p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3

Available online at www.sciencedirect.com

Public Health

journal homepage: www.elsevier.com/puhe

Original Research

Individual and environmental predictors of health risk

behaviours among Dutch adolescents: The HBSC study

Z. Harakeh a,*, M.E. de Looze a, C.T.M. Schrijvers c,d, S.A.F.M. van Dorsselaer b,
W.A.M. Vollebergh a
a
Child and Adolescent Studies, Faculty of Social and Behavioural Sciences, Utrecht University, Utrecht, The Netherlands
b
Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
c
Centre for Public Health Forecasting, National Institute for Public Health and the Environment, Bilthoven, The Netherlands
d
IVO, Addiction Research Institute, Rotterdam, The Netherlands

article info summary

Article history: Objective: To examine unique and common predictors of tobacco smoking, binge drinking,
Received 19 October 2010 cannabis smoking, early sexual intercourse and multiple health risk behaviours.
Received in revised form Study design: Cross-sectional survey study.
31 January 2012 Methods: The Dutch Health Behaviour in School-aged Children (HBSC) study was used to
Accepted 9 April 2012 provide data on 1742 adolescents aged 15 and 16 years of age. This study focused on
Available online 16 May 2012 a variety of individual and environmental predictors of health risk behaviours, tapping into
four domains (mental health, family, peers and school), retrieved by adolescent self-
Keywords: reports and corrected for sociodemographic variables. Logistic and linear regression
Substance use analyses were performed.
Early sexual debut Results: Unique predictors (i.e. gender, low and very low education level, general health,
Adolescents hyperactivity problems, conduct problems, incomplete family, religion, knowledge of
Multiple risk behaviours mother, parental rules on alcohol drinking, time spent with friends, number of friends,
Individual factors perceived tobacco use of classmates, truancy) were identified. In addition, common
Environmental factors predictors (i.e. permissive rules on alcohol drinking and much time spent with friends)
were also identified, explaining an increase in engagement in all investigated health risk
behaviours in adolescence, including multiple risk behaviours.
Conclusions: A prevention strategy targeting restrictive parenting and time spent with
friends may be effective to reduce/discourage engagement in health risk behaviours.
ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction Jessor’s problem behaviour theory,1 risk behaviours (e.g.

alcohol drinking, early sexual involvement, illicit drug use,
Adolescence is a period in which young people are likely to delinquent behaviour) often co-occur in adolescents. More
start experimenting and engaging in risk behaviours that may recently, a study by Willoughby et al. showed that risk
have adverse health consequences. According to Jessor and behaviours can be subdivided into three latent factors: (1)

* Corresponding author. Interdisciplinary Social Science, Utrecht University, PO Box 80.140, 3508 TC Utrecht, The Netherlands. Tel.: þ31
30 2539084; fax: þ31 30 2534733.
E-mail address: z.harakeh@uu.nl (Z. Harakeh).
0033-3506/$ e see front matter ª 2012 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.puhe.2012.04.006
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3
substance use and sexual activity; (2) aggression; and (3)
delinquency.2 Our present study focused on the risk behav-
iours included in the first factor (i.e. substance use and sexual
activity). These behaviours are distinguished from other risk
behaviours for the following reasons. First, in contrast to the
behaviours in the two other latent factors, these behaviours
have negative health consequences such as lower quality of
life, anal cancer, cervical cancer, impotence, birth complica-
tions, etc.3 Second, they are often referred to as adult-like
behaviours, and adolescents have been hypothesized to
engage in them ‘to seek acceptance in adult society’.4,5 Third,
they all have seductive, addictive qualities.3 The dopami-
nergic system, which is related to pleasure and facilitates
dependence, is involved in these behaviours.3 Fourth, these
behaviours in adolescence may be a function of behavioural
disinhibition, and reflect low self-control, high impulsivity
and sensation seeking.3 Finally, there is no intention to
directly harm other people or the property of other people by
engaging in these behaviours.3
In line with these reasons, previous studies have suggested
that these behaviours may have an underlying basis and
similar predictors. If so, the development of a prevention
strategy targeting multiple health risk behaviours would be
useful. To date, most interventions targeting adolescent
health risk behaviours have been behaviour specific.6 If
common predictors of the selected health risk behaviours
could be identified, broader interventions could be developed,
targeting multiple health risk behaviours simultaneously; this
would be more cost-effective.
According to Bronfenbrenner,7 factors from different
domains influence human behaviour. Besides individual
factors (e.g. mental health factors), Bronfenbrenner’s ecology of
human development theory7 suggests the importance of envi-
ronmental factors such as the microsystem (e.g. family, peers
and school) and larger social contexts (e.g. socio-economic
status, ethnic background).8e12 The aim of this study was to
examine the associations between individual (mental health
problems) and environmental factors (school, family and peer
factors) on the one hand, and health risk behaviours (daily
tobacco smoking, binge drinking, monthly cannabis use and
early sexual intercourse) on the other hand. In addition, this
study also focused on multiple health risk behaviours by the
construct of a latent factor, ‘multiple risk behaviours’, and
examined whether this can be predicted by a similar set of
predictors. To the authors’ knowledge, no studies to date have
examined the predictors of all four risk behaviours and multiple
risk behaviours extensively in one design. The advantage of this
approach is that, when examining these various health risk
behaviours in one design and correcting for sociodemographic
variables, the most important predictor(s) can be identified for
each domain and across domains.
Methods
Participants and procedure
This study is part of the cross-sectional ‘Health Behaviour in
School-aged Children’ (HBSC) study, conducted in collabora-
tion with the World Health Organization Regional Office for
567
Europe. The Dutch HBSC database includes data for 5422
students who are representative for the Dutch youth in
secondary education aged 12e16 years (mean age 13.83 years,
standard deviation 1.27 years). The sample was stratified
according to urbanicity, and the schools were selected at
random. Schools were excluded when not all required grades
were present, or when they provided special education. In
total, 137 schools were approached from all schools in the
Netherlands, and 64 were willing to participate. Students from
four classes of each school participated: one class was
selected at random for each grade, for each of the first four
grades. Parents were informed of the aim of the study by
means of a letter. If parents had any objections to their child
participating in this study, they could inform the research
assistant or teacher. This was the case for three students. Data
were not collected for students who were absent on the day of
data collection due to truancy (1%) or illness and other reasons
(7%). Data were collected from October to November 2005
according to the protocol of the international HBSC study.13,14
All data were collected by means of questionnaires, which
were distributed in classes and administered by research
assistants during a lesson (usual duration 50 min). The
anonymity of the students was stressed by the research
assistants, and was guaranteed by enclosure of each
completed questionnaire in a sealed envelope.
For the purpose of this study, only the data from adoles-
cents aged 15 or 16 years were used (n ¼ 1742, 51.3% male). The
education level was distributed as follows: 29.2% very low
(preparatory middle-level applied education, profession-
oriented learning path), 32.2% low (preparatory middle-level
applied education, theoretic learning path), 24.2% middle
(higher general continued education) and 14.5% high (prepa-
ratory scientific education). Furthermore, 74.9% of adolescents
in the sample had a Dutch origin (native).
Measures
All variables were assessed through self-reports of the
adolescents. Due to limited space, not all variables depicted in
Tables 1e3 are described below. More information on these
measures can be retrieved from the protocol of the interna-
tional HBSC study and/or the HBSC website.13,14
Tobacco smoking, binge drinking, cannabis smoking and
early sexual intercourse were measured with single questions.
Answer categories were recoded as ‘currently not smoking
daily’ vs ‘currently smoking daily’; ‘did not drink or occa-
sionally drank less than five glasses in the previous month’ vs
‘drank five or more glasses on one or more occasions in the
previous month’15; ‘not used cannabis the previous month’ vs
‘did use cannabis in the previous month’; and ‘no early sexual
intercourse’ vs ‘early sexual intercourse (<17 years old)’.
General health was measured with a single item: ‘What do
you think of your health?’ Response categories were recoded
as ‘not healthy’ vs ‘healthy’.16
Life satisfaction was measured with a single item: ‘How do
you currently feel about your life?’, and responses were
recoded as ‘happy’ (7e10) vs ‘not happy’ (0e6).17
Psychosomatic complaints were measured with eight
items (e.g. headache, stomach ache, feeling dizzy, feeling
nervous).18e20 Response categories were dichotomized as
568 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3

Table 1 e aeMultivariate logistic and linear regression analyses regarding sociodemographic predictors of health risk
behaviours (i.e. tobacco smoking, binge drinking, cannabis smoking, early sexual intercourse, and multiple health risk
behaviours), with inclusion of the variables depicted in Tables 2 and 3.
Predictor Tobacco smoking Binge drinking Cannabis smoking Early sexual Multiple risk
(n ¼ 1670) (n ¼ 1651) (n ¼ 1622) intercourse (n ¼ 1642) behaviours (n ¼ 1632)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) b (coef; SE)

Sociodemographic characteristics
Age 1.47 (1.05e2.06) 0.97 (0.71e1.31) 1.33 (0.95e1.87) 1.48 (1.09e2.00) 0.06 (0.07; 0.03)
Gender (ref. girls) 0.81 (0.59e1.12) 1.87 (1.42e2.45) 2.03 (1.43e2.87) 0.96 (0.69e1.34) 0.07 (0.09; 0.03)
Education level
High (ref.) 1.00 1.00 1.00 1.00 ref.
Middle 1.51 (0.76e2.98) 1.49 (0.84e2.63) 0.99 (0.52e1.87) 1.91 (1.14e3.19) 0.06 (0.09; 0.04)
Low 3.13 (1.56e6.28) 1.65 (0.98e2.76) 1.25 (0.63e2.49) 2.17 (1.32e3.56) 0.11 (0.16; 0.04)
Very low 4.55 (2.26e9.18) 1.64 (0.95e2.80) 1.07 (0.57e2.04) 3.16 (1.90e5.28) 0.16 (0.21e0.05)
Ethnicity (ref. Dutch origin) 1.21 (0.68e2.14) 0.65 (0.45e0.93) 1.43 (0.86e2.36) 1.32 (0.89e1.97) 0.01 (0.01; 0.04)

Ref., reference group; CI, confidence interval; SE, standard error.

Significant odds ratio (OR) in are shown in bold (P < 0.01). Empty cells with ‘e‘ represent non-significance in the first model. The results in Tables
1e3 were derived from one analysis but, to enhance visual clarity, the tables have been split up into three. However, the findings in these tables
should not be interpreted separately.

‘none’ vs ‘at least one’ psychosomatic complaint more than
once a week in the previous 6 months.
Emotional problems, hyperactivity problems, conduct
problems and problems with peers were assessed with the
Strength and Difficulties Questionnaire (SDQ).21 The Dutch
translation of the SDQ was used,22 and each of the four
subscales consisted of five items. The responses were recoded
as ‘normal’ vs ‘borderline/abnormal’ (i.e. the highest 15e20%)
in the previous 6 months.
Prosperity refers to the current material goods in the family
and is developed as a proxy indicator for socio-economic
position. It was measured with the four items of the Family
Affluence Scale (FAS),23 inquiring about the number of cars,
computers and family holidays, and the adolescent’s disposal
of a private and single bedroom. Previous studies have
assessed the psychometric properties of this instrument and
indicated good (criterion) validity.24,25
Quality of communication with mother was assessed with
a single item: ‘How easy is it for you to talk to your mother
about things that really bother you?’ Responses were recoded
as ‘good’ vs ‘not good’.
Knowledge of mother was defined as how much the
adolescents’ mothers knew about their friends, whereabouts
and activities. It was assessed with five items, and recoded as
‘mother knows much’ vs ‘mother knows little/nothing’.26
Cronbach’s alpha was 0.77.
Parental rules on alcohol drinking refers to the tolerance
of parents with regard to the adolescent drinking alcohol at
home or at parties.27 An abbreviated version was used with
four items (i.e. ‘I am allowed to have one glass of alcohol
when my parents are at home’, ‘I am allowed to drink several
glasses of alcohol when my parents are not at home’, ‘I am
allowed to drink alcohol at a party with my friends’ and ‘I am
allowed to drink alcohol on the weekend’). Response

Table 2 e Multivariate logistic and linear regression analyses regarding individual predictors of health risk behaviours (i.e.
tobacco smoking, binge drinking, cannabis smoking, early sexual intercourse, and multiple health risk behaviours), with
inclusion of the variables depicted in Tables 1 and 3.
Predictor Tobacco smoking Binge drinking Cannabis smoking Early sexual Multiple health
(n ¼ 1670) (n ¼ 1651) (n ¼ 1622) intercourse risk behaviours
(n ¼ 1642) (n ¼ 1632)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) b (coef; SE)

Individual factors
Mental health
General health (ref. not healthy) 0.36 (0.23e0.56) e 0.58 (0.38e0.88) e L0.08(-0.12e0.04)
Life satisfaction (ref. happy) e e e e e
Any psychosomatic problem (ref. none) e e e e e
Emotional problems (ref. normal) e e e
Hyperactivity problems (ref. normal) 1.52 (1.04e2.20) 1.48 (1.06e2.07) 1.33 (0.93e1.88) e 0.07 (0.11e0.03)
Conduct problems (ref. normal) 1.51 (0.99e3.31) 1.65 (1.14e2.40) 2.02 (1.42e2.89) 2.58 (1.88e3.56) 0.12 (0.21; 0.04)
Problem with peers (ref. normal) e e e e e

Ref., reference group; CI, confidence interval; SE, standard error.

Significant odds ratio (OR) in are shown in bold (P < 0.01). Empty cells with ‘e‘ represent non-significance in the first model. The results in Tables
1e3 were derived from one analysis but, to enhance visual clarity, the tables have been split up into three. However, the findings in these tables
should not be interpreted separately.
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3 569

Table 3 e Multivariate logistic and linear regression analyses regarding environmental predictors of health risk behaviours
(i.e. tobacco smoking, binge drinking, cannabis smoking, early sexual intercourse, and multiple health risk behaviours),
with inclusion of the variables depicted in Tables 1 and 2.
Predictor Tobacco Binge Cannabis Early sexual Multiple health
smoking drinking smoking intercourse risk behaviours
(n ¼ 1670) (n ¼ 1651) (n ¼ 1622) (n ¼ 1642) (n ¼ 1632)

OR (95%CI) OR (95%CI) OR (95%CI) OR (95%CI) b (coef; SE)

Environmental factors
Family
Incomplete family (ref. e 1.56 (1.11e2.20) 1.54 (1.09e2.17) 1.54 (1.14e2.09) 0.07 (0.11; 0.03)
complete family)
Prosperity: e e e e e
High (ref.)
Middle
Low
Religious (ref. not religious) e e 0.55 (0.37e0.82) 0.64 (0.49e0.84) 0.06 (0.07; 0.02)
Quality of communication e e e e e
with mother (ref. good)
Knowledge of mother (ref. 2.20 (1.30e3.72) e 3.41 (2.00e5.82) 1.44 (0.82e2.52) 0.11 (0.24; 0.07)
knows much)
Rules on alcohol drinking:
Strict (ref.) 1.00 1.00 1.00 1.00 ref.
Moderate 2.13 (1.04e4.36) 4.87 (3.09e7.66) 2.57 (1.24e5.32) 1.34 (0.77e2.34) 0.18 (0.26; 0.05)
Permissive 4.62 (2.30e9.25) 15.28 (9.81e23.82) 4.06 (1.94e8.52) 2.72 (1.66e4.44) 0.40 (0.49; 0.05)
Peers
Time with friends:
Little (ref.) 1.00 1.00 1.00 1.00 ref.
Moderate (33%) 2.48 (1.34e4.61) 1.99 (1.39e2.85) 3.28 (1.91e5.66) 1.49 (0.93e2.39) 0.12 (0.15; 0.03)
Much (33%) 6.37 (3.53e11.49) 3.19 (2.25e4.52) 5.84 (3.27e10.43) 3.04 (2.15e4.30) 0.30 (0.37; 0.03)
Number of friends 1.25 (1.12e1.38) e e e
Quality of communication e e e e e
with friends (ref. difficult)
Perceived tobacco use of 1.64 (1.21e2.24) 1.64 (1.18e2.28) 1.51 (0.96e2.40) e 0.10 (0.13; 0.04)
classmates (ref. none/little)
Perceived alcohol use of e 1.40 (1.02e1.92) e e e
classmates (ref. none/little)
Perceived cannabis use of e e 1.31 (0.89e1.92) e e
classmates (ref. none/little)
School
Satisfaction with school 0.88 (0.65e1.19) e e e 0.01(0.01; 0.04)
(ref. not fun)
School-related stress e e e e e
(ref. no pressure)
Truancy (ref. no) 1.58 (1.04e2.40) 1.52 (1.08e2.13) 2.05 (1.44e2.90) e 0.08 (0.12; 0.04)
Academic achievement 0.85 (0.60e1.21) e e e 0.02(0.02; 0.03)
(ref. not good)
Classmate support e e e
Bullying (ref. never bullied) e 1.10 (0.80e1.52) 1.37 (1.05e1.78) 1.16 (0.90e1.51) 0.02 (0.03; 0.03)
Been bullied (ref. never e e e e d
been bullied)

Ref., reference group; CI, confidence interval; SE, standard error.

Significant odds ratio (OR) in are shown in bold (P < 0.01). Empty cells with ‘e‘ represent non-significance in the first model. The results in Tables
1e3 were derived from one analysis but, to enhance visual clarity, the tables have been split up into three. However, the findings in these tables
should not be interpreted separately.

categories ranged from 1 ¼ completely applicable to 5 ¼ not
applicable at all. Cronbach’s alpha was 0.92.
Time with friends refers to how much the adolescent has
contact with their peers directly after school, in the evenings
or via electronic-media communication (phone, e-mail, MSN
or SMS).
Number of friends at present was assessed with two items.
Responses were combined from 0 ¼ none to 6 ¼ six or more.
Perceived tobacco, alcohol or cannabis use of classmates
were each assessed with single items (‘How many of your
classmates smoke cigarettes?’; ‘How many of your classmates
drink alcohol weekly?’; ‘How many of your classmates use
cannabis?’), and responses were coded as ‘no/few classmates’
vs ‘half/most/many classmates’.
Satisfaction with school was assessed with a single item:
‘How do you feel about school at present?’ Responses were
recoded as ‘not experiencing school as fun’ vs ‘experiencing
school as fun’.
School-related stress was assessed with a single item:
‘How pressured do you feel by the schoolwork you have to do?’
570 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3
Responses were recoded as ‘not feeling pressure of school-
work’ vs ‘feeling much pressure of schoolwork’.
Truancy was measured with a single item: ‘In the last 4
weeks, how many classes did you skip?’ Responses were
recoded as ‘not cutting classes’ vs ‘cutting classes’.
Academic achievement refers to the adolescent’s percep-
tion of what his/her class teacher thinks about his/her school
performance compared with his/her classmates. Responses
were recoded as ‘not good (i.e. average or below average)
school performance’ vs ‘good (i.e. good or very good) school
performance’.
Classmate support was assessed with three items [e.g.
‘Most of the students in my class(es) are kind and helpful.’].
Response categories varied from 1 ¼ completely agree to
5 ¼ completely disagree. Cronbach’s alpha was 0.71.
Both bullying and being bullied at school were assessed
with single items,28 and responses were recoded as ‘never
(being) bullied’ vs ‘(being) bullied once or more’ in the past
couple of months.
Statistical analyses
Multivariate logistic regression analyses were conducted to
examine which determinants predicted tobacco smoking,
binge drinking, cannabis smoking and early sexual intercourse.
Next, the question of whether tobacco smoking, binge drinking,
cannabis smoking and early sexual intercourse formed one
underlying latent construct ‘multiple health risk behaviours’
was tested using confirmatory factor analysis (CFA) with the
software package Mplus (Muthén & Muthén, Los Angeles).29
A good model fit is when the Comparative Fit Index (CFI) and
Tucker Lewis Index (TLI) are both >0.95 and Root Mean Square
Error of Approximation (RMSEA) >0.05.30 Furthermore, the
weighted least square method was used, with adjusted mean
and variance chi-square statistic (WLSMV) estimator in
Mplus,29 and the derived factor scores for this underlying latent
construct were transported to Stata version 11 (Stata Statistical
Software, release 11.1. Stata Corporation, College Station, TX)40.
Multivariate linear regression analyses were conducted to test
which determinants predicted multiple risk behaviours.
Data were weighted for school level, grade, gender and
urbanicity. In addition, all analyses were corrected for
possible cluster effects of pupils within the same schools by
using the first-order Taylor series linearization method.
Analyses were conducted in Stata Version 9.0 as this enables
correction for cluster effects using weighted data, and
controls for multicollinearity by excluding variables that are
highly correlated from the analyses.
For each domain, two models for each of the five outcome
variables were tested in order to identify which predictors
were most influential for the pertinent outcome. In the first
model, the predictors were tested separately for each domain
(mental health problems, family, peers and school), control-
ling for sociodemographic factors. For example, all variables
for mental health problems were tested in one model
controlling for all the sociodemographic variables. The same
approach was used to test family factors, peer factors and
school factors. In the second and final model, all the significant
variables from the first model were included, again correcting
for all the sociodemographic variables. Variables (except the
sociodemographic variables) with a P-value <0.01 in the first
model were included in the final model. A P-value <0.01 was
taken to indicate significance in the final model due to the
large sample size and multiple testing in order to minimize
random associations. Only the results of the final model are
shown in this paper (see Tables 1e3; the results of the first step
are available on request from the corresponding author).
Results
In this sample, 16.7% of the adolescents smoked daily, 57.8%
had drunk five or more glasses of alcohol on one or more
occasions in the previous month, 14.4% had used cannabis in
the previous month, and 29.7% had their sexual debut before
17 years of age (early sexual intercourse). In addition, 5.7%
were engaged in all four health risk behaviours, 9.3% in three
health risk behaviours, 17% in two health risk behaviours,
33.5% in one health risk behaviour; and 34.6% in none of these
health risk behaviours.
The question of whether tobacco smoking, alcohol
drinking, cannabis smoking and early sexual intercourse
formed one underlying latent construct ‘multiple health risk
behaviours’ was tested. The model showed a good fit:
c2(2) ¼ 2.84, P ¼ 0.242, CFI ¼ 0.999, TLI ¼ 0.998, RMSEA ¼ 0.016.
The standardized coefficients for tobacco smoking, alcohol
drinking, cannabis smoking and early sexual intercourse were
0.86, 0.63, 0.88 and 0.68 respectively (P ¼ 0.000).
The associations between sociodemographic, individual
(mental health problems) and environmental factors (school,
family and peer factors) were examined on the one hand, and
the four health risk behaviours and multiple risk behaviours
on the other hand. The results of the final model for all five
outcome variables are depicted in Tables 1e3. The predictors
explained 39.9% of the variance of engaging in multiple health
risk behaviours, 25.6% for tobacco smoking, 29.3% for alcohol
drinking, 24.7% for cannabis smoking, and 15% for early
sexual intercourse.
Sociodemographic characteristics
Low and very low education were found to be a risk factor
compared with high education: adolescents with low and very
low education were more likely to engage in tobacco smoking,
early sexual intercourse and multiple health risk behaviours.
In particular, adolescents with a very low education were at
greatest risk of engaging in these behaviours. However,
education level was not related to binge drinking and
cannabis smoking. With respect to gender, males were more
likely to binge drink, smoke cannabis, and engage in multiple
health risk behaviours.
Mental health
Conduct problems were found to be a risk factor for engage-
ment in all health risk behaviours except for tobacco smoking.
Feeling healthy was only a protective factor for tobacco
smoking and engagement in multiple health risk behaviours.
Hyperactivity problems were only found to be a risk factor for
multiple health risk behaviours.
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3
Family
Rules of parents on alcohol drinking were found to be an
important predictor: adolescents perceiving permissive
parental rules on alcohol drinking were more likely to engage
in all five outcome variables. Instead, moderate parental rules
on alcohol drinking were only found to be a risk factor for
binge drinking and engaging in multiple health risk behav-
iours. Furthermore, adolescents with mothers who had little
knowledge about their friends, whereabouts and activities
were more likely to engage in health risk behaviours, except
for tobacco smoking and binge drinking. Finally, adolescents
from incomplete families or adolescents who had not been
brought up in a religious way were more likely to have early
sexual intercourse and engage in multiple health risk behav-
iours. In addition, adolescents who had not been brought up in
a religious way were also more likely to smoke cannabis.
Peers
Time spent with friends was shown to be an important risk
factor for health risk behaviours: adolescents who spent a lot of
time with their friends were more likely to engage in all five
outcome variables. Adolescents who spent a moderate amount
of time with their friends were more likely to engage in all health
risk behaviours except for early sexual intercourse. The number
of friends was only found to be a risk factor for binge drinking.
Furthermore, adolescents who perceived much tobacco use
among their classmates were more likely to engage in tobacco
smoking, binge drinking and multiple health risk behaviours.
School
Truancy appeared to be a risk factor for health risk behav-
iours: adolescents who cut classes were more likely to engage
in cannabis smoking and multiple risk behaviours.
Discussion
The objective of this epidemiological study was to identify the
predictors of engagement in single and multiple health risk
behaviours among a nationally representative sample of
Dutch adolescents aged 15 or 16 years. Sociodemographic,
individual (mental health) and environmental (family, peers
and school) factors were examined, and the strongest
predictors were: gender and education level (sociodemo-
graphic factors), conduct problems (mental health factor),
permissive parental rules on alcohol drinking (family factor)
and much time spent with friends (peer factor) and truancy
(school factor). However, only permissive parental rules on
alcohol drinking and much time spent with friends were
identified as common predictors of engagement in all health
risk behaviours (tobacco smoking, binge drinking, cannabis
smoking and early sexual intercourse) as well as in the latent
construct ‘multiple health risk behaviours’. These two
predictors remained important when considering predictors
from other domains, and they explained a major part of the
variance of each of these health risk behaviours. A broad
prevention programme focusing on these two common
571
predictors which have a predictive association with all health
risk behaviours may, therefore, be highly effective.
First, the findings showed that permissive parental rules
on alcohol drinking are the strongest predictor in the family
domain, which is in line with previous studies examining
alcohol use.31e33 However, the findings showed that this is
also related to other health risk behaviours among adoles-
cents (tobacco and cannabis use, early sexual intercourse and
multiple health risk behaviours). Abdelrahaman et al. showed
that adolescents with parents who set clear rules against
alcohol and drug use are also less likely to smoke cigarettes.34
To the authors’ knowledge, this is the first study to show that
these alcohol-specific rules are also a protective factor for
other health-comprising behaviours such as sexual inter-
course and multiple health risk behaviours. A possible
explanation for this finding may be that alcohol-specific rules
are an expression of underlying general restrictive parenting
practices (e.g. control and supervision), norms and beliefs35
targeting the adolescent’s risk behaviour.
Second, spending much or moderate time with peers was
found to be the strongest predictor within the peer domain, as
it increases the risk of engagement in all four health risk
behaviours as well as in multiple risk behaviours. A possible
explanation may be that adolescents who spend a lot of time
with their peers are also those whose parents undertake little
efforts to control their child, such as parental control and
monitoring.36 Therefore, in future, it would be interesting to
examine whether the level of parental control and monitoring
is related to the time spent with peers, which may, in turn,
influence engagement in risk behaviours. Another possible
explanation may be that adolescents who are engaged in risk
behaviours often do so in public settings where they subse-
quently meet others, spend more time with them and estab-
lish new peer and intimate relationships.37 It is likely that
adolescents who spend more time with their peers are more
exposed to the health risk behaviours of their peers.
Limitations and future research
This study has some limitations which should be mentioned
and considered in future research. First, self-reports of health
risk behaviours were used. Self-reports may be biased by
inaccuracies arising from cognitive processes such as
comprehension and recall, or from factors related to social
desirability and interviewing conditions.38 However, in the
present study, these biases may have been reduced by
guaranteeing anonymity and privacy to the subjects. Second,
the results were derived from cross-sectional data. It is
therefore not possible to provide information about cau-
seeconsequence relationships. Finally, this study focused on
four domains which have been described in previous studies.
However, these domains may not be all-encompassing.
Conclusions and implications
This study showed that although some predictors are specif-
ically related to single health risk behaviours, these behav-
iours have common predictors. These tap into the family
(parental rules on alcohol drinking) and peer (time spent with
572 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3
peers) domains and should be considered when developing
intervention programmes targeting multiple risk behaviours
simultaneously. These results imply that adolescents engaged
in health risk behaviours are those whose parents exert less
control and supervision, and who have closer bonds and
attachments with their peers (time spent with peers). This
does not automatically mean that increased peer contacts are
detrimental for adolescents’ development; on the contrary,
intense peer relationships enable youth to reflect on their own
ideas and opinions with people of their own age,39 discuss
their worries and learn specific communication skills,37 and in
this way serve an important function in young people’s
learning to function in society. Moreover, adopting health risk
behaviours and/or positive attitudes and beliefs regarding risk
behaviours may even be an essential part for the maturation
of adolescents.4,12 Nevertheless, increased peer contact may
become detrimental when the increase in bonding and
attachment with peers is accompanied by low parental
control and supervision, especially when adolescents are still
young and need supervision to prevent them from excessively
high levels of engagement in multiple health risk behaviours.
Acknowledgements
The authors are grateful to the study participants. Further-
more, the authors would like to thank Dr Quinten A.W.
Raaijmakers for his helpful advice in computing an underlying
construct ‘multiple health risk behaviours’.
Ethical approval
The Advisory Board of the Ethics Committee of the Faculty of
Social Sciences at Utrecht University gave their approval.
Funding
Data collection of 2005 was supported by grants from the
Netherlands Organization for Health Research and Develop-
ment (ZonMw; 6000.0970), the Netherlands Organization for
Scientific Research (NWO; 481-08-002), the Netherlands Insti-
tute for Social Research, the Ministry of Youth and Family,
Trimbos Institute and Utrecht University. Z. Harakeh was
supported by a grant (VENI) from NWO during the preparation
of this manuscript. None of these sponsors had any involve-
ment in the study design; in the collection, analysis and
interpretation of the data; in the writing of the manuscript; or
in the decision to submit the manuscript for publication.
Competing interests
None declared.
references
1. Jessor R, Jessor SL. Problem behaviour and psychosocial development:
a longitudinal study of youth. New York: Academic Press; 1977.
2. Willoughby T, Chalmers H, Busseri MA. Where is the
syndrome? Examining co-occurrence among multiple
problem behaviors in adolescence. J Consult Clin Psych
2004;72:1022e37.
3. Sussman S. The relations of cigarette smoking with risky
sexual behaviour among teens. Sex Addict Compulsiv
2005;12:181e99.
4. Moffitt TE. Adolescence-limited and life-course-persistent
antisocial behaviour: a developmental taxonomy. Psychol Rev
1993;100:674e701.
5. Moffit TE. A review of research on the taxonomy of life-course
persistent versus adolescence-limited antisocial behavior. In:
Flannery DJ, Vazsonyi AT, Waldman ID, editors. The
Cambridge handbook of violent behavior and aggression. New
York: Cambridge University Press; 2007. p. 49e74.
6. Guilamo-Ramos V, Litardo HA, Jaccard J. Prevention programs
for reducing adolescent problem behaviors: implications of
the co-occurrence of problem behaviors in adolescence. J
Adolesc Health 2005;36:82e6.
7. Bronfenbrenner U. The ecology of human development: history
and perspectives. Psychologia-Wychowawcza 1976;19:537e49.
8. Buhi ER, Goodson P. Predictors of adolescent sexual behaviour
and intention: a theory-guided systematic review. J Adolesc
Health 2007;40:4e21.
9. Donovan JE. Adolescent alcohol initiation: a review of
psychosocial risk factors. J Adolesc Health 2004;35:7e18.
10. Galea S, Nandi A, Vlahov D. The social epidemiology of
substance use. Epidemiol Rev 2004;26:36e52.
11. Goodson P, Evans A, Edmundson E. Female adolescents and
onset of sexual intercourse: a theory-based review of
research from 1984 to 1994. J Adolesc Health 1997;21:147e56.
12. Tyas SL, Pederson LL. Psychosocial factors related to
adolescent smoking: a critical review of the literature. Tob
Control 1998;7:409e20.
13. Currie CW, Samdal O, Boyce W, Smith R. Health behaviour in
school-aged children: a World Health Organization cross-national
study. Research protocol for the 2001/02 survey. Edinburgh: HBSC;
2002.
14. http://www.hbsc.org/[last accessed 17.05.10].
15. Hibell B, Guttormsson U, Ahlström S, Balakireva O,
Bjarnasson T, Kokkevi A, et al. The 2007 ESPAD Report.
Substance use among students in 35 European countries. Sweden:
Modintryckoffset AB; 2009.
16. Idler EL, Benyamini Y. Self-rated health and mortality:
a review of twenty-seven community studies. J Health Soc
Behav 1997;38:21e37.
17. Cantril H. The pattern of human concern. New Brunswick, NJ:
Rutgers University Press; 1965.
18. Ravens-Sieberer U, Erhart M, Torsheim T, Hetland J,
Freeman J, Danielson M, et al. An international scoring
system for self-reported health complaints in adolescents.
Eur J Public Health 2008;18:294e9.
19. Hagquist C, Andrich D. Measuring subjective health among
adolescents in Sweden. Soc Indic Res 2004;68:201e20.
20. Haugland S, Wold B, Stevenson J, Aarø LE, Woynarowska B.
Subjective health complaints in adolescence e a cross-
national comparison of prevalence and dimensionality. Eur J
Public Health 2001;11:4e10.
21. Goodman R, Meltzer H, Bailey V. The strengths and
difficulties questionnaire: a pilot study on the validity of the
self-report version. Eur Child Adolesc Psychiatry 1998;7:125e30.
22. Van Widenfelt BM, Goedhart AW, Treffers PDA, Goodman R.
Dutch version of the strengths and difficulties questionnaire
(SDQ). Eur Child Adolesc Psychiatry 2003;12:281e9.
23. Parry-Langdon N, Clements A, Harris L, Roberts C, Kingdon A.
Family affluence: a parentestudent validation study in Wales.
Health Promotion Division/Is-adran Hybu Iechyd, Welsh
Assembly Government; 2005.
 p u b l i c h e a l t h 1 2 6 ( 2 0 1 2 ) 5 6 6 e5 7 3
24. Boyce W, Torsheim T, Currie C, Zambon A. The family
affluence scale as a measure of national wealth: validation
of an adolescent self-report measure. Soc Indic Res
2006;78:473e87.
25. Currie C, Molcho M, Boyce W, Holstein BE, Torsheim T,
Richter M. Researching health inequalities in adolescents: the
development of the health behaviour in school-aged Children
(HBSC) family affluence scale. Soc Sci Med 2008;66:1429e36.
26. Rispens J, Hermanns JMA, Meeus WHJ. Opvoeden in Nederland
[Parenting in the Netherlands]. Assen: van Gorcum; 1997.
27. Van der Vorst H, Engels RCME, Meeus W, Dekovic  M. The
impact of alcohol-specific rules, parental norms about early
drinking and parental alcohol use on adolescents’ drinking
behavior. J Child Psychol Psyc 2006;47:1299e306.
28. Olweus D. The revised Olweus bully/victim questionnaire. Bergen,
Norway: research Center for health Promotion (HEMIL Center).
University of Bergen; 1996.
29. Muthén LK, Muthén BO. Mplus user’s guide. 5th ed. Los
Angeles: Muthén & Muthén; 1998e2007. pp. 55e6.
30. Kline RB. Principles and practice of structural equation modelling.
3rd ed. New York: The Guilford Press; 2010.
31. Koning IM, Engels RCME, Verdurmen JEE, Vollebergh WAM.
Alcohol-specific socialization practices and alcohol use in
Dutch early adolescents. J Adolesc 2010;33:93e100.
32. Spijkerman R, Van den Eijnden RJJM, Huiberts A.
Socioeconomic differences in alcohol-specific parenting
practices and adolescents’ drinking patterns. Eur Addict Res
2008;14:26e37.
573
33. Van der Vorst H, Engels RCME, Meeus W, Dekovic  M. Van
Leeuwe. The role of alcohol-specific socialization in
adolescents’ drinking behaviour. Addiction 2005;100:1464e76.
34. Abdelrahman AI, Rodriguez G, Ryan JA, French JF,
Weinbaum D. The epidemiology of substance use among
middle school students: the impact of school, familial,
community and individual risk factors. J Child Adoles Subst
1998;8:55e75.
35. Van Zundert RMP, Van der Vorst H, Vermulst AA,
Engels RCME. Pathways to alcohol use among Dutch students
in regular education and education for adolescents with
behavioral problems: the role of parental alcohol use, general
parenting practices, and alcohol-specific parenting practices.
J Fam Psychol 2006;20:456e67.
36. Wang J, Simons-Morton B, Farhart T, Luk JW. Socio-
demographic variability in adolescent substance use:
mediation by parents and peers. Prev Sci 2009;10:387e96.
37. Engels RCME, Ter Bogt T. Influences of risk behaviors in the
quality of peer relations in adolescence. J Youth Adolesc
2001;30:675e95.
38. Brener ND, Billy JOG, Grady WR. Assessment of factors
affecting the validity of self-reported health-risk behavior
among adolescents: evidence from the scientific literature. J
Adolesc Health 2003;33:436e57.
39. Johnson KA, Jennison KM. The drinking-smoking syndrome
and social context. Int J Addict 1992;27:749e92.
40. Stata Corp., 2009. Stata Statistical Software, release 11.1. Stata
Corporation, College Station, TX.