Abstract
Purpose
The 21 Critical National Health Objectives (CNHOs) for Adolescents and Young Adults derived from Healthy People 2010 addressed the most significant threats to the health of individuals aged 10–24 years. This study assessed trends in the 21 CNHOs between 1991 and 2009, and from baseline years for which 2010 targets were established to 2009, and the extent to which targets were achieved.
Methods
For one CNHO (new HIV diagnoses), national data were not available. For CNHOs measured by census systems, the percentage of change in each health outcome was calculated between 1991 and 2009 and between baseline years and 2009. Any change ≥5% was considered as an improvement or deterioration. For CNHOs measured by national probability-based surveillance surveys, multivariate logistic regression was conducted using Stata Version 10.0 (StataCorp, College Station, TX) to calculate odds ratios for each outcome from 1991, and from baseline years to 2009, controlling for gender, race/ethnicity, and age or school grade-level. To calculate the percentage of targets being achieved, the difference between baseline data and 2009 data was divided by that between baseline data and target.
Results
Adolescents and young adults achieved two targets (rode with a driver who had drunk alcohol, physical fighting), improved for 12 CNHOs, made mixed progress by sub-objective for two, showed no progress in four, and regressed in achieving two (Chlamydia infections; overweight). Progress varied by demographic variables.
Conclusion
Although encouraging trends were seen in young people's health, the United States achieved only two CNHOs. Attention is needed to improve the health and reduce disparities among young people.
Keywords
See Editorial p. 111
During the critical developmental transition between childhood and adulthood, adolescents and young adults often develop important personal attributes; explore sexual, substance use, other risk behaviors; and too frequently experience injuries and adverse health outcomes [
1
, 2
]. These stages of life provide a special opportunity to help young people establish personal strengths and healthy patterns of behavior that could improve both their current and their future health and well-being [[3]
].Given the importance of this transitional period, it is essential to systematically monitor and assess the health and well-being of adolescents and young adults, and evaluate the nation's efforts to improve the health of young people. However, since the last broad and comprehensive assessment of adolescent health published in 1991 by the now defunct U.S. Office of Technology Assessment [
[4]
], few studies have assessed the health of adolescents and young adults by using a comprehensive set of critical health indicators designed to monitor the most serious health problems and contributing risk factors among young people.This study was conducted to examine the 21 Critical National Health Objectives (CNHOs) for adolescents and young adults. The 21 CNHOs were selected in 2000 by the National Adolescent Health Steering Committee as part of the Healthy People 2010 development process to address the most significant threats to the health of young people aged 10–24 years [
[3]
]. The 21 CNHOs address six areas: mortality, unintentional injury, violence, substance use and mental health, reproductive health, and chronic diseases [[3]
]. Among the 21 CNHOs, nine address health outcomes (underlined in Table 1, Table 2) and the remaining 12 address behaviors that contribute to relevant outcomes. Five of the 21 CNHOs included age or behavioral sub-objectives (delineated in Table 2). The United States had not set age-specific 2010 targets for young people for five CNHOs.| Objective number | Objective | Data in 1991 or next available year % (95% CI) | Baseline data % (95% CI) | Latest available data % (95% CI) | 2010 target | (A) Change from 1991 to latest year of data | (B) Change from baseline year to latest year of data | (C) Percentage of targets achieved | (D) Subgroup that showed worse health outcome or behaviors | ||
|---|---|---|---|---|---|---|---|---|---|---|---|
| Gender | Age group or grade | Race/ethnicity | |||||||||
| Overall mortality | |||||||||||
| 16-03 (a,b,c) | Reduce deaths of adolescents and young adults | Per 100,000 | Per 100,000 | Per 100,000 | Per 100,000 | ||||||
| 10–14 year-olds | 25.6 (1991) | 21.5 (1998) | 16.9 (2007) | 16.5 | Improved | Improved | 92.0% | Male | Older age groups | Black | |
| 15–19 year-olds | 88.7 (1991) | 69.5 (1998) | 62.0 (2007) | 38.0 | Improved | Improved | 23.8% | Male | Black | ||
| 20–24 year-olds | 109.9 (1991) | 92.7 (1998) | 98.7 (2007) | 41.5 | Improved | Worsened | −11.7% | Male | Black | ||
| Unintentional injury | |||||||||||
| 15-15 (a) | Reduce deaths caused by motor vehicle crashes | Per 100,000 | Per 100,000 | Per 100,000 | Improved | No change | NA | Male | NA | White | |
| 15–24 year-olds | 31.6 (1991) | 25.6 (1999) | 25.3 (2006) | ||||||||
| 26-01 (a) | Reduce deaths caused by alcohol-related motor vehicle crashes | Per 100,000 | Per 100,000 | Per 100,000 | Improved | Improved | NA | Male | NA | Hispanic | |
| 15–24 year-olds | 13.7 (1991) | 10.1 (1998) | 9.3 (2007) | ||||||||
| 15–19 |
|
|
|
| 92.0% | Improved | Improved | 79.8% | Male | NA | Black |
| 26-06 |
|
|
|
| 30.0% | Improved | Improved | 100.0% | Male | Lower grade | Hispanic |
| Violence | |||||||||||
| 15–32 | Reduce homicides | Per 100,000 | Per 100,000 | Per 100,000 | |||||||
| 10–14 year-olds | 2.1 (1991) | 1.2 (1999) | 1.1 (2007) | Improved | Improved | NA | Male | Older age group | Black | ||
| 15–19 year-olds | 19.3 (1991) | 10.4 (1999) | 10.4 (2007) | Improved | No change | Male | Black | ||||
| 15–38 |
|
|
|
| 32.0% | Improved | Improved | 100.0% | Male | Lower grade | Black |
| 15–39 |
|
|
|
| 4.9% | Improved | Improved | 65.0% | Male | NA | Hispanic |
| Substance use and mental health | |||||||||||
| 18-01 | Reduce suicide rates | Per 100,000 | Per 100,000 | Per 100,000 | |||||||
| 10–14 year-olds | 1.5 (1991) | 1.2 (1999) | 0.9 (2007) | Improved | Improved | NA | Male | Older age group | White | ||
| 15–19 year-olds | 11.0 (1991) | 8.0 (1999) | 6.9 (2007) | Improved | Improved | ||||||
| 18-02 |
|
|
|
| 1.0% | No change | Improved | 43.8% | Female | Lower grade | Hispanic |
| 26-11 (d) |
|
|
|
| 3.1% | Worsened | Improved | 37.8% | Male | NA | White |
| 26-10 (b) |
|
|
|
| 0.7% | Worsened | Improved | 17.3% | Male | NA | White |
| 06-02 |
|
|
| 17.0% | Improved | 75.7% | Female | NA | Black | ||
| 18-07 |
| (2001), 59.1% (54.0–64.2) | (2009), 63.0% (57.5–68.6) | 67.0% | No change | 49.4% | Female | NA | Hispanic | ||
| Reproductive health | |||||||||||
| 09-07 |
| Per 1,000 | Per 1,000 | Per 1,000 | Per 1,000 | Improved | Improved | 95.1% | NA | NA | Black |
| 15–17 year-olds | 76.1 (1991) | 63.4 (1996) | 40.2 (2005) | 39.0 | |||||||
| 13-05 | (Developmental) reduce the number of new HIV diagnoses among adolescents and adults. | NA | NA | NA | NA | NA | NA | ||||
| 13–24 year-olds | |||||||||||
| 25-11 (a,b,c) | Increase the proportion of adolescents (9th–12th grade students) who: | ||||||||||
| Have never had sexual intercourse | (1991), 45.9% (42.8–48.9) | (1999), 50.1% (46.2–54.0) | (2009), 54.0% (50.8–57.1) | 56.0% | Improved | No change | 66.1% | Male | Higher grade | Black | |
| If sexually experienced, are not currently sexually active | (1991), 30.7% (28.5–33.0) | (1999), 27.3% (24.7–30.0) | (2009), 25.6% (24.3–26.9) | 30.0% | Worsened | No change | −63.0% | Female | Higher grade | Black | |
| If currently sexually active, used a condom the last time they had sexual intercourse | (1991), 48.2% (45.2–51.3) | (1999), 60.5% (57.3–63.7) | (2009), 61.1% (59.0–63.1) | 65.0% | Improved | No change | 13.3% | Female | Higher grade | Hispanics | |
| 25-01 (a,b,c) | Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections | ||||||||||
| 15–24 year-olds | |||||||||||
| Females attending family planning clinics | 5.0% (1997) | 7.5% (2007) | 3.0% | Worsened | −125.0% | Male | NA | Black | |||
| Females attending sexually transmitted disease clinics | 12.2% (1997) | 15.3% (2007) | 3.0% | Worsened | −33.7% | Male | NA | Black | |||
| Males attending sexually transmitted disease clinics. | 15.7% (1997) | 22.4% (2007) | 3.0% | Worsened | −52.8% | Male | NA | Black | |||
| Chronic diseases | |||||||||||
| 27-02 (a) |
|
|
|
| 21.0% | Improved | Improved | 72.4% | Male | Higher grade | White |
| 19-03 (b) |
| (1988–1994), 10.9% (9.0–12.7) | (2007–2008), 17.7% (14.3–21.2) | 5.0% | Worsened | −115.3% | Male | NA | Hispanic | ||
| 22-07 |
| 1993, 65.8% (63.6–67.9) | (1999), 64.7% (62.5–66.9) | 2009, 67.7% (65.0–70.3) | 85.0% | No change | No change | 14.8% | Female | Higher grade | Black |
Underlined objectives address critical health outcomes. The other objectives not underlined address critical health behaviors that contribute to the relevant health outcomes.
Abbreviations: CI = confidence interval; NA = not applicable.
1 A 2010 target had not been established for adolescents and young adults.
2 Based on trend analyses using a logistic regression model controlling for gender, race/ethnicity, and school grade-level.
3 Based on trend analyses using a logistic regression model controlling for gender and race/ethnicity.
4 Based on trend analyses using a logistic regression model controlling for gender, race/ethnicity, and age.
5 Developmental objective: baseline had not been established for adolescents and young adults.
6 National means had not been established to measure the health outcome.
Table 2Rank of critical health objectives and sub-objectives by percentage of the 2010 targets achieved
| Objective number | Objective | Baseline data | Latest available data | 2010 target | Percentage of targets achieved | Objective category |
|---|---|---|---|---|---|---|
| Improved | ||||||
| 26-06 |
| 33.1% (1999) | 28.3% (2009) | 30.0% | 100.0% | Unintentional injury |
| 15–38 |
| 35.7% (1999) | 31.5% (2009) | 32.0% | 100.0% | Violence |
| 09-07 | Reduce pregnancies among adolescent females | Per 1,000 | Per 1,000 | Per 1,000 | 95.1% | Reproductive health |
| 15–17 year-olds | 63.4 (1996) | 40.2 (2005) | 39.0 | |||
| 16-03 (a) | Reduce deaths of adolescents and young adults | Per 100,000 | Per 100,000 | Per 100,000 | 92.0% | Mortality |
| 10–14 year-olds | 21.5 (1998) | 16.9 (2007) | 16.5 | |||
| 15–19 |
| 83.6% (1999) | 90.3% (2009) | 92.0% | 79.8% | Unintentional injury |
| 06-02 |
| 42.1% (1997) | 23.1% (2007) | 17.0% | 75.7% | Substance use and mental health |
| 27-02 (a) |
| 40.2% (1999) | 26.3% (2009) | 21.0% | 72.4% | Chronic diseases |
| 15–39 |
| 6.9% (1999) | 5.6% (2009) | 4.9% | 65.0% | Violence |
| 18-02 |
| 2.6% (1999) | 1.9% (2009) | 1.0% | 43.8% | Substance use and mental health |
| 26-11 (d) |
| 11.3% (2002) | 8.2% (2009) | 3.1% | 37.8% | Substance use and mental health |
| 16-03 (b) | Reduce deaths of adolescents and young adults | Per 100,000 | Per 100,000 | Per 100,000 | 23.8% | Mortality |
| 15–19 year-olds | 69.5 (1998) | 62.0 (2007) | 38.0 | |||
| 26-10 (b) |
| 8.2% (2002) | 6.9% (2009) | 0.7% | 17.3% | Substance use and mental health |
| 26-01 (a) | Reduce deaths caused by alcohol-related motor vehicle crashed | Per 100,000 | Per 100,000 | NA | Unintentional injury | |
| 15–24 year-olds | 9.3 (1998) | 9.3 (2007) | ||||
| 18-01 | Reduce suicide rates | Per 100,000 | Per 100,000 | NA | Substance use and mental health | |
| 10-4 year-olds | 1.2 (1999) | 0.9 (2007) | ||||
| 15–19 year-olds | 8.0 (1999) | 6.9 (2007) | ||||
| 15–32 | Reduce homicides | Per 100,000 | Per 100,000 | NA | Violence | |
| 10–14 year-olds | 1.2 (1999) | 1.1 (2007) | ||||
| Remained unchanged | ||||||
| 25-11 (a) |
| 50.1% (1999) | 54.0% (2009) | 56.0% | 66.1% | Reproductive health |
| 18-07 |
| 59.1% (2001) | 63.0% (2009) | 67.0% | 49.4% | Substance use and mental health |
| 22-07 |
| 64.7% (1999) | 67.7% (2009) | 85.0% | 14.8% | Chronic diseases |
| 25-11 (c) |
| 60.5% (1999) | 61.1% (2009) | 65.0% | 13.3% | Reproductive health |
| 25-11 (b) |
| 27.3% (1999) | 25.6% (2007) | 30.0% | −63.0% | Reproductive health |
| 15-15 (a) | Reduce deaths caused by motor vehicle crashes | Per 100,000 | Per 100,000 | NA | Unintentional injury | |
| 15–24 year-olds | 25.6 (1999) | 25.3 (2006) | ||||
| 15–32 | Reduce homicides | Per 100,000 | Per 100,000 | NA | Violence | |
| 15–19 year-olds | 10.4 (1999) | 10.4 (2007) | ||||
| Worsened | ||||||
| 16-03 (c) | Reduce deaths of adolescents and young adults | Per 100,000 | Per 100,000 | Per 100,000 | −11.7% | Mortality |
| 20–24 year-olds | 92.7 (1998) | 98.7 (2007) | 41.5 | |||
| 25-01 (b) | Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections | 12.2% (1997) | 15.3% (2007) | 3.0% | −33.7% | Reproductive health |
| Females attending sexually transmitted disease clinics | ||||||
| 15–24 year-olds | ||||||
| 25-01 (c) | Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections | 15.7% (1997) | 22.4% (2007) | 3.0% | −52.8% | Reproductive health |
| Males attending sexually transmitted disease clinics | ||||||
| 15–24 year-olds | ||||||
| 19-03 (b) | Reduce the proportion of children and adolescents who are overweight or obese | 10.9% (1988–1994) | 17.7% (2007–2008) | 5.0% | −115.3% | Chronic diseases |
| 12–19 year-olds | ||||||
| 25-01 (a) | Reduce the proportion of adolescents and young adults with Chlamydia trachomatis infections | 5.0% (1997) | 7.5% (2007) | 3.0% | −125.0% | Reproductive health |
| Females attending family planning clinics | ||||||
| 15–24 year-olds | ||||||
| Objective not measured | ||||||
| 13-05 | (Developmental) reduce the number of new HIV diagnoses among adolescents and adults | NA | Reproductive health | |||
| 13–24 year-old |
Underlined objectives address critical health outcomes. The other objectives not underlined address critical health behaviors that contribute to the relevant health outcomes.
NA = not applicable.
1 A 2010 target had not been established for adolescents and young adults.
2 Developmental objective: baseline had not been established for adolescents and young adults.
3 National means had not been established to measure the health outcome.
This study assessed trends in the 21 CNHOs from 1991 to 2009 by gender, race/ethnicity, and age group or school grade-level, using multivariate logistic regression models. We selected 2009 because it was the latest year of data and the final point of data for assessing progress toward achieving many Healthy People 2010 targets. The most recent year of data for 21 CNHOs ranged from 2005 to 2009. The study examined whether the health outcomes and behaviors had improved, worsened, or remained unchanged from 1991 (or a later year during which data were first collected) to 2009 (or the latest year of data), and from the baseline year for which the 2010 target was established (hereafter referenced as “baseline year”) and 2009. The study also assessed the extent to which each 2010 target was achieved since its respective baseline year. To our knowledge, no study has examined the long-term trends in the health, safety, and well-being of young people as indicated by the 21 CNHOs.
Methods
The study protocol was approved by the Indiana University Institutional Review Board.
Instruments
The 21 CNHOs were measured by four census systems and five national probability-based surveillance surveys. The census systems include the National Vital Statistics System, Fatality Analysis Reporting System, HIV/AIDS Surveillance Report, and STD Surveillance System. The national surveillance surveys include the Youth Risk Behavior Survey (YRBS), National Survey on Drug Use and Health (NSDUH), National Health Interview Survey (NHIS), National Health and Nutrition Examination Survey, and National Survey of Family Growth. Details about these census or surveillance systems can be found elsewhere [
5
, 6
, 7
, 8
, 9
, 10
, 11
, 12
, 13
, 14
]. The outcomes reported or measured by these systems represented the official Healthy People 2010 data for the nation.Statistical analysis
For one of the 21 CNHOs, Objective No. 13-05, which aims to reduce the number of new HIV diagnoses among young people aged 13–24 years, a method had not been established for every state in the nation to measure and report new HIV diagnoses. Therefore, this study could not analyze progress toward meeting this objective.
For the seven objectives measured by census systems, we obtained the data from the Centers for Disease Control and Prevention (CDC) and Fatality Analysis Reporting System. We listed the percentage of each health outcome by gender, race/ethnicity, and age group between 1991 (or a later year that reliable data were collected) and 2009 (or the latest year of data). Race/ethnicity groups included whites (non-Hispanics), blacks (non-Hispanics), and Hispanics. We used Excel to examine the percentage of change in each health outcome between 1991 and 2009, and between the baseline year and 2009. For the purposes of this study, if change between 1991 and 2009 or between the baseline year and 2009 was ≥5% of the relevant comparison measures (i.e., 1991 data and baseline data), we concluded that the health outcome had improved or deteriorated; if the change was <5%, we concluded that the outcome had remained unchanged.
For the 13 objectives measured by national probability-based surveys, we downloaded publicly available datasets from the Web sites of the CDC and the Substance Abuse and Mental Health Services Administration. The available datasets were usually cleaned by the data management agencies. We merged the multiyear datasets from 1991 to 2009 for each surveillance system. Data were analyzed with Stata Version 10.0. The weighted percentage and 95% confidence interval (CI) of each health outcome and behavior were calculated by gender, race/ethnicity, and grade (for YRBS data) between 1991 (or a later year in which reliable data were collected) and 2009 (or the latest year of data). Because of the low frequencies of some race/ethnicity groups within the collected probability samples, this study only analyzed trends in each objective for four race/ethnicity groups: whites (non-Hispanics), blacks (non-Hispanics), Hispanics, and others (collectively). Multivariate logistic regression was performed for each objective between 1991 and 2009, and between the baseline year and 2009, controlling for gender, race/ethnicity, and age (for NHIS data) or grade (for YRBS data), to determine whether the health outcome or behavior had improved, remained unchanged, or worsened. Change (e.g., improvement or deterioration) was considered significant if p < .05. Significant results were reported, respectively, for each objective and sub-objective during two periods.
We reviewed the percentage or weighted percentage of each health outcome or behavior for all subgroups between 1991 and 2009, and identified the subgroups that showed the worst health outcome or behavior for most or all survey years. To calculate the percentage of 2010 targets attained, the difference between the baseline data and the latest data were divided by the difference between the baseline data and the targets. For CNHOs measured by national probability-based surveys, the weighted percentages of the baseline data and 2009 data were used for calculation. Changes were reported for each CNHO and sub-objective. For the five CNHOs that contain sub-objectives, if all the sub-objectives contained in one CNHO showed the same trend, we reported that this CNHO was improved, remained unchanged, or worsened. If sub-objectives contained in one CNHO showed different trends, we considered the CNHO to show “mixed progress,” and reported the change for each sub-objective.
Results
Table 1 shows the overall trend in each of the 21 CNHOs from 1991 to 2009 (A), from the baseline year to 2009 (B), the percentage of each target achieved since the baseline year (C), and the subgroups which experienced the worst health outcomes and behaviors (D).
Overall mortality
Mortality rates from all combined causes among young people aged 10–14, 15–19, and 20–24 years were lower in 2007 compared with 1991 and the baseline year 1998, except for young adults aged 20–24 years who showed a higher mortality rate in 2007 compared with 1998. Adolescents and young adults had not met the 2010 target by 2007, except subgroups of females aged 10–14 years (13.8 deaths per 100,000) and 15–19 years (35.8/100,000), white adolescents aged 10–14 years (15.7/100,000), and Hispanics aged 10–14 years (15.0/100,000). Males and older age groups had higher mortality rates than females and younger age groups, respectively. Among white, black, and Hispanic adolescents and young adults, blacks showed the highest mortality rates among all age groups from 1991 to 2007.
Unintentional injury
Four unintentional injury objectives included (1) motor vehicle crash (MVC) mortalities among 15–24 year-olds, (2) alcohol-related MVC mortalities among 15–24 year-olds, (3) seat belt use among students in 9th–12th grade, and (4) riding with a driver who had been drinking alcohol among students in grades 9–12. Young people had shown improvement from 1991, and from the baseline years to 2009, except MVC mortalities which remained unchanged since the baseline year. In general, alcohol-related MVC mortalities represented more than one-third of the MVC mortalities. Students in grades 9–12 had not achieved the target for seat belt use, but had achieved the target for not riding with a driver who had drunk alcohol by 2010. For most of the survey years, males showed a higher prevalence of unintentional injury outcomes and related behaviors compared with females.
Violence
Three violence objectives included (1) homicides among adolescents aged 10–14 and 15–19 years, (2) physical fighting among students in grades 9–12, and (3) carrying weapon on school property among students grades in 9–12. These factors have shown improvement among young people from 1991, and from the baseline year to 2009, except homicides among adolescents aged 15–19 years who displayed the same rates in 1999 and in 2007. Students had met the target for reducing physical fighting by 2010, but had not reached the target for not carrying weapon on school property except the subgroup of females (22.9%, 95% CI = 21.2–24.6%). Males showed a higher prevalence of homicides and violent behaviors than females in all survey years. Older adolescents aged 15–19 years had higher homicide rates than younger adolescents aged 10–14 years. The higher the grade levels, the lower the prevalence of physical fighting among students. Black adolescents showed the highest prevalence of homicides and physical fighting, whereas Hispanics had the highest prevalence of carrying weapons on school property.
Substance use and mental health
Suicide rates among adolescents aged 10–14 and 15–19 years were lower in 2007 than in 1991 and in the baseline year 1999. Suicide attempts requiring medical attention among students in grades 9–12 in 2009 were the same as in 1991, but were lower than the baseline year. By 2010, students had not reached the target for reducing suicide attempts that required medical attention. Males and older adolescents aged 15–19 years had higher suicide rates than females and younger adolescents aged 10–14 years, but females showed a higher prevalence of suicide attempts than males. Ominously, the lower the grade levels, the higher the prevalence of suicide attempts.
The proportion of children aged 4–17 years with disabilities who were reported to be unhappy, sad, or depressed was lower in 2007 than in baseline year 1997. Disabled children had not reached the target for not being unhappy, sad, or depressed by 2007. The proportion of children aged 4–17 years with mental health problems who received treatment remained the same in 2009 as it was in the baseline year 2001. In 2009, children with mental health problems had approached the target of receiving mental health treatment, with the target included in the parameter's estimated 95% CI. Females displayed a higher prevalence of being unhappy, sad, or depressed, and a lower prevalence of receiving mental health treatment than males.
Two substance use behaviors, that is, binge drinking and marijuana use among adolescents aged 12–17 years, showed a higher prevalence in 2009 than in 1991, but showed a lower prevalence in 2009 than in the baseline year 2002. Adolescents had not reached the two targets for reducing substance use by 2009. Males exhibited a higher prevalence of substance use than females. White adolescents had the highest prevalence of substance use among the four race/ethnicity groups.
Reproductive health
Pregnancy rates among adolescent females aged 15–17 years were lower in 2005 than in 1991 and the baseline year 1996. However, adolescent females had not reached the target by 2005, except the subgroup of white adolescents (21.5 pregnancies per 1,000). Chlamydia infection rates among young people aged 15–24 years increased from the baseline year 1997 to 2007, and the rates in 2007 were much higher than the 2010 targets. Three related sexual behavior sub-objectives—including never had sex, no current sex in the past 3 months if sexually active, and condom use at last sexual intercourse among the students in grades 9–12—showed the same prevalence in the baseline year 1999 and in 2009. However, compared with 1991, the prevalences of no sexual intercourse and condom use were higher in 2009, but the prevalence of no current sex was lower in 2009. Although students made no progress in achieving the targets for sexual behaviors from the baseline year, they displayed a rate of no sexual intercourse in 2009 with the target included in the parameter's estimated 95% CI. Students had not met the targets for condom use and no current sex, except the subgroup of males (68.6%, 95% CI = 66.0%–71.3%) who had met the target for condom use. Males had a higher prevalence of Chlamydia infections, having had sex, and condom use than females; females had a higher prevalence of engaging in current sex in the past 3 months than males. Students in higher grades displayed a higher prevalence of engaging in risky sexual behaviors than students in lower grades. Blacks showed the highest prevalence of pregnancies, Chlamydia infections, having had sex, and engaging in current sex among all race/ethnicity groups; and Hispanics displayed the lowest prevalence of condom use.
Chronic diseases
The prevalence of tobacco use among the students in grades 9–12 was lower in 2009 than in 1997 and the baseline year 1999. However, students had not reached the 2010 target, except the subgroup of black adolescents (17.6%, 95% CI = 15.1%–20.0%) who met the target. The prevalence of combined overweight and obese adolescents aged 12–19 years increased from the baseline survey years 1988–1994 to latest survey year 2007–2008. The rate in 2007–2008 was much higher than the target. The prevalence of regular vigorous physical activity (VPA) among the students in grades 9–12 was the same in 2009 as it was in 1993 and the baseline year 1999, and these students had not reached the target. Males showed a higher prevalence of tobacco use, being overweight and obese, and regular VPA than females. The higher the grade level, the higher the prevalence of tobacco use and the lower the prevalence of regular VPA.
Summary of progress in achieving the 21 CNHOs
Table 2 categorizes the 21 CNHOs and sub-objectives into four groups to delineate objectives and sub-objectives that improved, remained unchanged, worsened, and were not measured. Table 2 also ranks the objectives and sub-objectives by percentage of each target achieved by 2010. Since the baseline year, adolescents and young adults made varying progress in achieving 12 CNHOs (rode with a driver who had drunk alcohol, physical fighting, pregnancies, seat belt use, sadness among disabled children, tobacco use, weapon carrying in school, suicide attempts, binge drinking, marijuana use, alcohol-related MVC mortalities, suicides); made mixed progress by sub-objective for two CNHOs (overall mortality, homicides); made no progress in four CNHOs (sexual behavior, mental health treatment, physical activity, MVC deaths); regressed in achieving two CNHOs (Chlamydia infections; overweight and obese); and did not have national means to monitor one CNHO (new HIV diagnoses). The United States achieved two CNHOs (i.e., reduced riding with a driver who had drunk alcohol and physical fighting).
Among the 12 CNHOs for which young people made progress, more than 50% of the targets had been achieved with regard to seven health outcomes and behaviors: that is, rode with a driver who had drunk alcohol, physical fighting, pregnancies, seat belt use, sadness among disabled children, tobacco use, and weapon carrying in school. Two CNHOs (Chlamydia infections, overweight and obesity) and one sub-objective (mortalities among 20–24-year-olds) had worsened and least reached the 2010 targets.
Males, blacks, and older age groups generally exhibited worse health outcomes and more risk behaviors. Among the 19 measured CNHOs examined by gender, in most or all of the survey years, males displayed worse results than females in 14 CNHOs, mainly in categories of overall mortality, unintentional injury, violence, reproductive health, and chronic diseases. Blacks displayed the worst results for eight of the 20 measured CNHOs among all race/ethnicity groups, mainly in overall mortality, violence, and reproductive health. Older age groups displayed worse results than younger counterparts in overall mortality, homicides, suicides, sexual behaviors, tobacco use, and physical activity.
Discussion
The adolescents and young adults from United States made some progress in achieving many of the 21 CNHOs since 1991, and from baseline years to 2009. However, only two CNHOs were achieved, reducing riding with a driver who had drunk alcohol and physical fighting. No progress was seen among young people with regard to achievement of four CNHOs, and they also regressed in meeting targets for Chlamydia infections, overweight and obesity, and mortalities among 20–24 year-olds. These findings are concordant with previous studies which found that many health indicators for young people have shown little change or have worsened [
15
, 16
, 17
, 18
].The 21 CNHOs remain important indicators of the health and well-being of young people, which could be used during the next decade to assess the extent to which adolescents and young adults are continuing to grow more or less healthy. These CNHOs or similar indicators also could be used to focus and shape priorities, policies, programs, and resources to improve the health of young people; perhaps to focus on racial and gender disparities among young people [
17
, 18
, 19
]; and especially to address CNHO indicators that have worsened. However, for five CNHOs, Healthy People 2010 did not establish age-specific targets for adolescents and young adults, that is, MVC mortalities, alcohol-related MVC mortalities, homicides, suicides, and new HIV diagnoses. Additionally, national data about new HIV diagnoses among 13–24-year-olds are not available because strategies have not been developed to enable every state to measure and report new HIV diagnoses. More broadly, national strategies should be considered to enable the United States to systematically monitor and report on the health of young people. Future studies might assess the extent to which the 21 CNHOs, or similar indicators, may be achieved by 2020, and to help monitor the Healthy People 2020 Adolescent Health Objectives [[20]
].Findings from this study emphasize the need for a focused and sustained national effort to improve the health and well-being of adolescents and young adults. Traditionally, adolescents are included among age groups addressed by Maternal and Child Health Programs. However, adolescents historically fare poorly in competition with younger age groups for needed attention and resources; young adults rarely are considered. Further, scarce attention and resources are divided without coordination: among those who provide youth development, education, and health services; among public-, not-for-profit-, and private-sector agencies; and among categorical initiatives to improve health and well-being (e.g., pregnancy, drug, and injury prevention) [
[21]
]. The needs of a young person as an individual are infrequently addressed [[22]
].In the early 1990s, CDC's Division of Adolescent and School Health and the Health Resources and Services Administration's Office of Adolescent Health jointly established a National Initiative to Improve Adolescent Health by the Year 2010, the purpose of which was to attain the 21 CNHOs by 2010 [
[23]
]. Since then, the Health Resources and Services Administration's National Adolescent Health Information and Resource Center established the means to provide the ongoing national- and state-level data about progress in achieving these CNHOs [[24]
]. A National Network of State Adolescent Coordinators [[25]
] has evolved, and the National Association of County and City Health Officials recently launched an Adolescent Health Initiative [[26]
]. A not-for-profit-sector National Alliance to Advance Adolescent Health [[27]
] has been created, and an Office of Adolescent Health [[28]
] has been established in the Office of the Assistant Secretary for Health.Healthy People 2020 has designated Adolescent Health as a new topic area, with a Healthy People 2020 Web site [
[20]
]. A Healthy People 2020 Adolescent Health Workgroup has been established and charged to delineate a core set of Healthy People 2020 adolescent objectives, identify actions and resources to attain these objectives, and monitor progress in achieving these objectives throughout the decade [[29]
]. We hope that the data presented in the foregoing assessment of the health of adolescents and young adults in the United States might help the Healthy People 2020 Adolescent Health Workgroup delineate its core set of critical objectives. Moreover, we hope that the data will stimulate a national discussion about the need for a clear, sustained, and appropriately supported national mandate for relevant agencies to collaboratively pursue a new National Initiative to Improve the Health of Adolescents and Young Adults by the Year 2020.Findings from this study should be interpreted in light of two limitations. First, national probability-based surveillance systems used different modes of survey administration, including paper-and-pencil self-administered questionnaires (YRBS), computer-administered questionnaires (NSDUH), and face-to-face interviews (NHIS). Different modes of administration might evoke different self-report biases. Second, behavioral objectives were measured by self-reported surveys. Participants might over- and under-report their behaviors. Thus, results may be subject to measurement errors. Despite these limitations, this study contributes to the literature in several ways. This is the first study that used multivariate logistic regression models to examine long-term trends in the health and well-being of adolescents and young adults in the United States, as indicated by the 21 CNHOs. It provides in-depth analyses of changes in these health indicators among young people. The study demonstrates the need to continuously monitor and improve critical indicators of the health of young people during the long-term, and provides insights about the extent to which 2010 targets were achieved.
Acknowledgments
The authors thank Dr. Kerry Krutilla for his comments on this study.
Dr. Claire D. Brindis' research time was supported in part by grants from the Maternal and Child Health Bureau, Health Resources and Services Administration, and the United States Department of Health and Human Services (U45MC 00002 and U45MC 00023).
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Article info
Publication history
Accepted:
April 28,
2011
Received:
January 26,
2011
Identification
Copyright
© 2011 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.
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- Focusing on Populations to Improve the Health of Individual Adolescents and Young AdultsJournal of Adolescent HealthVol. 49Issue 2
- PreviewIn this issue of the Journal of Adolescent Health, Jiang et al present the first comprehensive analysis of the 21 Critical National Health Objectives (CNHOs) of Healthy People 2010 (HP 2010), deemed to represent the most significant threats to the health of adolescents and young adults aged 10–24 years [1]. Spanning the period between 1991 and 2009, data for each CNHO (grouped into six areas: mortality, unintentional injury, violence, substance use and mental health, reproductive health, and chronic disease) were trended over time and categorized as improved, unchanged, or worsened, and then rank ordered as health indicators.
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