kipke, Montgomery, & MacKenzie, 1993). Other studies focused on multi health

risk behaviors in specific populations such as high risk adolescents (Kulbok, Earls, &

10

 

MODIFYING FACTORS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

0 Demographic Variables 0 Psychosocial Variables
0 Age Gender Race 0 Social Class Peer Group
INDIVIDUAL CUES 'I‘O BENEFITS
PERCEPTIONS ACTION
Positive Value
Susceptibility Internal
e Symptoms e BARRIERS
Seriousness
External Media Negative Value
HEALTH RISK BEHAVIORS
OSexualBehaviors 0Tobacco,AIcohol,IlIicitDrugUse

0 Suicide Ideation, Plans, Attempts 0 Weapon Carrying, Fighting

 

OBehaviorsRelatedtoMotorVehicles

 

 

13ml. Conceptual Model Adapted From Health Belief Model (Rosenstock,
Kegeles, Leventhal, and Hochbaum, 1974)

11

Montgomery, 1988), adolescents in a suburban population (Marks, Malizio, Hoch,
Brody, & Fisher, 1983), among young adolescents (Millstein et al., 1992), in regular
high school students compared with alternative education students (Grunbaum &
Basen-Engquist, 1993), and among American Indian--Alaska Native Youth (Blum,
Harmon, Harris, Bergeisen, & Resnick, 1992). Surveys tracking a broad range of
risk behaviors have been done on a national level involving high school students
(Kann, Warren, Collins, Ross, Collins, & Kolbe, 1993; National Adolescent Student
Health Survey, 1989).

S l B' l H l .

Sonenstein et al. (1991) described levels of sexual activity among US. males
from 15 to 19 years of age using data from the National Survey of Adolescent Males
(NSAM). The survey included 1,880 never married American males, both in and out
of school, who lived with their families or in other types of households. The overall
response rate was 74%. The authors found that 60% of the sample had experienced
sexual intercourse. About 5% reported heterosexual intercourse before age 13, 11%
by age 14, and 21% by age 15. Approximately 38% had intercourse before they
reached age 16 and 58% had intercourse before age 17. By age 19, about 79% had
had intercourse. The sexually experienced young men reported an average of 5.1
sexual partners since their first sexual intercourse. The mean number of partners in
the last year was 1.9. Because this survey was limited to males who lived in
households, the data excluded men who may have been in high risk groups, such as
homeless and runaway youth, those living in institutions, dormitories, and military
barracks. No information was presented regarding reliability and validity of the

survey instrument.

12
Kann et al. (1993) reported results from the national school based 1991 Youth

Risk Behavior Survey. Of the schools that were asked to participate, 75 % (137)
agreed. Usable questionnaires were received from 90% (12,272) of the 13,568
eligible students in the participating schools. Students were distributed evenly among
grades 9 through 12 and between genders. After weighting, white students were 70%
of the sample, black students 14%, and Hispanic students 9% which mirrors the
actual distribution of 9th through 12th grade students in the United States. This study
found that among all students, 54.1% had participated in sexual intercourse with
18.7% having had four or more sex partners during their lifetime. Among students
who engaged in sexual intercourse, 69.3% had done so during the 3 months preceding
the survey. Black students were significantly more likely than white or Hispanic
students to have had sexual intercourse and to have had four or more sex partners.
The prevalence of having had sexual intercourse, having had four or more sex
partners, and being currently sexually active increased significantly with increasing
grade in school. Among curremly sexually active students, 81.8% had used a
contraceptive method (birth control pill, condom, or withdrawal) during their most
recent sexual intercourse; 46.2 had used a condom on that occasion. Contraceptive
use increased significantly from 9th to 12th grade. White students used a
contraceptive method during their most recent sexual intercourse significantly more
often than black students or Hispanic students.
W

The age at which a person begins to smoke cigarettes has been found to be

related to the total number of years of subsequent smoking. Taioli & Wynder (1991)

studied the relation between the age at which a person starts smoking and the number

13

of cigarettes smoked per day in adulthood. Among men who began to smoke at or
before the age of 14 years, 19.6% smoked 41 or more cigarettes (about 2 packs) per
day in adulthood, compared with 10.3% of those who started smoking at age 20 or
older. Among women, 26.9% of those who started smoking at or before the age of
16, smoked 31 or more cigarettes (about 1 and a half packs) per day in adulthood, as
compared with 15.4% of those who started at age 20 or older (Taioli & Wynder,
1991). The finding of an association between smoking at an early age and subsequent
heavy cigarette consumption suggests that additional efforts should be made to
postpone the beginning of smoking among young people. This study utilized a
standardized questionnaire administered by trained interviewers to patients with cancer
and matched control subjects to collect a history of smoking. No information was
presented about the questionnaire. The cases and controls were grouped together for
a total of 30,174 men and 11,828 women.

Kann et al. (1993) in the national Youth Risk Behavior Survey found that 70%
of students had tried cigarette smoking and 27.5% were current smokers (had smoked
cigarettes on one or more of the 30 days preceding the survey). Among students who
had smoked a whole cigarette, the average age at first use was 12.6 years. Cigarette
use did not vary by gender. Among all students, 10.5% had used chewing tobacco or
snuff in the past 30 days.

In the 1993 national Youth Risk Behavior Survey, 82% of students had
consumed alcohol during their lifetime, and 51% did so during the 30 days preceding
the survey. Lifetime and current alcohol use did not vary by gender. Among
students who had drunk alcohol, the average age at first use was 12.5 years. Among

all students, 31% reported consuming 5 or more drinks of alcohol on at least one

14

occasion during the past 30 days and occurred significantly more often among male
students (Kann et al., 1993).

Results from the national Youth Risk Behavior Survey indicate that 30% of
students had used marijuana during their lifetime with 15% reporting use during the
30 days preceding the survey. Lifetime use was reported by 6% with 1.7% reporting
use in the 30 days preceding the survey. Lifetime and current marijuana use did not
vary by gender; lifetime and current cocaine use occurred significantly more often
among male than female students. Among all students, 3 % used steroids during their
lifetime with male students significantly more likely than female students to have used
steroids (Kann et al., 1993).

The National Adolescent Student Health Survey (N ASHS) was administered in
1987 to 8th and 10th grade students from 217 different junior and senior high schools
(American School Health Association, 1989). This survey was designed to assess
students’ health related knowledge, attitudes, and behaviors in eight areas including
injury, suicide, violence, tobacco, drug and alcohol use, nutrition, consumer skills,
and sexually transmitted disease. Completed questionnaires were obtained from 89%
of the 8th grade students and 86% of the 10th grade students. Data from 12,067
students were analyzed. Of the sample, 69% were white, 17% black, and 9%
Hispanic. Fifty one percent of the students were males and 49% females. Results
from the National Adolescent Student Health. Survey (NASHS) revealed that 57 % of
students had ever tried cigarettes and 12% of males and 1% of females used chewing
tobacco or snuff during the last month. Eighty three percent of students reported at
least one occasion in which they had an alcoholic beverage, 42 % reported alcohol use

in the past month, and 32% reported consuming five or more drinks on one occasion

15

in the past two weeks. Lifetime marijuana use was reported by 25% of the students
with 10% reporting use in the past month. Lifetime cocaine use was reported by 6%
with 3% reporting use in the past month.

Buckley et al. (1988) studied 12th grade male students in private and public
high school to determine anabolic steroid use. The sample was drawn from 150 high
schools across the nation that employed certified athletic trainers and schools that had
participated in a sports epidemiology survey within the past 2 years. Of the 6,765
male senior students who were eligible, 3 ,403 voluntarily participated. Results
indicated that 6.6% of 12th grade male students'use or have used anabolic steroids
and that over 66% of the user group initiated use when they were 16 years of age or
younger. The authors believe that educational intervention strategies should begin as
early as junior high school. This study was designed to help establish the prevalence
of anabolic steroid use among the male portion of the general population. The
authors did note that the 150 schools included in the survey did not represent a
random sample of all high schools in the United States because only 10% of high
schools employ a certified athletic trainer.

Millstein et al. (1992) examimd the health concerns and behaviors of 563
adolescents aged 11 through 14 from a variety of social, racial, and ethnic
backgrounds. Subjects were recruited from an inner city public middle school and
attended grades 6 through 8. Subjects completed a modified version of the Teen
Health Risk Appraisal, a 63 item questionnaire developed by the Centers for Disease
Control. Results of this study showed that adolescents in this study were engaging in
a variety of behaviors that placed them at risk of injury, disability, illness, or death.

Experimentation with substance use was common; alcohol was the most common

16
substance followed by tobacco and marijuana. More than one half of the sample

(56%) reported having smoked cigarettes on at least one occasion. Among these
subjects, 16% identified themselves as current smokers. Seventy three percent had
tried alcohol on at least one occasion with alcohol use beginning most frequently in
the sixth grade. Marijuana use on at least one occasion was reported by 31 % of the
subjects. This study looked at a very specific age group from a specific location
which provides useful information about health risk behaviors in subgroups of the
general adolescent population.

Riggin (1993) reported statistics from the National High School Senior Drug ‘
Abuse Survey which indicated that 63 % of adolescents have tried cigarettes, 18.5 %
reported daily use, and of daily users, 10.7% smoked at least one half pack per day.
Of high school seniors, 88% have used alcohol at some time with 77.7% reporting
use during the past 12 months, 54% used alcohol during the past month, and 3.6%
reported daily use. Thirty percent of high school seniors reported consuming five
drinks in a row during the past 2 weeks. The author did not present information
regarding how the sample was recruited, breakdown of the sample by gender or race,
or information about the questionnaire.

WM

Friedman et al. (1987) investigated prevalence of suicidal behaviors among
380 students attending an academically select public high school in New York.
Students completed the Harkavy Asnis suicide survey demographic form, a
questionnaire that ascertains basic demographic data, past psychiatric or counseling
history, and specifics about their experience with their own suicidal behavior and that

of their family and peers. The authors did not give information regarding validity and

17

reliability of this instrument. Of the 380 high school students, 38.4% stated that they
had never thought about killing themselves (no suicide group), 52.9 % stated that they
had thought about killing themselves at least once (suicide ideator group), and 8.7 %
stated that they had tried to kill themselves at least once (suicide attempter group).
The ”no suicide" group consisted of more males than females, the ”suicide ideators"
had equal numbers of males and females, and the "suicide attempters" had
significantly more females than males. The study was concerned primarily with
adolescents attending an academically competitive high school and results may need to
be replicated in other high school samples before conclusions about the frequency of
suicidal behavior among high school students can be made.

Kann et al. (1993) found that 29% of the students in their sample had thought
seriously about attempting suicide, 19% had made a specific plan to auempt suicide,
7% actually had attempted suicide and 1.7% made an attempt that resulted in a visit
to a doctor or nurse. More females (37%) than males (21 %) reported thinking
seriously about committing suicide. Approximately twice as many females as males
made actual suicide plans and more females (11%) than males (4%) made a suicide
attempt.

Data from the NASHS revealed that 34% of the students reported that they
have seriously thought about committing suicide with 14 % having actually tried to
commit suicide. More females (42%) than males (25 %) reported serious thoughts
about committing suicide and more females (18%) than males (11%) reported actual
suicide attempts.

Garrison et a1. (1993) utilized the Youth Risk Behavior Survey (YRBS) to

analyze the frequency and correlates of suicidal behaviors in a sample of South

18

Carolina public high school students. A total of 3 .764 students completed the survey.
Eleven percent reported serious suicidal thoughts, 6% reported specific suicidal plans,
6% actually attempted suicide and 1.6% reported attempts requiring medical care.
Each of these types of suicidal behaviors was reported one and a half to two times
more frequently by females than by males.

Wining

Karin et al. (1993) reported that 28% of students always used a seat belt when
riding in a car or truck driven by someone else. Data regarding seat belt use when
they themselves were driving was not presented. Among students who rode a
motorcycle, 39% always wore a motorcycle helmet. During the 30 days preceding
the survey, 26% of students had carried a weapon on at least 1 day. During the 12
months preceding the survey, 43% were in at least one physical fight.

Data from the NASHS showed that 41% of students reported wearing a seat
belt the last time they rode in a car, truck, or van. While 60% reported riding on a
motorcycle or minibike, 42 % rarely or never wore a helmet. During the past month,
39% reported that they rode with a driver who had used drugs or alcohol. During the
past year, 39% of students reported having been involved in at least one physical
fight.

Slimmer!

Specific health risk behaviors were widely covered in the literature. The
studies that focused on one or two health risk behaviors provided in depth information
about specific risk behaviors but did not provide information that might address the
multiple, interrelated risk behaviors practiced by many youth. The studies that

utilized survey instruments that addressed multiple risk behaviors were also plentiful,

l9

and they provided valuable information on the specific adolescent groups studied.
Studies that focused on national samples provided needed information on adolescent
risk behavior on a national level. Some studies focused on specific age groups
attending specific types of schools which provided information on health risk
behaviors in specific populations. Information relating health risk behavior to gender
and race was presented in some of the studies.

Despite the broad range of available literature related to health risk behaviors,
there was no data that specifically addressed health risk behavior among
predominantly white youth who live in a rural community such as Crawford County.
There remains a med for studies to be done on the prevalence of health risk behaviors
among these youth.

Crawford County is located in central northern Michigan. Data from the
Michigan Information Center, Michigan Department of Management and Budget,
from 1990 reveals that Crawford County had a total population of 12,260 of which
96.3% were white. There were 480 adolescents 16 to 18 years of age. Of these
adolescents, 53.5% (257) were male and 46.5% (223) were female. According to
1990 census data, there were 1,688 persons living below 100% of poverty, 4,865
persons living below 200% of poverty, 1,300 uninsured persons, and 2,014 persons
eligible for Medicaid. According to data from the public school administration office,
34 % of students attending public school were eligible for free or reduced lunch.

Health care is provided by one part time pediatrician! internist, three family
practice physicians, two general surgeons, four internists, and one obstetrician. In
addition there is a four person orthopedic group, a walk in clinic, and the county

health department. A rural health clinic, staffed by a physician assistant, was recently

20
opened. Patients covered by the Medicaid program have difficulty finding a primary
care provider because many practitioners are refusing to see Medicaid clients. The
school system does not employ a school nurse.

Data collected on a local level, in this case a predominantly white, rural area,
will reflect health risk behaviors of adolescents residing in that local community.
This information will be vital for family nurse practitioners and other health care
providers who provide primary care to rural adolescents. These data will be useful to
school officials, members of the Board of Education, and community members as
plans of health curriculum are developed. Parents will be able to utilize this data as
part of their discussions with adolescents when addressing health risk behaviors.
Finally, adolescents themselves may find this data useful as they evaluate their own
health risk behaviors.

Methods
Wan

The research design for this project was a nonexperimental descriptive ex post
facto design. According to Polit and Hungler (1991) the purpose of descriptive
studies is to obtain information about the current status of phenomena of interest and
to describe what exists in terms of frequency of occurrence or its presence versus
absence. Nonexperimental ex post facto research is research that has been conducted
after the variations in the independent variables have occurred in the natural course of
events without any researcher intervention.

Sample
The target population was a convenience sample of all students attending 11th

grade at a rural high school in northern Michigan. Students attending 11th grade

21

were chosen for this study because the majority of students have taken the required
one semester health class in their sophomore year and theoretically have received
health information necessary for making decisions regarding behaviors that may put
them at risk for adverse health outcomes. This group of students is likely to be at
least 16 years of age and most will have a driver’s license. School district
administration was supportive of using this particular age group. The sample
consisted of all students attending school the day the survey was administered whose
parents consented to their participation and who themselves consented to complete the

survey.

 

The principal dependent variable of interest to this study was health risk
behavior. Frequency of sexual risk behaviors that may put the adolescent at risk for
STD, HIV infection, and pregnancy was measured by questions 46 through 55 (Q46-
55). Frequency of tobacco, alcohol and other drug use was measured by Q70-87.
Feelings of depression, suicide ideation and suicide attempts were measured by Q40-
45. Potential for unintentional injury was measured by Q56-69. The independent
variable of gender was measured by Q2.

We

Subjects completed the Youth Risk Behavior Survey (YRBS) developed by The
Centers for Disease Control and Prevention (CDC). Individual items on the survey
are designed to measure risk behaviors in 6 areas: (1) sexual behaviors; (2) tobacco,
alcohol, and illicit drug use; (3) suicide ideation and suicide attempts; (4) behaviors
related to unintentional injury; (5) dietary patterns; and (6) physical activity.

Questions related to current health care utilization, desired health services, and

22

demographic data were added to the survey instrument and their numbers are
indicated by bold print in the questionnaire included in Appendix A. The Centers for
Disease Control allows the questionnaire to be copied, modified, or administered
without permission (Public Health Reports, 1993).

The CDC began designing the YRBS in 1988 by reviewing the leading causes
of morbidity and mortality among youth and adults. The review of the leading causes
of morbidity and mortality among youth and among persons in all age groups
combined showed that nearly all contributing behaviors could be categorized within
six previously mentioned behavioral areas. The first version of the questionnaire was
completed in October 1989 and was reviewed at a national conference by
representatives of each State’s department of education. The second version was
completed in November 1989 and was used the following spring to generate data from
national, state, and local samples of students in grades 9 through 12. That version of
the questionnaire was sent to the Questionnaire Design Research Laboratory for four
waves of laboratory and field testing with high school students. The field testing
sought to identify survey conditions that could be expected to encourage honesty in
answering survey questions. In October 1990, the core questionnaire was complete.
The core questionnaire is self administered and has about a 7th grade reading level
(Kann et al. , 1993).

YRBS results are based on self reports that appear valid for estimating the
prevalence of health behaviors within adolescent populations, however a respondent
may underreport or overreport a behavior, depending on the perceived social stigma

or support for that behavior and the perceived confidentiality of responses.

23

Establishing criterion related validity for responses to most of the questions on the
questionnaire may be impractical, if not impossible (Kann et al. , 1993).

The YRBS was chosen for this study because this instrument included the
questions the author was interested in. The YRBS has been utilized in many national
studies and allows for meaningful comparisons to be made between local findings and
state and national data. Parents and school administration were also more likely to
support a survey that has been developed by the Centers for Disease Control and
Prevention (CDC), a nationally renowmd organization. In addition, the CDC allows
the survey to be used without charge and allows modifications to be made to reflect
local needs.

Emeritus:

Permission to conduct the survey was obtained from the school district.
Letters were mailed to parents of all eligible students. Eligible students were defined
as those students enrolled in the 11th grade at the time of the survey and included 134
students. Parents were asked to provide written consent for their child’s participation.
Follow up phone calls were made to parents who didn’t respond. Eleventh grade
classroom teachers were notified of the survey date by the building principal. The
researcher met with classroom teachers, the eleventh grade counselor, and the
principal prior to that date to answer specific questions about the survey and to
provide oral and written instructions on procedures. The researcher was available in
person the day of the survey to answer questions that occurred during the survey
process. The high school principal provided classroom teachers with a list of students
who had received parental consent to participate in the survey. The students who had

received parental consent were asked by their classroom teacher to report to the

24

library during third hour. Instructions were read by the eleventh grade counselor to
the students from a prepared script. Students were instructed to not write their names
or other identifying markers on the questionnaires and to place their answers directly
on the survey instrument. When the student was finished with the survey, he/ she
placed the completed survey in a sealed "ballot type" box. Students who were absent
the day the survey was administered were not included.

W

Research questions that were answered included:

(1) What is the frequency of sexual risk behavior that may put the adolescent at risk
for sexually transmitted disease (STD), human immunodeficiency virus (HIV)
infection, and pregnancy?

(2) What is the frequency of tobacco, alcohol, and other drug use?

(3) What is the frequency of feelings of depression, suicidal ideation and attempted
suicide?

(4) What is the frequency of behaviors that may result in unintentional injuries?

(5) What is the relationship of gender to selected health risk behaviors?

Descriptive statistical analysis including frequencies and percentages were used
to answer research questions 1 through 4. Chi square analysis was used to test the
relationship between gender and selected health risk behavior.

WW
Prior to administering the survey, approval was obtained from Michigan
State University Committee on Research Involving Human Subjects (UCRIHS) (see
Appendix E) and from the school district (see Appendix D). A letter explaining the

research proposal was sent home to parents of all 11th grade students eligible to

25

participate in the survey (see Appendix D). Parents were asked to provide written
consent for their students’ participation. Parents and students were assured that
participation was voluntary. Parents and students had a right to refuse to participate
without penalty of any kind. Students were also asked for their consent. They
indicated voluntary agreement to participate by completing and returning the survey.
Students whose parents did not provide written or oral consent and students who
chose not to participate remained in their regular classroom and did not report to the
high school library.
mm

It is assumed that the researcher offered the opportunity for participation in the
study to all eligible students equally. It is assumed that the survey questions correctly
identified levels of risk behavior. It is also assumed that all the adolescents answering
the survey understood the questions and that they answered them as honestly as
possible.

8 l I . . .

Only students who received parental consent were allowed to participate. It is
not known how this group of students differed from the subjects whose parents did
not provide consent. Dent, Galaif, Sussman, Stacy, Burma, & Flay (1993) showed
differences between youths who were recruited by active versus passive consent
procedures. Active consent requires that parents provide written or verbal consent for
their students to participate. This is referred to as active consent because the parent
must take some action for their child to be included in the study (Dent et al. , 1993).
Passive consent requires no action by parents to allow their childrens’ participation.

In this approach, parents are informed that their non response implies permission for

26
their children to participate in a study (Dent et al. , 1993). In studies requiring active
consent there is a lower representation of minorities, children with less educated
parents, children who receive poorer grades at school, and children who are cigarette
or marijuana smokers (Dent et al., 1993).

Students who were absent the day the survey was administered did not have an
opportunity to participate and may have had a different profile of risk behaviors than
the participants. Turner, Irwin, Tschann, & Millstein (1993) found that absentees
were more likely to report experience with sexual intercourse, getting into fights, and
were less likely to live with both biological parents. Their conclusion was that
students who are absent from school are at greater risk for participating in health
damaging behaviors.

Another limitation of the study arises from the potential for distortion inherent
in the use of self reports. Some students may misrepresent their actual behaviors and
attitudes when responding to the survey. Distortions may involve both over and
under representation of certain behaviors (Koble et al. , 1993). Another limitation
may be that the survey questions did not correctly identify levels of health risk
behavior.

Results
ri tio
Of the 134 students attending 11th grade, 56% (75) received parental consent
to participate in the survey; 38% (51) of the students actually completed the survey.
Of the 24 students who received parental consent but did not participate in the survey,
6 were partiCipating in ”out of building" activities and classes, 8 were absent, and 10

were non participants for unknown reasons.

27

Of the sample, 39.2% (20) were 16 years of age, 56.9% (29) were 17 years of
age, and 3.9% (2) were 18 years of age. The mean age was 16.7 years with a SD of
0.56. The sample included 52.9% (27) females and 47.1% (24) males. The mean
age for females was 16.4 years with a SD of 0.51. The mean age for males was 16.9
years with a SD of 0.54. As shown in Table 1, 56.9% (29) of the students had
private health insurance such as Blue Cross Blue Shield, 13.7% (7) had a prepaid
health plan such as an HMO, 5.9% (3) had Medicaid, 21.6% (11) didn’t know their
insurance and 2% (I) didn’t answer the question. Approximately 57% (29) of the
students lived with both parents, 21.6% (11) lived with one parent, 11.8% (6) lived

with one parent and one step parent, and 9.8% (5) lived with ”other adult".

Table 1

 

 

 

Demographic Variable n %
Age in Years 16 20 39.2
17 29 56.9
18 2 3.9
Gender Female 27 52.9
Male 24 47.1
Medical insurance private 29 56.9
HMO 7 13.7
Medicaid 3 5.9
Don’t Know 11 21.6
No Answer 1 2.0
Reside With Both Parents 29 56.9
One Parent 11 21.6
Parent and Step 6 11.8
Other Adult 5 9.8

—

28

w tio
(At ‘t f 31n- ’ ' k Ltd/10 Lot M Pu e Adolesce ; " k f
r‘ t--«. l Tr mugs! Pr‘ 1.; I. , 4.1-4 -1111 -1010 fi .611 V°r tx—r -0!

W
The frequency of sexual behaviors that may put the adolescent at risk for

STD’s, HIV, and pregnancy is reported in Table 2. While 31.4% (16) students never
experienced sexual intercourse, 68.6% (35) students reported having had sexual
intercourse. Of students who reported having sexual intercourse, the majority of
students (57.1%, n=20) had their first experience between the ages of 14 and 15,
while 34.3% (12) were 16 or older, and 8.6% (3) were 13 or younger. One lifetime
partner was reported by 42.9% (15), 25.7% (9) had 2 to 3 lifetime partners, and
31.4% (11) had 4 or more lifetime partners. Approximately 51% (26) students
reported sexual intercourse in the past 3 months and of these students, 73% (19) had
1 partner, 23% (6) had 2 to 3 partners, and 4% (1) had 4 or more partners. Alcohol
or drug use with last intercourse was reported by 17.1% (6) students. Of students
reporting sexual intercourse, 22.9% (8) used no contraception with last intercourse,
11.4% (4) used birth control pills, 54.3% (19) used condoms, and 11.4% (4) used
withdrawal. Condoms with last intercourse were used by 57.1% (20) students. Only
1 (2%) student reported being pregnant or having gotten someone pregnant. Pressure
to have sex was felt by 19.6% (10) students with 18.2% (2) students indicating that
the pressure came from a boyfriend, 9.1% (1) indicating pressure from a girlfriend,

63.6% (7) reporting pressure from fiiends, and 9.1% (1) reporting pressure from

29

"other". Although 10 students reported pressure to have sex, 11 students responded
to the question of where the pressure came from to engage in sexual intercourse.
13W

As shown in Table 3, 72.5% (37) students reported trying cigarette smoking,
even one or two puffs. Of those who reported smoking a whole cigarette, 35.7% (10)
were 10 or younger, 28.6% (8) were 11 to 13, 17.9% (5) were 14 to 15, and 17.9%
(5) were 16 or older when they smoked a whole cigarette for the first time. Current
tobacco use (had smoked cigarettes on one or more of the 30 days preceding the
survey) was reported by 37.3% (19) students. For students reporting current tobacco
use, 10.5% (2) smoked 1 day, 5.3% (I) smoked 2 to 5 days, 26.3% (5) smoked 6 to
10 days, and 57.9% (11) smoked 11 or more days in the month. As shown in Table
3, the majority (63.2%, n=12) smoked 2 to 5 cigarettes daily with only 10.5% (2)
indicating more than one half pack daily. Approximately 33% (17) have tried to quit
smoking and 7.9% (4) used snuff or chewing tobacco in the past 30 days.
W

As shown in Table 4, 82.4% (42) students report having had a drink of alcohol.
Of those students indicating alcohol use, the majority (45.2%, n= 19) were 14 to 15
years of age when they had their first drink of alcohol; 21.4% (9) were 11 to 13
years, 19.1% (8) were 16 or older, and 14.3% (6) were 10 or younger. Current
alcohol use (drank alcohol in the past 30 days) was reported by 56.8% (29) students.
Of those students reporting current alcohol use, 31 % (9) used alcohol 1 day, 27.6%
(8) used 2 to 5 days, 24.1% (7) used 6 to 10 days, and 17.2% (5) used 11 or more

days. Approximately 35.3% (18) had 5 or more drinks in a row on at least one day

30
in the past 30 days; 16.7% (3) reported 5 or more drinks in a row on 11 or more of

the past 30 days.
P of U

Marijuana use was reported by 47.1% (24) students. Although the majority
(41.7%, n= 10) were 16 or older with first marijuana use, 37.5% (9) indicated first
use at 14 to 15 and 20.8% (5) were 11 to 13 years of age. Marijuana use in the past
30 days was reported by 21.6% (11) students with 5 of those students indicating use
on 11 or more of the past 30 days. Cocaine use was reported by 7.8% (4) students
who were all 16 years of age or older with first use; 5.9% (3) of these students used
cocaine in the past 30 days. As shown in Table 5, 13.7% (7) students reported
lifetime inhalant use, and 25.5% (13) students indicated other drug use such as LSD,
PCP, ecstasy, mushrooms, speed, ice, or heroin. Only one student reported anabolic
steroid use. Illegal drugs had been offered to 23.5% (12) students on school
property. No students used injectable drugs.

11.1-1. I ’-. °' o by mu ° " is; to! an _ .- '_.' a 13m . 9

As shown in Table 6, 11.8 % (6) students often felt that life was not worth
living, 39.2% (20) sometimes felt that life was not worth living, and 49% (25) never
felt that life was not worth living. Being depressed for long periods in the past six
months was reported by 45.1% (23), 11.8% (6) were currently depressed while
54.9% (28) reported no depression. Suicide was considered by 15.7% (8) students,
11.8% (6) made a suicide plan, and 5.9% (3) made an actual attempt. Injury
requiring a visit to a health care provider following an attempted suicide was reported

by 3.9% (2) students.

 

As reported in Table 7, 64.7% (33) students reported using seatbelts all or most
of the time with 17.6% (9) indicating use sometimes, 11.8% (6) reporting rare use
and 5.9% (3) never using seatbelts. Motorcycle use during the past 12 months was
reported by 23.5% (12) students and 83.3% (10) of those students always wore a
helmet. Snowmobile or other all terrain vehicle (ATV) use was reported by 51% (26)
students and 73% (19) of these students always wore a helmet. Approximately 43%
(22) students rode in a vehicle driven by someone who had been drinking alcohol one
or more times in the past month and 23.5% (12) students drove a vehicle one or more
times inthepastmonthwhentheyhadbeendrinkingalcohol.

Duringthepastthirtydays, 14% (7)studentscarriedaweapon. Asreportedin
Table 8, 15.7% (8) students had been threatened or injured with a weapon and 37.3%
(19)hadbeenthevictimoftheftorpropertydamageinthepast 12 months. Inthe
past 12 months, 41.2% (21) participated in a physical fight; one students required
treatmentbyadoctorormrrseasaresultofafight. Nostudentreportedmissing
school due to fear.

B. l B l . l E I

S l . l l l .

As shown in Table 9, significantly more males (83.3%, n=20) tlnn females
(55.6%, n=15) have ever had sexual intercourse. More males (62.5%, n=15) than
females (40.7%, n=11) reported sexual intercourse in the past 3 months. However,
both groups reported a similar number of lifetime partners. Contraceptive use with

last intercourse was higher for females (44.4%, n= 12) than males (62.5%, n= 15).

32

 

Table 2
S IIIIIB'IEIV'
_
Variable n %
Intercourse Ever Yes 35 68.6
No 16 31.4
Age First Intercourse 13 or Younger 3 8.6
14 to 15 Years 20 57.1
16 or Older 12 34.3
Lifetime Partners 1 Partner 15 42.9
2 to 3 Partners 9 25.7
4 or More Partners 11 31.4
Partners Past Three Months 1 Partner 19 73.0
2 to 3 Partners 6 23.0
4 or More Partners 1 4.0
Alcohol/Drug Use Last Yes 6 17.1
Intercourse No 29 82.9
Contraceptive Use Last None 8 22.9
Intercourse BCP 4 11.4
Condoms 19 54.3
Withdrawal 4 11.4
Condoms Use Last Yes 20 57.1
Intercourse No 15 42.9

 

33

 

 

 

 

Table 3

I! II HIIE'IEIV

Variable n %

Smoking Ever (Even I Yes 37 72.5

or 2 Puffs) No 14 27.5

Age First Whole Cigarette 10 or Younger 10 35.7
11 to 13 Years 8 28.6
14 to 15 Years 5 17.9
16 or Older 5 17.9

Tobacco Use Past Thirty Days 1 Day 2 10.5
2 to 5 Days 1 5.3
6 to 10 Days 5 26.3
11 or More Days 11 57.9

Cigarettes/Day Past Thirty 1 Cigarette 2 10.5

Days 2 to 5 Cigarettes 12 63.2
6 to 10 Cigarettes 3 15.8
11 to 20 Cigarettes 2 10.5

 

34

 

Table 4
El 1 181 III IIE'lEl v‘
“
Varrab’ le 11 %
Alcohol Use Ever Yes 42 82.4
No 9 17.6
Age First Alcohol 10 or Younger 6 14.3
11 to 13 Years 9 21.4
14 to 15 Years 19 45.2
16 or Older 8 19.1
Alcohol Use Past Thirty Days 1 Day 9 31.0
2 to 5 Days 8 27.6
6 to 10 Days 7 24.1
11 or More Days 5 17.2
Five or More Drinks Past 1 Day 3 16.7
Thirty Days 2 to 5 Days 7 38.9
6 to 10 Days 5 27.8
11 or More Days 3 16.7

 

35

 

Table 5
mm]! E] III IIB'IEI v'
—
Variable n %
Marijuana Use Ever Yes 24 47.1
No 27 52.9
Age First Marijuana Use 11 to 13 Years 5 20.8
14 to 15 Years 9 37.5
16 or Older 10 41.7
Marijuana Use Past Thirty 2 to 5 Days 5 45.5
Days 6 to 10 Days 1 9.0
11 or More Days 5 45.5
Age First Cocaine Use Never 47 92.2
16 or Older 4 7.8
Cocaine Use Past Thirty Days 0 Days 48 94.1
1 Day 1 2.0
2 to 5 Days 2 3.9
Lifetime Inhalant Use Never 44 86. 3
1 0r 2 Times 5 9.8
20 or More Times 2 3.9
Other Illicit Drug Use Never 38 74.5
1 to 2 Times 7 13.7
3 to 9 Times 2 3.9
10 to 19 Times 3 5.9
20 or More 1 2.0
Lifetime Steroid Use Never 50 98.0
1 to 2 Times 1 2.0
Offered Drugs At School Yes 12 23.5
No 39 76.5

 

36

 

Table 6

Depgssion, Suicide Idgtign, Suicig Agempts

Variable n %

Felt Life Not Worth Living Often 6 11.8
Sometimes 20 39.2
Never 25 49.0

Depression Past Six Months Yes, Not Now 17 33.3
Yes, Now 6 11.8
No 28 54.9

Consider Suicide Past Year Yes 8 15.7
No 43 87.3

Suicide Plan Yes 6 11.8
No 45 88.2

Suicide Attempt No 47 92.2
1 Time 3 5 .9
No Answer 1 2.0

 

Table 7

 

37

 

 

Variable n %
Seat Belt Use Never 3 5.9
Rarely 6 11.8
Sometimes 9 17.6
Most Times 18 35.3
Always 15 29.4
Motorcycle Use Past Year 0 Times 39 76.5
1 to 10 Times 9 17.6
21 to 39 Times 2 3.9
40 or More Times 1 2.0
Helmet Use With Motorcycle Never 1 8.3
Most of the Time 1 8.3
Always 10 83.3
Snowmobile/ATV Use 0 Times 25 49.0
Past Year 1 to 10 Times 15 29.4
11 to 20 Times 4 7.8
21 to 39 Times 2 3.9
40 or More Times 5 9.8
Helmet Use With Never 1 3.8
Snowmobile/ ATV Use Sometimes I 3.8
Most of the Time 5 19.2
Always 19 73.0
Ridden With Alcohol Use Past 0 Times 29 56.9
Thirty Days 1 Time 7 13.7
2 to 3 Times 9 17.6
4 to 5 Times 2 3.9
6 or More Times 4 7.8
Driven With Alcohol Use Past 0 Times 39 76.5
Thirty Days 1 Time 1 2.0
2 to 3 Times 7 13.7
6 or More Times 4 7.8

 

Table 8

38

 

 

 

Variable n %
Carry Weapon Past Thirty 0 Days 44 86.3
Days 2 to 3 Days 2 3.9
4 to 5 Days 1 2.0
6 or More Days 4 7.8
Threatened/Injured With 0 Times 43 84.3
Weapon 1 Time 4 7.8
2 to 3 Times 3 5.9
6 or More Times 1 2.0
Victim Theft/Damage Past 0 Times 32 62.7
Year 1 Time 8 15.7
2 to 3 Times 10 19.6
6 or More Times 1 2.0
Participate In Fight Past Year 0 Times 30 58.8
1 Time 11 21.6
2 to 3 Times 7 13.7
4 to 5 Times 3 5.9
Fight Needing Treatment 0 Times 50 98.0
2 to 3 Times 1 2.0

 

39

Islam

As reported in Table 10, significantly more males (91.7%, n=22) than females
(55.6%, n=15) reported ever trying a cigarette. In the past 30 days, males (41.7%,
n=10) had slightly higher cigarette use than females (33.3%, n=9). Significantly
more males (16.7%, n=4) than females (0 %, n=0) reported use of chewing tobacco
or snuff.

Almanacs.

A higher percentage of males (87.5%, n=21) than females (77.7%, n=21)
report ever consuming alcohol in their lifetime and more males (62.5%, n= 15) than
females (51.9%, n=14) report use of alcohol in the past month. As shown in Table
10, consumption of 5 or more drinks on one occasion was reported by 41.7% (10)
males compared to 29.6% (8) females. There were no significant gender differences
in alcohol use.

111' . 1

As shown in Table 11, more males (58.3%, n=14) than females (37%, n=10)
reported lifetime marijuana use and more males (25%, n=6) than females (18.5%,
=5) indicated current marijuana use (marijuana use in the past 30 days). Lifetime
cocaine use was reported by 12.5% (3) males compared to 3.7% (1) females; current
cocaine use was indicated by 8.3% (2) males and 3.7% (1) females. Other illicit drug
use was similar for males and females. One female and no males reported anabolic
steroid use. More males (25%, n=6) than females (3.7%, n=1) reported lifetime

inhalant use. The only significant difference by gender was inhalant use.

I!..' to 1-. " r; 1' _-.-—.~_ .0 1.3.01 -‘t .' id rug...” i i - -.- - 1U -

More females (22.2%, n=6) than males (8.3%, n=2) considered attempting
suicide in the past 12 months (suicide ideation). As indicated in Table 12, 18.5% (5)
females compared to 4.2% (1) males had made a suicide plan, and 7.4% (2) females
compared to 4.2% (1) males made an actual suicide attempt.

L..!.' L!‘ n ... ' he 1- ‘1'. .o 1!. .t v _! - _--- w-..» 1-. .-t..t frr 1‘.

As noted in Table 12, no female reported never wearing a seat belt compared to
12.5% (3) males who reported never wearing a seat belt. More males (50%, n=12)
than females (37%, n=10) rode in a vehicle the past month driven by someone who
had been drinking alcohol and more males (29.2%, n=7) than females (18.5%, n=5)
drove a vehicle the past month when they had been drinking alcohol.

More males (20.8%, n=5) than females (7.4%, n=2) carried a weapon in the
past 30 days. As shown in Table 12, more males (25%, n=6) than females (7.4%,
n=2) had been threatened or injured with a weapon. Significantly more males
(54.2%, n=13) than females (22.2%, n=6) had been the victim of theft or damage.
Males (58.3%, n= 14) were significantly more likely than females (25.9%, n=7) to
have been in a fight in the past 12 months.

Discussion
W

Survey results among these rural adolescent youth were compared with national

averages. In many cases, results from this survey closely mirror those found in other

national studies which might indicate that rural youth are at equal risk for

participating in health risk behaviors. In some instances results from this study were

Table 9

 

 

 

 

10 r T n _ an I. 1.1.- al.-91-4-1 a Lg. _- -1 r 1-1Vor 1-1.!
Gender
Variable Female % Male % x2

(n=27) (n=24)

Intercourse Ever 55.6 (15) 83.3 (20) (1, N=51)=4.554*
Four or More Lifetime 18.5 (5) 25.0 (6) (2, N=35)=0.453
Partners
Intercourse Past Three 40.7 (11) 62.5 (15) (1, N=35)=0.012
Months
Contraception Use Last 44.4 (12) 62.5 (15) (1, N=35)=0.122
Intercourse
Table 10

rt . = u 0 t 2-1.! 0h. lunar ‘ ta. -. t 0 02--.! 2-1.! a. It 9.0 ‘. an! mus-i,
Variable Female % Male % x2

(n=27) (n=24)

Cigarette Use Ever 55.6 (15) 91.7 (22) (1, N=51)=8.319"
Cigarette Use Past Thirty 33.3 (9) 41.7 (10) (3, N=19)=3.575
Days
Chewing Tobacco/Snuff 00.0 (0) 16.7 (4) (1, N=51)=4.883*
Alcohol Use Ever 77.7 (21) 87.5 (21) (l, N=51)=0.826
Alcohol Use Past Thirty 51.9 (14) 62.5 (15) (3, N=29)=0.921
Days
Five or More Drinks 29.6 (8) 41.7 (10) (3, N=18)=0.797

 

*p < .05; "p < .01

42

 

 

Table 11

.10 r - bu 110 t- -r.! ["11 err ‘ L. _ 0 I i i J ' U; nu 1‘ Id'
Variable Female % Male % x2

(n=27) (n=24)

Lifetime Marijuana Use 37.0 (10) 58.3 (14) (1, N=51)=2.313
Marijuana Use Past Thirty 18.5 (5) 25.0 (6) (2, N=11)=4.547
Days
Lifetime Cocaine Use 3.7 (1) 12.5 (3) (1, N=51)=1.360
Cocaine Use Past Thirty 3.7 (1) 8.3 (2) (1, N=3)=0.750
Days
Other Illicit Drug Use 22.2 (6) 29.2 (7) (1, N=51)=0.323
Lifetime Anabolic Steroid 3.7 (1) 0.0 (0) (1, N=51)=0.907
Use
Lifetime Inhalant Use 3.7 (1) 25.0 (6) (1, N=51)=4.866*

 

*p< .05

43

 

 

 

Table 12

10 - T u -' L nu _ or u ' Of n ' 1.0m om ULL; I! 5.1- Ins
mm
Variable Female % Male % x2

(n=27) (n=24)

Suicide Ideation 22.2 (6) 8.3 (2) (1, N=51)=1.853
Suicide Plan 18.5 (5) 4.2 (1) (1, N=51)=2.521
Suicide Attempt 7.4 (2) 4.2 (1) (2, N=51)=l.182
Never Wear Seat Belt 0.0 (0) 12.5 (3) (1, N=51)=3.586
Rode Vehicle With 37.0 (10) 50.0 (12) (1, N=51)=0.870
Someone Drinking
Driven Vehicle While 18.5 (5) 29.2 (7) (1, N=51)=0.801
Drinking
Carried Weapon 7.4 (2) 20.8 (5) (1, N=51)=1.934
Threatened/Injured With 7.4 (2) 25.0 (6) (1, N=51)=2.973
Weapon
Victim Theft/Damage 22.2 (6) 54.2 (13) (1, N=51)=5.547*
Been In Fight 25.9 (7) 58.3 (14) (l, N=51)--'5.509*

 

*p< .05

44

slightly higher or lower than those found in national averages. These deviations could
be due to the relatively small sample size or the ages of the adolescents in this
sample. Adolescents in this study were in the 11th grade whereas Kann et al. (1993)
included adolescents in the 9th through 12th grade. Students in 11th grade may have
had greater opportunities and a longer period of time to initiate and participate in
health risk behaviors. In some cases such as slightly lower contraceptive use, the fact
that adolescents live in a rural area may influence access to agencies or clinics that
provide these services. Suicide ideation and suicide attempts were lower among these
rural youth. This possibly could be due to living in what some people consider a less
stressful environment. The higher use of helmets when riding motorcycles may be
directly related to the helmet law in Michigan. One might speculate that reports of
health risk behavior among this group of rural adolescents might have been higher if
passive consent had been utilized and if absentees had been allowed to take part.
Some studies indicate that students whose parents failed to respond to the consent
procedure and absentees have higher reports of health risk behavior (Iurner et al. ,
1993; Dent et al., 1993). In addition, follow up phone calls were made to parents
who did not return the consent form. According to 1990 census data, there were 424
households in Crawford County without telephones. Students who lived in households
without telephones may not have had an opportunity to participate. It is not known
how this group of students differed from the students whose parents were contacted
by telephone and who provided consent. Overall, results from this study confirm the
fact that many rural youth are participating in health risk behaviors that place them at

significant risk for morbidity and mortality.

45

mm

The results in this study indicate that rural adolescents are engaging in sexual
behaviors that place them at risk for unintended pregnancy, sexually transmitted
disease including HIV infection. Approximately 69% of the students in this survey
reported sexual intercourse and 31.4% had 4 or more lifetime partners. Kann et a1.
(1993) found that 54% of students had participated in sexual intercourse and 19% had
4 or more lifetime partners. In this study, approximately 51% had sexual intercourse
in the three months preceding the survey compared to 69% reported by Kannet al.,
(1993).

Birth control pills, condoms, or withdrawal were used by approximately 77%
of students in this survey while Kann et al., (1993) reported 82% of students using
one of these contraceptive methods. The use of birth control pills and condoms by
66% of these students is encouraging, however approximately 23 % used no method of
birth control and 11% used withdrawal placing these adolescents at high risk for
unintended pregnancy. The 43% of students who did not use condoms with last
intercourse are placed at risk for sexually transmitted disease including HIV. Lack of
contraceptive and condom use might be due to a myriad of factors. These students
may not perceive themselves as susceptible or vulnerable to pregnancy, sexually
transmitted disease, or HIV, or perhaps they do not recognize the potential serious
consequences of their behaviors. They may perceive barriers to condom or
contraceptive use such as lack of confidence in how to use the method or lack of
partner acceptance. The student may lack the finances to fund contraceptive and

condom use and may lack the knowledge that contraceptives and condoms are

46

available at the local health department through Title X regardless of ability to pay.
Transportation to clinics may be problematic or clinic hours may be inconvenient.
Students may not want parents to know they are sexually active and may not realize
that according to Michigan law family planning services are obtainable without
parental consent. Many adolescents tend to have spontaneous rather than
premeditated sex (Cates, 1990), and without a prior acknowledgment that intercourse
may occur, preventive actions are hindered. Many teenagers are awkward when
communicating about sexuality, whether with the opposite sex or with their health
care provider.
W

These data show that youth in this study are participating in health risk
behaviors involving smoking cigarettes at a rate slightly above rates reported in other
studies and the use of chewing tobacco and snuff was slightly lower. In this survey,
73% reported trying cigarette smoking, 37.3% were current smokers (had smoked
cigarettes on one or more days of the 30 days preceding the survey), and 8% had
used snuff or chewing tobacco during the past 30 days. Kann et al. (1993) found that
70% of students Ind tried cigarette smoking, 27 .5% were current smokers, and 11%
had used chewing tobacco or snuff in the past 30 days. Data from this survey
indicated that only 3.9% (2) students were smoking 11 to 20 cigarettes per day which
might indicate that these adolescents are not heavy smokers. It is also encouraging
that 33.3% (17) students tried to quit. This may indicate that students are aware of
the adverse consequences of tobacco use and may be ready for smoking cessation

intervention. Even though these adolescents were not heavy smokers, tobacco use of

any magnitude is alarming.

47

Aleuhnlllee

Results related to alcohol use were very similar to those reported by Kann et
al., (1993), Millstein et al., (1992), and Riggs (1994). In this study 82% of students
had a drink of alcohol, 57% reported alcohol use in the past 30 days, and 35%
percent had 5 or more drinks in a row during the past 30 days. These data may
reflect an overall societal acceptance of alcohol use. Even though alcohol use is
prohibited by Michigan law until the age of 21, these students clearly have access to
alcoholic drinks. Students having 5 drinks in a row on more than 1 occasion in the
past 30 days may indicate binge type drinking. Approximately 16% had 5 or more
drinks on 6 or more days in the past 30 which indicates alcohol use is occurring on
more than just weekends. Teenagers who engage in binge drinking or who frequently
use alcohol have been shown to be more likely to smoke or chew tobacco, use illicit
drugs, have unprotected sex, and exhibit antisocial behaviors (Morrison, Rogers, &
Thomas, 1995). Accidental injury is the leading cause of mortality and morbidity
among adolescents and young adults. Motor vehicle accidents account for up to 75 %
of these deaths with a large percentage being alcohol related (Morrison et al. , 1995).
Alcohol is also related to a large percentage of the nonvehicle related injury deaths,
suicides, and homicides (Morrison et al., 1995).
III' . D II

Marijuana use, both lifetime and current, was higher among students in this
study than results reported by Kann et al., (1993). Lifetime and current cocaine use
was similar to results found in other studies. In this study, 47% of students reported
marijuana use with 22% using marijuana in the past 30 days. Cocaine use was

reported by 8% of students and 6% used cocaine in the past 30 days. Other illicit

48

drugs such as LSD, PCP, ecstasy, mushrooms, speed, ice, or heroin were used by
25.5% (13) students. Kann et al. (1993) reported that 30% of students reported
marijuana use, 15% used marijuana in the past 30 days, 6% reported cocaine use and
1.7% used cocaine in the past 30 days. Four percent of students in this study
reported lifetime steroid use compared to 3% of students reported by Kann et al.,
(1993). The use of marijuana and cocaine by these students indicates that although
these substances are illegal, they are available in this rural community. More
students (47 %) used marijuana than cocaine (6%) which may indicate that marijuana
is more available or that marijuana is perceived as more ”socially acceptable” to use.
Legal consequences and personal consequences of using marijuana compared to
cocaine may be perceived as less severe. It is also important to note that 25.5% (13)
of the students used other illegal drugs such as LSD, PCP, ecstasy, mushrooms,
speed, ice, or heroin which indicates that these drugs are also available in this rural
community. The question regarding other illegal drug use was worded so that the
researcher does not know which of the listed drugs the student used.

5"1111' 15.1!

Data from this study show that students attending this rural public high school
were less likely to think seriously about committing suicide, were less likely to make
a specific plan, and were less likely to make an attempt than youth polled from other
national studies. In this study, 16% of the subjects thought seriously about attempting
suicide, while 12% made a specific plan, and 6% actually attempted suicide. Kann et
al. (1993) reported that 29% of students had seriously thought about attempting
suicide, 18.6% had made a specific plan, and 7% actually attempted suicide. Suicidal

ideation, plans, and attempts may be lower in this population because students feel

49

less stress. The majority lived with both parents which might indicate a stable home

life and the students may feel they have someone to turn to in times of stress.

 

Data from this study indicated that seat belt and motorcycle use was similar to
results from other studies, and that helmet use was higher in this study. In this study,
29% of students always wore a seatbelt. Kann et al. (1993) reported seat belt use in
28% of the students. In this study 24% of students rode a motorcycle and 83% of
those students always wore a helmet. Kann reported motorcycle use among 28 % of
students with 39% always wearing a helmet. In this study 49% rode a snowmobile or
ATV the past year with 73% always wearing a helmet. Approximately 43% of
students reported riding with someone who had been drinking alcohol and 23.5%
drove while using alcohol. National data were not available for comparison.

Although seat belt use by drivers and front seat passengers is mandated by
Michigan law, back seat passengers over the age of 16 are not required by law to do
so. This may account for the fact that only 29% of students always wore a seatbelt.
The high rate of helmet use with motorcycle and ATV use may be directly related to
a mandatory helmet law in Michigan. Since helmet use is also very visible, students
may fear the legal consequences of getting ”caught. "

Students riding in a vehicle with someone who has been drinking or driving
while they themselves have been drinking may be due to a variety of reasons.
Students may not perceive themselves as vulnerable to injury or may not recognize
the serious consequences of such behavior. Although the legal consequences of
drinking and driving are severe, adolescents may feel, "It can’t happen to me" or that

alcohol will not impair their driving ability.

50
Uningntignal [Him Related tg Wmm Q4 Fighting
Data from this study show that adolescents in this rural community did not carry
a weapon as often as reported in other studies, but the incidence of physical fighting
was similar to other nationally reported results. In this study 14% of students carried
a weapon and 41% participated in a fight. Kann et al. (1993) reported that 26% of
students carried a weapon and 43 % were in at least one fight during the 12 months
preceding the survey. Weapon carrying may not be as prevalent in this rural
community because the students feel less need to protect themselves. The school
district has a very strict policy banning weapons from school premises and this policy
is strictly enforced. Students caught with weapons or weapon "look alikes" are
expelled from school.
vi rs

As shown in Tables 9, 10, 11, and 12 gender was a significant variable in a
number of health risk behaviors. Males were significantly more likely to ever have
experienced sexual intercourse, ever use cigarettes, to use chewing tobacco or snuff,
to use inhalants in their lifetime, to have been in fight, or have been the victim of
theft or damage. Reasons for greater male participation in these behaviors may be
due to the fact that they see themselves as less susceptible to consequences of these
behaviors or they may not perceive the consequences as severe. Males perhaps do
not have the fear of pregnancy because they do not actually have to be pregnant.
They may see abortion as a solution to a potential pregnancy. The consequences of
sexually transmitted disease may be perceived as not as severe for the male as for the
female. Males may find greater peer acceptance for some of these behaviors such as

fighting and chewing tobacco or snuff use. In addition, the males in this study were

51

significantly older than the females. This could possibly be a contributory factor to
some of the above findings.
vio

In this study males were statistically significantly more likely to report ever
having had sexual intercourse. There was no significant gender difference in number
of lifetime partners, current sexual activity, or contraceptive use with last intercourse.
Kann et al. (1993) found that female students were significantly more likely to be
currently sexually active (had intercourse in past 3 months) than male students, and
that male students were significantly more likely to have had four or more sex
partners than female students. Contraceptive use did not vary significantly by gender
among currently sexually active students.

Masseuse.-

Results from this study indicate that males were statistically significantly more
likely than females to ever use tobacco and to use chewing tobacco or snuff. There
was no significant gender difference in current tobacco use. Kann et al. (1993) found
that cigarette use did not vary by gender.

Attendee.

Results from this study found no statistically significant difference between
gender in lifetime alcohol use, current alcohol use or likelihood of consuming 5 or
more drinks on one occasion. Kann et al. (1993) found that lifetime and current
alcohol use did not vary by gender, but that males were significantly more likely to

have 5 or more drinks on at least one occasion.

52
111° . I
In this study no statistically significant gender difference was found for lifetime
or current marijuana use, lifetime or current cocaine use, other illicit drug use, or
lifetime anabolic steroid use. Males were statistically significantly more likely to
report lifetime inhalant use. Kann et al. (1993) found that lifetime and current
marijuana use did not vary by gender; lifetime and current cocaine use occurred
significantly more often among male than female students and males were
significantly more likely to use anabolic steroids than female students.
5 . .1 .1 . . . l
Statistically no significant difference was found between males and females in
suicidal thoughts, plans, or attempts. Kann et al. (1993) and data from the NASHS
(American School Health Association, 1989) indicated that females were more likely
to have thought about committing suicide, were more likely to have made a suicide

plan, and were more likely to have attempted suicide than male students.

 

In this study no statistically significant difference was found between male and
female safety belt use. There was no statistically significant gender difference in
reports of riding with someone who had used alcohol or drugs or driving after using

alcohol or drugs. Kann et al. (1993) found that safety belt use did not vary by

 

In this study males were statistically significantly more likely to be the victim of

a theft or property damage and were more likely to have been involved in a physical

53

fight. There was no statistically significant difference in likelihood of carrying a
weapon or of being threatened or injured with a weapon. Kann et al. ( 1993) reported
that male students were significantly more likely to have been in a physical fight
during the preceding 12 months than female students. Male students were
significantly more likely to have carried a weapon than female students.
W1

The primary focus of this study was to gather descriptive data relevant to
prevalence of specific risk behaviors among adolescents attending eleventh grade at a
rural public high school in northern Michigan. An analysis of gender differences and
specific risk behaviors was completed. This study did not examine any other
variables in the health belief model that influence health risk behavior. Study of
other modifying factors that influence health risk behaviors such as peer group
influence and social class might be useful in order to target students who may be at
greatest risk for participation in health risk behaviors. Determining the students’
perceptions of susceptibility and their knowledge regarding potential serious
consequences of health risk behaviors may be necessary to better understand which
interventions may be useful in reducing health risk behavior. There is a need to
understand how the adolescent views benefits and barriers associated with individual
behaviors to better implement strategies aimed at reducing health risk behavior. In
addition, there remains a need to identify which cues to action adolescents are most
likely to respond to, so that these may be employed when targeting the adolescent

population.

54

 

This study was designed to investigate health risk behaviors in students attending
eleventh grade at a rural public high school. Ideally, the sample would have included
all of the eligible adolescents. Of the 134 eligible students, 75 (56%) received
consent to participate and 51 (38 %) students completed the survey. Several reasons
contributed to the small sample size: (a) Active consent was required from the
parents; (b) Follow up telephone calls were made to parents who had not received the
consent form and parents who did not have telephones could not be contacted; (c)
The survey was given during regular classroom time and students may not have
wanted to miss material that was being presented that day; and (d) Absentees were not

included in the survey.

 

The Family Nurse Practitioner (FNP) in primary care is in a front line position
to reduce health risk behavior among adolescents. In order to reduce health risk
behaviors, a thorough assessment for health risk behaviors must be part of every
primary care visit. The most important screening tool FNP’s have at their disposal in
assessing adolescents for risk behaviors is a thorough intake history which should
include questions about sexual behaviors, questions about tobacco, alcohol, and illicit
drug use, and questions about behaviors that may lead to unintentional injury.
Questions about depression and suicide ideation should also be asked. The physical
examination is also important; deviations in pupil size, nystagmic eye movements,
periorbital edema, conjunctivitis, rhinorrhea, nasal septum erythematosis, and
malnutrition would alert the nurse practitioner to possible drug and alcohol use

(Riggs, 1994). Genital lesions or genital discharge can indicate sexual risk behaviors.

55

The FNP will need to utilize her/his teaching role to increase the adolescent’s
knowledge about the adverse affects of health risk behaviors and their susceptibility to
such effects. Of the adolescents who reported sexual intercourse, approximately 23 %
used no contraception with last intercourse which puts them at risk for unintentional
pregnancy. Students need to know that adolescents who become parents risk lifelong
social and economic disadvantages. Adolescent parents are less likely to complete
their educations, to be employed, and if employed to have lower incomes.

Adolescent parents are also more likely to have larger families, more marital
disruptions, and greater need for welfare assistance (Morris, Warren, & Aral, 1993).
Children of adolescent mothers often grow up in families with limited financial
resources and few opportunities for upward mobility (Alexander & Guyer, 1993).

Approximately 43 % of adolescents in this study did not use a condom at last
intercourse which places them at significant risk for sexually transmitted disease.
Adolescents need to know that they are at higher risk physically for sexually
transmitted disease than persons in other age groups for two reasons. During
adolescence, columnar epithelia is more apparent on the cervix than during adulthood;
both chlamydia and gonorrhea have a predilection for this tissue. Second, adolescents
often have a relatively unchallenged immune system, since they are less likely than
older persons to have been exposed to STD (Morris et al., 1993). They need to
understand that sexually transmitted disease such as chlamydia and gonorrhea may
progress to pelvic inflammatory disease (PID) which places female adolescents at risk
for chronic pelvic pain, infertility, and ectopic pregnancy (Morris et al. , 1993).
Sexually active adolescents who have genital ulcers associated with syphilis or genital

herpes may be at greater risk for acquiring HIV as genital ulcers facilitate

56

transmission of the virus (Hein, 1993). In addition, adolescents need knowledge
about signs and symptoms of sexually transmitted diseases so they can recognize a
potential infection, as well as knowledge that prompt treatment of some diseases can
lead to cure.

Of the adolescents in this study, 82% reported having drunk alcohol and 47 %
reported marijuana use. Cocaine and other drug use was also reported although to a
much lesser extent. Adolescents need to understand that alcohol and other drug use
behaviors established during youth may extend into adulthood (Blanken, 1993). The
use of these substances jeopardizes physical, mental, and social development during a
person’s formative years, thereby endangering successful transitions from adolescent
to adult roles (Blanken, 1993). Alcohol use is a factor in approximately half of all
deaths from motor vehicle crashes and intentional injuries (Gans et al. , 1990).
Alcohol and drug use contribute directly and indirectly to the epidemic of sexually
transmitted disease, HIV, and pregnancy due to impairment of judgment and reduced
inhibitions (Blanken, 1993). Recognition of the impact and prevalence of alcohol and
other drug use among adolescents can be used to increase awareness of the problem
and may be important in helping adolescents reduce risk behaviors in this area.

Approximately 73 % of the students in this study reported cigarette use.
Adolescents need to know that nicotine addiction does occur during adolescence and
that adolescent tobacco users are likely to become adult tobacco users (Morbidity and
Mortality Weekly Report, 1994). The age at which a person begins to smoke
cigarettes has been found to be related to the total number of years of subsequent
smoking and the number of cigarettes smoked per day in adulthood (Taioli &

Wynder, 1991). Health problems associated with smoking are associated with

57

duration (years) of tobacco use and intensity (amount) of use (Morbidity and Mortality
Weekly, 1994). Preventing tobacco use among adolescents is therefore likely to
affect both duration and intensity of tobacco use which potentially will reduce long
term health consequences.

Adolescents med knowledge and reinforcement that most injuries are
preventable. Some behaviors that are risk factors for unintentional injuries are
initiated during adolescence and may persist into adulthood (W axweiler, Harel, and
O’Carroll, 1993). In 1990, 77% of persons killed in motor vehicle crashes were not
wearing safety belts. Fatal head injuries among motorcyclists, snowmobilers, and
ATV users are another . problem. Each year, motorcyclists account for about 12% of
all deaths from injuries sustained in motor vehicle crashes, and slightly more than half
of these injuries involve head injury (W axweiler et al. , 1993). Risk reduction for
unintentional injuries calls for the increased use of safety belts and helmets. Among
front seat motor vehicle occupants, use of safety belts reduces the risk for fatal injury
by 40 to 50 percent (Waxweiler et al., 1993). Helmet use reduces the risks for death
from motorcycle crashes 28 to 73 percent (Waxweiler et al. , 1993).

Weapon carrying may significantly increase the risk that a violent argument will
result in death, disability, or other serious injury. The immediate accessibility of a
weapon may be the factor that turns a violent altercation into a lethal event
(O’Carroll, Harel, and Waxweiler, 1993). Physical fighting among adolescents is a
prominent cause of injuries and homicides in this age group (O’Carroll et al., 1993).
Even adolescents who are not directly involved with interpersonal violence are
affected by the threat of such violence. Interventions designed to reduce the

prevalence of physical fighting and weapon carrying may help prevent such injuries.

58

Although the percentages of students who reported that they have seriously
thought about committing suicide and who have actually tried to commit suicide were
not high, suicide prevention efforts are necessary. Screening students for depression,
suicidal thoughts, suicidal plans, and past suicide attempts may be as important as
other screening procedures. The most important antecedent behavior associated with
adolescent suicide is a history of a previous suicide attempt. Although less than 10%
of attemptors eventually complete suicide, they are still 20 to 50 times more likely to
complete suicide than peers who have not attempted suicide (Grossman & Rivera,
1992). Suicidal behavior in adolescents has also been linked to depression (Lamb &
Pusker, 1991). Forty five percent of students in this study reported depression in the
past 6 months. Questions relating to depression and suicide should be part of every
assessment.

Knowledge alone will not be effective in reducing health risk behavior. In
addition to being an educator, the FNP needs to actively involve the adolescent in
plans to reduce risk behaviors and to decrease negative consequences of risk
behaviors. She/he may need to help the adolescent acquire the skills necessary to
change or reduce health risk behaviors. Use of role playing may help the adolescent
say no to health risk behaviors. The FNP may need to refer some adolescents to
other professionals with more expertise in dealing with certain problems such as
alcohol abuse, substance abuse, depression, suicide ideation, and suicide attempts.

The FNP may serve as a consultant to the school system, teachers, and parents.
The school health curriculum needs to address the health risk behaviors that impact
the lives of adolescents. Health educators need to know when specific health risk

behaviors are initiated so that educational material can be presented before the

59

majority of students initiate those behaviors. Students need knowledge so they can
make fully informed choices regarding behaviors that may impact their health for a
lifetime, but educational programs also need to teach students skills such as how to
say no in spite of peer pressure. Categorical programs that focus on only one
behavior, such as substance abuse, are important, but these programs need to be
linked together in a planned sequential curriculum. The FNP may serve as a
consultant to classroom teachers as they plan specific lesson plans. She/he may be
called upon to be a guest lecturer to present specific programs to students and parents.
Parents as well as students need knowledge about the prevalence, signs and
symptoms, treatment, and prevention of sexually transmitted disease. The FNP may
act as consultant for further research projects that address health risk behaviors among
adolescents.

The FNP may need to be a leader in organizing a ”task force" that will bring
together all local groups that have an interest in adolescent health. Meetings
involving the public health agency, social services, mental health, local law
enforcement, the juvenile justice system, the religious community and the school
system need to be coordinated on a regular basis to plan strategies to reduce
adolescent risk behaviors. No single agency or group is capable of providing the
range of services needed by adolescents at risk. The FNP may serve as a catalyst to
develop focus groups of youth, parents, and grandparents to help identify potential
strategies for dealing with health risk behaviors.

The FNP may also need to be proactive in the political arena. She/he will need
to work with the state legislators to advocate for allocation of funds to establish

school based health clinics. School based health clinics throughout the country have

60

shown a decrease in health risk behaviors, an increase in compliance with treatment
protocols for sexually transmitted disease, a decrease in the pregnancy and birth rate,
delays in the initiation of sexual activity, and earlier detection of health problems
(Lear, Gleicher, St. Germaine, and Porter, 1991).
W

This study found that rural youth are engaging in health risk behaviors related to
sexual behaviors, tobacco, alcohol and drug use, and intentional and unintentional
injury. Suggestions for further research include the following:
(a) Repeat this study utilizing a cross sectional design to help identify when risk
behaviors are initiated and how risk behaviors change with grade level and age. This
information will be necessary to determine when health education materials need to be
introduced.
(b) Execute a longitudinal study of several grade levels to follow particular age
groups over a period of time to determine how risk behaviors change over time.
(c) Target intervention strategies such as utilization of peer group educators using
experimental studies to determine whether intervention strategies impact risk
behaviors.
(d) Target adolescents who currently are in non traditional school settings such as
those who are attending Alternative Education Classes in the evening and those youth
who have dropped out of school. These adolescents may have a significantly different
level of health risk behaviors from students attending traditional school.
(e) Expand investigation efforts aimed at identifying the influence of other variables
in the health belief model that may influence health risk behaviors. The individual’s

perceptions of seriousness and susceptibility, the cues to action, the benefits and

61

barriers, and the modifying factors such as social class, peer group, and race may
help to identify which adolescents are at greatest risk.
(f) Repeat this study utilizing a larger sample size in other rural school districts to
determine whether health risk behaviors are similar to results found in this study.
Summary

This study examined health risk behaviors of rural adolescents and the
relationship of gender to selected health risk behaviors using descriptive statistics and
chi square analysis. The findings, though limited by a relatively small sample size,
suggest that these rural youth are engaging in health risk behaviors that place them at
risk for morbidity and mortality related to sexual behaviors, tobacco, alcohol, and
drug use, and intentional and unintentional injury. The study contributes useful health

information for Family Nurse Practitioners in primary care.

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14.

APPENDICES

APPENDIX A

YOUTH RISK BEHAVIOR SURVEY

67

1995

YOUTH RISK BEHAVIOR
SURVEY

This survey is about health behavior. It has been developed so you
can tell us what you do that may affect your health. The information you
give will be used to deve10p better health education for young people like
yourself.

DO NOT write your name on this survey. The answers you give
will be kept private. No one will know what you write. Answer the
questions based on what you really do.

Completing the survey is voluntary. You indicate your voluntary
agreement to participate by completing and returning this survey.

The questions that ask about your background will only be used to
describe the types of students completing this survey. The information
will not be used to find out your name. No names will ever be reported.

Try to answer eVery question. When you are finished, follow the
instructions of the person giving you the survey.

Thank You Very Much For Your Help.

10.

ll.

68
YOUTH RISK BEHAVIOR SURVEY

How old are you?

(a) 15 (b) 16 (c) 17 (d) 18
Sex: (a) Female (b) Male
How important is your health?

(a) very important (b) somewhat important (c) not important

How healthy are you?
(a) excellent health (c) fair health
(1)) 800d health ((1) poor health

How often do you worry about your personal health?

(a) a lot (b) sometimes (c) hardly ever
How often do you worry about getting sick?

(a) a lot (b) sometimes (0) hardly ever
When you are sick, how much do you worry about it?

(a) a lot (b) some (c) little to none

How much responsibility do you feel for your health?

(a) a lot (b) some (c) little to none

How often do you do things not good for your health?

(a) a lot (b) sometimes (c) hardly ever
How many days are you absent from school in a typical month?

(a) almost never (c) 3-5 days a month
(b) l-2 days a month ' (d) 6 or more days a month

When did you last go to a doctor or nurse for a HEALTH check-up or physical when
you were NOT sick?

(a) during last 12 months (c) more than 2 years ago
(b) 1-2 years ago (d) never

69
12. How often do you go to a doctor, nurse, or Emergency Room?

(a) never (c) 3-5 times per year
(b) 1-2 times per year (d) more that 5 times per year

13. When you are sick, where do you go?

(a) Private doctor’s office

(b) Walk-In Clinic (Quick Care)
(c) Emergency Room

(d) Health Department

(e) Other - Where

 

14. When you are sick or hurt do you always get medical care when you feel you need it?

(a) Yes (Go to question 26)

(b) No (Go to question 15)
15. My parent(s) didn’t think I needed to see a doctor ............. (a) yes (b) no
16. It cost too much money ............................. (a) yes (b) no
17. I didn’t know where to go ........................... (a) yes (b) no
18. I didn’t have a way to get there ........................ (a) yes (b) no
19. I could not go during office hours ....................... (a) yes (b) no
20. I had to wait too long to get an appointment ................ (a) yes (b) no
21. I did not want to miss school .......................... (a) yes (b) no
22. My mother/father could not take time off work .............. (a) yes (b) no
23. I was afraid/embarrassed ............................ (a) yes (b) no
24. My visit would not be secret .......................... (a) yes (b) no
25. Other (a) yes (b) no

 

26. What kind of health insurance does your family have?

(a) Private (Blue Cross/Blue Shield, AETNA, etc.)

(b) Prepaid health maintenance plan, (Blue Care Network, HMO, Health Plus, etc.)
(c) Medicaid

(d) My family pays because we have no insurance

(e) I do not know

HAVE YOU BEEN CHECKED FOR THE FOLLOWING IN THE LAST 2 YEARS?

27. blood iron (anemia) ....... ‘. .............. (a) yes (b) no (c) don’t know
28. height and weight ....................... (a) yes (b) no (c) don’t know
29. blood pressure ......................... (a) yes (b) no (c) don’t know
30. pregnancy ............................ (a) yes (b) no (c) don’t know
31. pap smear ............................ (a) yes (b) no (c) don’t know
32. sexually transmitted disease (STD) ............ (a) yes (b) no (c) don’t know
33. scoliosis (curved back) .................... (a) yes (b) no (c) don’t know

34. hearing and vision ...................... (a) yes (b) no (c) don’t know

35.

36.

37.

38.

39.

41.

42.

43.

70
How do you describe your weight?
(a) Very underweight (c) Slightly overweight
(b) Slightly underweight (d) Very overweight
(c) About the right weight
How do you feel about your weight:

(a) I’m trying to lose weight (c) I want to stay the same
(b) I’m trying to gain weight (d) It doesn’t matter to me

Have you ever done any of the following shortly after eatirm (Mark only one)?

(a) made yourself throw up (c) both of the above
(b) used remedies such as laxatives (d) neither of the above

During the past 30 days, did you vomit or take laxatives to lose weight or to keep
from gaining weight?

(a) Yes (b) No

How many days a week do you usually eat breakfast?

(a) almost never ((1) 5-7 times a week

(b) 1-2 times a week (e) every day"

(c) 3-4 times a week

In the past six months, have you had the feeling that life wasn’t worth living?
(a) Yes, often (b) sometimes (c) never

In the past six months, have you been depressed for long periods of time?

(a) yes, but not right now

(b) yes, and I’m having real problems right now

(e) no

During the past 12 months, did you ever seriously consider attempting suicide?

(a) Y6 (b) no

During the past 12 months, did you make a plan about how you would attempt
suicide?

(a) Yes (b) no

45.

47.

48.

49.

50.

51.

71
During the past 12 months, how many times did you actually attempt suicide?
(a) 0 times ((1) 4 or 5 times
(b) 1 time (c) 6 or more times

(c) 2 or 3 times

If you attempted suicide during the past 12 months, did any attempt result in an
injury, poisoning, or overdose that had to be treated by a doctor or nurse?

(a) I did not attempt suicide during the past 12 months
0)) Yes

(c) No

Have you ever had sexual intercourse?

(a) Yes (b) No

How old were you when you had sexual intercourse for the first time?

(a) I have never had sexual intercourse (c) 14 or 15 years old
(b) 13 years or younger (d) 16 years old or older

During your life, with how many people have you had sexual intercourse?

(a) I have never had sexual intercourse (c) 2 or 3 people
(b) 1 person (d) 4 or more people

During the past 3 months, with how many people did you have sexual intercourse?

(a) l have never had sexual intercourse (c) 1 person
(b) I have had sexual intercourse, but not (d) 2 or 3 people
during the past 3 months (e) 4 or more people

Did you drink alcohol or use drugs before you had sexual intercourse the last time?

(a) I have never had sexual intercourse

(b) Yes
(c) No

The last time you had sexual intercourse, did you or your partner use a condom?
(a) I have never had sexual intercourse

0)) Yes
(c) No

52.

53.

54.

55.

56.

57.

58.

59.

72

The last time you had sexual intercourse, what one method did you or your partner
use to prevent pregnancy? (Select only one response.)

(a) I have never had sexual intercourse (d) Condoms-

(b) No method was used to prevent (e) Withdrawal
pregnancy (f) Some other method

(c) Birth control pills

How many times have you been pregnant or gotten someone pregnant?

(a) 0 times (c) 2 or more times
(b) 1 times (d) Not sure

Do you feel pressure to have sex?
(a) Yes (b) No

If you answered YES to question 54 where does the pressure come from?

(a) boyfriend (d) adult
(b) girlfriend (e) other
(c) friend(s)

How often do you wear a seat belt when riding in a motor vehicle?
(a) Never (d) Most of the time
(b) Rarely (e) Always

(c) Sometimes

During the past 12 months, how many times did you ride a motorcycle?

(a) 0 times
(b) l to 10 times (d) 21 to 39 times
(c) 11-20 times (e) 40 or more times

When you rode a motorcycle during the past 12 months, how often did you wear a
hehnet?

(a) I did not ride a motorcycle during the (d) Sometimes wore a helmet

past 12 months (e) Most of the time wore a helmet
(b) Never wore a helmet ' (0 Always wore a helmet
(c) Rarely wore a helmet

During the past 12 months, how many times did you ride a snowmobile or ATV?
(a) 0 times (d) 21 to 39 times

(b) l to 10 times (e) 40 or more times
(c) 11-20 times

61.

62.

63.

65.

73

When you rode a snowmobile or ATV during the past 12 months, how often did you
wear a helmet?

(a) I did not ride a snowmobile or ATV (d) Sometimes wore a helmet
during the past 12 months (e) Most of the time wore a helmet
(b) Never wore a helmet (f) Always wore a helmet

(c) Rarely wore a helmet

During the past 30 days, how many times did you ride in a car or other vehicle
driven by someone who had been drinking alcohol?

(a) 0 times (d) 4 or 5 times
(b) 1 time (c) 6 or more times
(c) 2 or 3 times

During the past 30 days, how many times did you drive a car or other vehicle when
you had been drinking alcohol?

(a) Otimes (d) 4or5times
(b) 1 time (c) 6 or more times
(c) 2 or 3 times

During the past 30 days, on how many days did you carry a weapon such as a gun,
knife, or club?

(a) 0 days (d) 4 or 5 days
(b) 1 day (e) 6 or more days
(c) 2 or 3 days

During the past 30 days, how many days did you not go to school because you felt
you would be unsafe at school or on your way to or from school?

(a) 0 days (d) 4 or 5 days
(b) 1 day (e) 6 or more days
(c) 2 or 3 days

During the past 12 months, how many times has someone threatened or injured you
with a weapon such as a gun, knife, or club?

(a) 0 times (d) 4 or 5 times
(b) 1 time ' (e) 6 or more times
(c) 2 or 3 times

During the past 12 months, how many times has someone stolen or deliberately
damaged your property such as your car, clothing, or books?

(a) 0 times (d) 4 or 5 times
(b) 1 time (c) 6 or more times
(c) 2 or 3 times

67.

68.

69.

70.

71.

72.

73.

74.

74
During the past 12 months, how many times were you in a physical fight?
(a) 0 times ((1) 4 or 5 times
(b) 1 time (c) 6 or more times

(c) 2 or 3 times

During the past 12 months, how many times were yOu in a physical fight in which
you were injured and had to be treated by a doctor or nurse?

(a) 0 times (d) 4 or 5 times
(b) 1 time (c) 6 or more times
(c) 2 or 3 times

The last time you were in a physical fight, with whom did you fight?

(a) I have never been in a physical fight (e) A parent, brother, sister, or other family

(b) A total stranger member
(c) A friend or someone I know (1) Someone not listed above
(d) A boyfriend, girlfriend, or date (7) More than one of the persons listed above

Have you ever tried cigarette smoking, even one or two puffs?

a. Yes
b. No

How old were you when you smoked a whole cigarette for the first time?

(a) I have never smoked a whole cigarette (d) 14 or 15 years old
(b) 10 years old or younger (e) 16 years old or older
(c) ll-13 years old

During the past 30 days, on how many days did you smoke cigarettes?

(a) 0 days (d) 6 to 10 days
(13) 1 day (e) 11 or more
(c) 2 to 5 days

During the past 30 days, on the days you smoked, how many cigarettes did you
smoke per day?

(a) I did not smoke cigarettes during the (d) 6 to 10 cigarettes per day
past 30 days (e) 11 to 20 cigarettes per day
(b) 1 cigarette per day (f) More than 20 cigarettes per day
(c) 2 to 5 cigarettes per day
Have you ever tried to quit smoking cigarettes?

(a) Yes (b) No

75.

76.

77.

78.

79.

80.

81.

75

During the past 30 days, on how many days did you use chewing tobacco or snuff,
such as Redman, Levi Garrett, Beechnut, Skoal, Skoal Bandits, or Copenhagen?

(a) 0 days (d) 6 to 10 days
(b) 1 day (e) 11 or more
(c) 2 to 5 days

How old were you when you had your first drink of alcohol other that a few sips?

(a) I have never had a drink of alcohol (d) 14 or 15 years old
other than a few sips (e) 16 years old or older

(b) 10 years old or younger

(c) 11-13 years old

During the past 30 days, on how many days did you have at least one drink of
alcohol?

(a) 0 days (d) 6 to 10 days
(b) 1 day (e) 11 or more
(c) 2 to 5 days

During the past 30 days, on how many days did you have 5 or more drinks of alcohol
in a row, that is, within a couple of hours?

(a) 0 days (d) 6 to 10 days
(1)) 1 day (e) 11 or more
(c) 2 to 5 days

How old were you when you tried marijuana for the first time?

(a) I have never tried marijuana (d) 14 or 15 years old
(b) 10 years old or younger (e) 16 years old or older
(c) 11-13 years old

During the past 30 days, how many times did you use marijuana?

(a) 0 days (d) 6 to 10 days
(13) 1 day (e) 11 or more
(c) 2 to 5 days

How old were you when you tried any form of cocaine, including powder, crack, or
freebase, for the first time?

(a) l have never tried cocaine (d) 14 or 15 years old
(b) 10 years old or younger (e) 16 years old or older
(c) 11-13 years old

82.

83.

85.

86.

87.

89.

76

During the past 30 days, how many times did you use any form of cocaine, including
powder, crack, or freebase?

(a) 0 days (d) 6 to 10 days
(b) 1 day (e) 11 or more
(c) 2 to 5 days

During your life, how many times have you sniffed glue, or breathed the contents of
aerosol spray cans, or inhaled any paints or sprays to get high?

(a) 0 times (d) 10 to 19 times
(b) lor2times (e) 20 or moretimes
(c) 3 to 9 times

During your life, how many times have you taken steroid pills or shots without a
doctor’s prescription?

(a) 0 times (d) 10 to 19 times
(b) lor2times (e) 20or more times
(c) 3 to 9 times

During your life, how many times have you used any other type of illegal drug, such
as LSD, PCP, ecstacy, mushrooms, speed, ice, or heroin?

(a) 0 times (d) 10 to 19 times
(b) l or 2 times (e) 20 or more times
(c) 3 to 9 times

During your life, how many times have you used a needle to inject any illegal drug
into your body?

(a) 0 times (b) 1 time (c) 2 or more times

During the past 12 months, has anyone offered, sold, or given you an illegal drug on
school property?

(a) Yes (b) No

When did you last go to the dentist?

(a) during last 12 months " (c) more than 2 years ago
(13) 1'2 years 880 (d) never

How often do you brush your teeth?

(a) I never brush my teeth (c) daily

(b) lessthan6timesaweek (d)20rmoretimesdaily

91.

77

How often do you floss your teeth?
(a) I never floss my teeth ' (c) daily
(b) less than 6 times a week (d) 2 or more times daily

Who do you live with now?

(a) both parents (d) other guardian/adults
(b) 1 parent only (e) no adult
(c) 1 parent and 1 step parent

WHAT HELP WOULD YOU WANT FROM YOUR DOCTOR OR OTHER HEALTH

333.333.3313

Hut-t
5.3.3

CARE PROVIDER?

Health check-up .................. ‘ ................ (a) yes (b) no
Sports physical .................................. (a) yes (b) no
A place to go when I’m sick .......................... (a) yes (b) no
Birth control .................................... (a) yes (b) no
Counseling for my problem ........................... (a) yes (b) no
Dental care ..................................... (a) yes (b) no
Skin care ...................................... (a) yes (b) no
Pregnancy test ................................... (a) yes (b) no
Care during pregnancy .............................. (a) yes (b) no
AIDS information ................................. (a) yes (b) no

Sexually transmitted disease (STD) information .............. (a) yes (b) no

APPENDIX B

FACT SHEET FOR PARENTS

78
Fact Sheet for Parents

How will education agencies and schools benefit from conducting this survey?

Results from this survey can be used to (1) monitor how health behaviors among high
school students increase, decrease, or remain the same over time; (2) evaluate the
impact of national, state, and local efforts to prevent health risk behaviors; and (3)
monitor progress in achieving relevant national health objectives and National
Education goals. Results can be used to help focus programs and policies for HIV
prevention education and school health education on the behaviors that contribute to
the leading causes or mortality and morbidity.

WhatisthefocusoftheYouthRiskBehaviorSurvey?

This survey focuses on health behaviors established during youth that result in the
most significant mortality and morbidity during youth and adulthood. These include:
(1) behaviors that result in unintentional and intentional injuries; (2) Tobacco use; (3)
alcohol and other drug use; (4) sexual behaviors that result in HIV infection and other
sexually transmitted diseases (STDs), and unintended pregnancies; (5) dietary
behaviors; and (6) physical activity.

Why were these behaviors selected?

Among persons aged 5 to 24 years, approximately 72% of all deaths are due to only
four causes: motor vehicle crashes (30%), other unintentional injuries (12%),
homicide (19%), and suicide (11%). In addition, each year an estimated 1 million
teenaged girls become pregnant and 86% of all STD cases occur among 15 to 29 year
olds. One out of every five persons diagnosed with AIDS in the United States is 20
to 29 years old; and many of these may have become infected as adolescents.

Among adults aged 25 and over in the U.S., 67% of deaths are due to only three
causes: heart disease (35%), cancer (25%), and stroke (7%). A number of
behaviors, often established during youth, contribute to these health problems. These
behaviors include the use of tobacco, excessive consumption of fat, and insufficient
physical activity.

Who developed the questionnaire?

The questionnaire was developed by representatives from all state education agencies,
16 local education agencies, and 19 federal agencies including the US. Department of
Education, and by the foremost scientists in each categorical area. These
representatives were asked to focus questions on the leading causes of mortality,
morbidity, and social problems nationwide. Additional questions were added to the

79

Centers for Disease Control survey to reflect local patterns of health utilization.
Will this survey cause students to initiate or increase risk behaviors?

Students are exposed regularly to information about tobacco, alcohol, and other drug
use; violence; and sexuality through the television, friends, and magazines. Exposure
to a small number of questions on any one topic is not likely to cause a significant
change in behavior-either good or bad.

How long does it take to fill out the questionnaire? Is there some sort of physical
test?

One class period is needed for administration of the questionnaire.» It will take
approximately 10 minutes to distribute survey materials and read directions to the
students. It will then take approximately 35 minutes for students to record their
responses. No physical test or exam is involved.

Is student participation anonymous? How is student privacy protected?
Survey administration procedures are designed to protect student privacy and allow
for anonymous participation. Students submit a completed questionnaire containing
no names or personal identifiers.

Are students tracked over time to see how their behavior changes?

No. Students who participate cannot be tracked because no identifying information is
collected.

What is the reading level of the questionnaire

The reading level is approximately 7th grade.

Will students be able to answer these questions?

Yes. Questions have been selected that have been used successfully in other school
based surveys of high school students. Evidence indicates that high school students
can understand and appropriately respond to the questions.

Do students answer the questions truthfully?

Research indicates data of this nature may be gathered as reliably from adolescents as
from adults. To obtain truthful answers, students must perceive the survey as
important and know that their privacy and confidentiality is assured.

Do Youth Risk Behavior Surveys have broad national support?

80

Yes. The survey is supported by many major national organizations. The American
Association of School Administrators, American Medical Association, American
School Health Association, Association for the Advancement of Health Education,
Association of State and Territorial Directors of Health Promotion and Public Health
Education, Association of State and Territorial Health Officials, Council of Chief
State School Officers, National Association of State Boards of Education, National
Education Association, National Education Goals Panel, National PTA, National
School Boards Association, National School health Education Coalition, and the
Society of State Directors of Health, Physical Education and Recreation have provided
letters of support.

This material is adapted from the Centers for Disease Control Fact Sheet.

APPENDIX C

SURVEY ADMINISTRATION GUIDELINES

81

Survey Administration Guidelines

Administrating the Survey

In a study of this kind, it is important to have a standardized format so that
procedures are consistent across the study. Therefore, where oral instructions are
given below, try to give them as written.

Introductory Procedure

As quickly as possible after the class period begins, bring the class to attention.
Students nwd approximately 30 to 45 minutes to take the survey, plus another 5
minutes for directions.

W

"Our school is involved in a very important study on student health behaviors,
health needs, and health care utilization. The purpose of this study is to help our
school better understand the health issues and problems students face. By tala’ng this
survey seriously, and by being as honest as you can, you will help to improve our
school ’s programs.

It is very important that you know that your survey will be anonymous. Since
your name will not be on the survey, no one will larow which survey you completed.

I will now give each of you a survey form. Please do not open the survey until
I tell you to do so. Remember: The survey is not a test. "

After distributing the materials, ask the students to follow along as you read the
paragraphs on the front page of the survey. When done reading the paragraphs,
continue.

"When you have finished the survey, raise your hand. I will come to your desk,
and you will place your survey form in this sealed box. No one in this school will
open the box or look at the surveys. They will be sent for processing to Michigan
State University graduate students. Again, no one here at this school will ever see
your survey forms. So, please answer the questions honestly.

If you have any questions during the survey, raise your hand, and I will try to
answer them. You have 45 minutes to do the survey. Make sure you read and answer
each question. When you are done, raise you hand, and I will have you put your
survey in this box. If you finish early, remain in your seat and use your time to study.

82
You may begin. "
Concluding Procedure
Announce when there are five minutes remaining. Do not make special arrangements
for students to finish later, or on their own. The hard and fast rule is to collect all
forms by the end of the period.

At the end of the session say, "Thank you very much for your participation. You
may return to your classes now. "

Additional Directives

If a student comes in late, let him or her do the survey if at least 20 minutes remain.

Should they ask, assure the students that having a sip of an alcoholic beverage
(communion wine included) does not constitute drinking.

Do not include in the sealed box any unused surveys. Return them separately to the
survey coordinator.

APPENDIX D

CONSENT FORMS

83

March 1995
Dear Parents:

Next month graduate students from Michigan State University College of Nursing will
be conducting a very important study of the health needs, health behaviors, and health
care utilization of students in grade 11. The Youth Risk Behavior Survey developed
by the Centers for Disease Control will be used for the study. It will take students
approximately 40 minutes to complete the survey. A copy of the survey, as well as
information on it, is available in the main office at Grayling High School for your
rev1ew.

This survey is voluntary. Parents and students have a right to refuse to participate
without penalty of any kind. All information will be collected anonymously with no
names or other identifying marks on the surveys. Michigan State University College
of Nursing graduate students will be coordinating the survey and analyzing the data.
The study will be conducted in a scientific manner guided by detailed administrative
guidelines. The final data analysis will be made available to school officials and the
Board of Education.

Please fill out the form below and retum it in the enclosed, pre-addressed and
stamped envelope by March _, 1995. If you have any questions about the study,
please contact Mr. Joel Raddatz, the high school principal.

Sincerely,

Mr. Joel Raddatz
High School Principal

OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

I hereby give my permission for (name of student/s) to participate
in the Health Survey.

 

 

Signature of Parent/Guardian Date

Crawford AuSable School District

 

403 Michigan Avenue
Grayling. MI 49738

Phone (517) 348-7641 Kent S. Reynolds, Super-imam
FAX (517) 348-6822 Paul B. berg, Assistant Superintendent
February 23. 1995
To Whom It May Concern:

TheanfordAuSableSchoolDisnictgivespermissionforMarilynRosi.BSN.RN.to
conductareeearchprojectincoopemionwithMichiganStateUniversity. Theprojectwill
involveasurveyofthehealthbehaviorsarxlhealthcareutilizationofGnylingHighSchool
elevemhgradesnldents. Participationintheau'veyissn'ictlyvohmryaMindividml
resporueswillbeanonymous. Thedistrictisbegimingareviewofhealthandscienee
auricuhmamnnmfomadonMs.Rosiwiflgaduisinvahnbletomdhnietm
assigndtohealdlaraiscieneecturicuhnnimprovemea.

WewmmmmWWmmherduiganheramlysuinm
cmricularimprovmeffort.

Simerely,

Items. ‘4

swam

APPENDIX E

UCRIHS

85

MICHIGAN STATE
u N l v a R SIT Y

March 27, 1995

so: Harilx: L. loci
9.0. x 411
Grayling al. 49738

RI: rare: 93-101

IIILI: HIALIH RISK IIERVIOIS anono ILSVINTH GRAD!
STUDENTS AITIIDIIO A RURAL PUBLIC BIGH senoon
RIVISIOI IIQUISIID: l/h
CAIIOORYt -c
APPROVAL earl: 03/26/95

the University Connieeoo on hoooarch Involving nunan Sub octa‘tUCIIni)
review or this project is coupleeo. I an planned to adv so than the
rightn and woltaro of tho hunan oubjoctn appear to bo adequately ,
noted and noehodn to obtain intornod conoon: aro appropriate.
u:rotoro. tho OCRIEB approved this project including any revision

IIIIIILs scares approval is valid for one calendar year. beginning with
the approval date shown above. Investigators planning to
continue a project nd one your nun: one the green renewal
torn (enclosed with e original :sproval letter or when a
project in renewed) to cook u e certification. thorn in a
no: of four such onpodit renewals oniblo. Investigators
wish to continue a project beyond the tin. hood to nub-it it
again or couples. rov ow.

Il'IlIdlls UCRIHS nun: review an changoo in E:ocoduroo involv hunan
oubjocco. ice to in elation o: e change. I! thigqio done at

the tin- o renewal. plea-o uno the n renewal torn. to
rovioo an appr protocol a: an hor tin. during tho your
oond your wr econ request to the 138 Chair. roquoeting roviood
approval and rotoroncing the project' III I and title. Include
t:.!our request a doocr peion of the change and any roviood
run-nts, consent tor-I or advertise-onto that are applicable.

DIDILIII
Glnlonlt’ Should either o! the following aria. during the course of the
work. invoctigaeora nun: noci I 0c3138.£ronptlyt {1) lol-
u ) involv ng unan

ed aide ottoctoinconp since.

subjects or 1:; changon tho rooonrch environ-one or now
leaning

     

intornation greater risk to the hunan nub acts than
existed whon the protocol was previously reviewed approvod.
It wo can be of any future hols planed do no: hooieato to contact on
at (517)333-2100 or. rs: (sin: 6- 171.
slncorol'. \c“.
avid I. Uri .
ocarna Chairlgtb
03':ij
«gang; cc: Carla L. Iarnoo
flfllsmll
ransom-1m
mun-anew
woman

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