Review and special article
Healthy passages: A multilevel, multimethod longitudinal study of adolescent health

https://doi.org/10.1016/j.amepre.2004.04.007Get rights and content

Abstract

Purpose

To provide an overview of a multisite, long-term study that focuses on risk and protective factors, health behaviors (e.g., dietary practices, physical inactivity, tobacco use, and violent activity), and health outcomes (e.g., diabetes, obesity, and sexually transmitted diseases) for a fifth-grade cohort to be followed biennially from ages 10 to 20 years.

Methods

A two-stage probability sampling procedure was used to select 5250 fifth-grade students from schools in Birmingham AL, Houston TX, and Los Angeles CA to ensure a sufficient sample size of African Americans, Hispanics, and non-Hispanic whites, to support precise statistical inferences. Computer-assisted technology was used to collect data from children and their primary caregivers. Teachers and other school personnel responded to questionnaires, and observational procedures were used to obtain information about schools and neighborhoods.

Results

To exploit the multilevel, multimethod structure of the data, statistical models include latent-growth mixture modeling, multilevel modeling, time-series analysis, survival analysis, latent transition analysis, and structural equation modeling. Analyses focus both on the co-occurrence and predictors of growth trajectories for different health behaviors across time.

Conclusions

By using a prospective research design and studying the predictors and time course of multiple health behaviors with a multilevel, multimethod assessment protocol, this research project could provide an empirical basis for effective social and educational policies and intervention programs that foster positive health and well-being during both adolescence and adulthood.

Introduction

Most chronic diseases that occur across the life span have their origins in behaviors and associated lifestyle habits established during childhood and adolescence. For instance, cardiovascular disease and many forms of cancer are associated with tobacco use, physical inactivity, and poor dietary habits initiated in childhood.1, 2 Similarly, early alcohol and other substance use and risky sexual behaviors may contribute to increased risks for adverse social outcomes (e.g., dropping out of school or encountering legal problems), debilitating psychiatric and substance use disorders, and acute and chronic medical conditions (e.g., human immunodeficiency virus, sexually transmitted diseases, and respiratory illnesses) that have both short- and long-term implications for health and well-being.3, 4 Despite substantial increases in intervention activities in recent years, both national and local surveillance studies continue to report an alarming increase among youth in the rates of many health problems, such as obesity,5 as well as the consistent use of high levels of alcohol and other substances.6, 7 It is widely recognized among healthcare professionals that health-related behaviors that unfold in adolescence are foreshadowed by experiences in early childhood that occur in the family, at school, and within the community. Nevertheless, relatively little research has been conducted to identify and trace these multiple influences during the preadolescence period, or to examine the importance of racial and ethnic differences in the way these behaviors develop.

This paper provides an overview of a multisite study entitled Healthy Passages: a Longitudinal Study of Adolescent Health. Healthy Passages uses a prospective research design that includes biennial assessments of multiple health behaviors and outcomes in a cohort of fifth-grade children followed from ages 10 to 20 years. The study employs a multilevel protocol to assess biological, family, peer, school, and neighborhood/community influences on youths' health. The overarching objective of Healthy Passages is to provide an empirical basis for effective policies and intervention programs to promote the health and optimal development of adolescents and adults.

The study has two major goals. The first goal is the characterization of development trajectories (i.e., patterns of intraindividual change across time) and the relative contribution of important multilevel risk and protective factors (e.g., family, peers, school, and community) on health behaviors (e.g., dietary practices, physical activity, and tobacco use). Social policy decisions based on such an approach may, for example, yield more cost-effective and encompassing interventions that target multiple health behaviors and their outcomes. The second goal is the elucidation of multilevel risk and protective factors that contribute to disparities in health, education, and social outcomes by race/ethnicity, gender, and socioeconomic status.8, 9, 10

Section snippets

Background and project history

Many longitudinal studies, such as the National Longitudinal Study of Adolescent Health,11 National Survey of Family Growth,12 National Longitudinal Survey of Youth,13 and National Educational Longitudinal Study,14 have added greatly to an understanding of the association of risk behaviors and their determinants. These longitudinal studies, however, either do not extend beyond a 2- or 3-year follow-up period or limit their focus to a single risk area or subpopulation. Healthy Passages was

Study population

The study population includes all fifth-grade students enrolled in public schools with an enrollment of ≥25 fifth graders in each of three geographic areas (this represents over 99% of all students enrolled in public schools in each of the three sites). These geographic areas are the catchment areas of (1) 25 contiguous public school districts in Los Angeles County, CA (2) approximately 20 contiguous public school districts in and around Birmingham AL and (3) the largest public school district

Measures

The measures selected for Healthy Passages provide a comprehensive assessment of adolescent health and behavior across multiple levels of influence, and with data from multiple sources (e.g., survey reports from children, primary caregivers, and teachers; interviewer observations of school and neighborhood environments). Using this approach across time, the resulting multilevel information data will provide a comprehensive portrait of influences on adolescents' health that can be used as an

Methodology

The distinctive features and broad scope of Healthy Passages present both challenges and opportunities for data collection. To address the challenges, qualitative studies were conducted during Phase I to evaluate the appropriateness of language (e.g., readability and comprehension across subgroups) and the general acceptability of field procedures (e.g., anthropometric measurement and sensitive topics) and the introductory materials (e.g., brochures, incentive materials, and informed-consent

Discussion

Healthy Passages builds on previous cross-sectional and longitudinal research to address significant issues in social development and health promotion among youth in an effort to assist in the development of health policies and programs. This study will advance the science in several ways by simultaneously focusing on multiple health behaviors (e.g., dietary practices, injurious behaviors, physical activity, and substance use), measuring multilevel determinants of health behaviors and outcomes,

Acknowledgements

This research was supported by the Centers for Disease Control and Prevention (Cooperative Agreements CCU409679, CCU609653, and CCU915773).

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