The results of the study show that many Romanian junior and senior high school as well as university students from our study sample engage in behaviours that place them at risk for health and social problems. Consistent with previous studies (Paavola et al. 2004; Ellickson et al. 2001; Lazcano-Ponce et al. 2003; Sutherland and Shepherd 2001), the likelihood of involvement in risk behaviours, such as substance use, increased with age, while some risks, particularly violence-related, tended to be replaced rather than compounded over time (Brenner and Collins 1998; Hibell et al. 2004).
Similar to other research results, many health risk behaviours were found to be interrelated rather than being a collection of independent activities (Brenner and Collins 1998; Potthoff et al. 1998; Fetro et al. 2001; Anteghini et al. 2001; Shrier et al. 1997). Almost one third of the junior high school students and around 60% of the senior high school as well as university students were involved in more than one risk behaviour. This shows that engagement in multiple risk behaviours starts in junior high school and increases with age, being already well established in senior high school.
Furthermore, we found that various health risk behaviours correlated. The strongest correlation was between smoking and alcohol-related behaviours in junior high school students and between smoking, alcohol and sex-related behaviours in senior high school and university students. This type of interrelationship is also documented by studies from other countries (Takakura et al. 2001; Everett et al. 2000; Anteghini et al. 2001; Shrier et al. 1997; Cooper 2002). There were also correlations between other health risk behaviours (e.g. between illicit drug use and violence and delinquency-related behaviours or between illicit drug use, smoking and alcohol abuse), but weaker.
Factor analysis was used to further examine the relationship among health risk behaviours. Several previous studies showed that a single common factor accounted for the positive correlations among a number of adolescent problem behaviours (Donovan and Jessor 1985; Jessor 1991). The results of the factor analysis in our study revealed that for junior high school students, no clear differentiation seemed to exist between health risk behaviours. This may suggest that at this age students involved in one risk behaviour are at greater risk of becoming involved in other health risk behaviours as well.
There were also studies that found that health risk behaviours are multidimensional, but the examined behaviours, as well as the precise number of dimensions involved and their behavioural content, varied between studies (Basen-Engquist et al. 1996; Ebin et al. 2001; Takakura et al. 2001; Kulbok and Cox 2002; Bartlett et al. 2005). This pattern was found in our study among senior high school students and university students where we identified two factors. Similar to other studies (Ebin et al. 2001) we interpret factors 1 and 2 as distinguishing between common and uncommon engagement in problem behaviours. Factor 1 comprised smoking, use of alcohol and alcohol intoxication as well as precocious sexual intercourse, behaviours, which were most frequently encountered and which are possibly part of the normal experimentation period that often characterizes adolescent behaviour at this age. Factor 2 included less common behaviours among the study subjects (violence, delinquency, illicit drug use), which may have more severe consequences regardless of the developmental stage.
Several studies showed that gender differences with regard to health risk behaviours vary within countries and regions (Hibell et al. 2004; Currie 2004). If, traditionally, young boys were more often engaged in risk behaviours than girls, in some countries the differences dissipated (The Global Youth Tobacco Survey Collaborative Group 2002; Hibell et al. 2004; Currie 2004). In our study, in all three groups, health risk behaviours were generally more frequent among boys than girls, but no significant gender differences were found with regard to the relationship between health-compromising behaviours.
The findings in this study have several implications for public health professionals, health educators and researchers. First, given the age-related changes seen in health risk behaviours, health promotion intervention for Romanian young people must be sensitive to developmental changes and appropriately timed. Additional research is needed to better understand the appropriate type and timing of interventions as well as the content of messages to address several health risk behaviours.
Second, the association between several health risk behaviours among Romanian adolescents from our sample raises the question of whether to address the promotion of healthy lifestyles among youth in one overall programme or by dealing with them as separate topics and whether the same approach has to be taken for younger and older adolescents. As other studies suggested (Neumark-Sztainer et al. 1997; Takakura et al. 2001), the categorization of behaviours into factors could assist in designing and implementing appropriate health promotion interventions among young people, helping to better address the range of health-related behaviours among them. Hence, focusing on behaviours, such as illicit drug use, without also addressing other related behaviours, such as violence or delinquency, may be less effective than health education programmes that are comprehensive. At the same time, a combination of smoking prevention programmes with activities, which prevent alcohol abuse or promote a healthy sexual behaviour, could be also more effective than programmes, which are focused only on one type of behaviour. However, the advantages and disadvantages of more generic programmes are not clear at this time (Wetzels et al. 2003; Flay et al. 2004; Werch et al. 2005). In order to draw any conclusions regarding how these behaviours should best be addressed, intervention studies are necessary, in which different approaches are compared.
Third, similar to other studies (Neumark-Sztainer et al. 1997; Currie 2004), our results show the importance of identifying high-risk youth and targeting them with comprehensive prevention programmes. Creative ways of reaching high-risk youth need to be considered, both regarding the types of messages offered and settings for health promotion intervention programmes. Furthermore, this study suggests that prevention efforts aimed at high-risk youth during early adolescence need such a multi-problem focus, because this co-occurrence of problem behaviours is already evident among junior high school students.
Fourth, no important differences with regard to the relationship between health risk behaviours were found between boys and girls, suggesting that the content of the comprehensive health promotion programmes needs no gender-specific approach.
Fifth, health care providers must also be aware of the interrelationship existing between health risk behaviours in order to identify, treat and prevent them correctly. Such an approach has been successfully used to identify probable substance use among smoking pregnant adolescent girls (Archie et al. 1997).
This study is subject to limitations. First, due to its cross-sectional nature, the associations reported here should be interpreted with caution and nothing may be assumed about causality or temporal precedence. Second, the conclusions are based on a sample of 1,598 young people from both the rural and urban areas of two counties of Romania, but it is inevitably a limit to the generalization of the study findings beyond this sample. Third, this study involved junior and senior high school students as well as university students, but no adolescents who dropped out of school and are probably more likely to engage in health risk behaviours. Moreover, in Cluj-Napoca the study included only university students from university dorms. Hence, future studies should use national representative samples and must try to include out of school young people as well. Fourth, another common limitation with most studies on this topic is the reliance on adolescents’ self-reports. Although some respondents may not report truthfully, the likelihood of honest responses is maximized in this survey by conducting it anonymously.
In spite of these limitations, the current study is probably the first research project that assessed the relationship existing between different health risk behaviours among Romanian youth. It confirms the complexity of Romanian adolescents’ health risk behaviours and shows the necessity of future research in this area in order to develop appropriate health promotion interventions.