Pediatrics International (2009) 51, 120125 doi: 10.1111/j.1442-200X.2008.02660.

Original Article

Self-rated health, psychosocial functioning, and health-related

behavior among Thai adolescents

Randy M. Page1 and Jiraporn Suwanteerangkul2

1
Department of Health Science, Brigham Young University, Provo, Utah, USA and 2Department of Community Medicine,
Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand

Abstract Background: Despite the popularity of self-rated health (SRH) in Western countries as a useful public health tool,
it has only rarely been used in Asian countries. The purpose of the current study was to determine whether measures
of psychosocial functioning and health-related factors differ according to SRH in a school-based sample of Thai
adolescents.
Methods: The survey was given to 2519 adolescents attending 10 coeducational secondary high schools in Chiang
Mai Province, Thailand and included measures of psychosocial functioning (loneliness, hopelessness, shyness, percep-
tions of social status, self-rated happiness, and perception of physical attractiveness) and certain health-related factors
(height/weight, physical activity, eating breakfast, sleep).
Results: The proportion of boys (5.1%) reporting that they were not healthy was similar to the proportion of girls
(4.6%) making the same rating. These adolescents showed a pattern of overall poor health risk. Compared to adolescent
peers who rated their health as healthy or very healthy, they were less physically active, got less sleep, were more likely
to be overweight, and scored lower on loneliness, shyness, hopelessness, and self-rated happiness.
Conclusions: The present pattern of poor health risk warrants attention and supports the merit of using SRH in ado-
lescent health assessment. SRH is easy to obtain and simple to assess and single-item assessments of SRH appear to be
valid measures of health status in adults and adolescent. Interventions, such as health counseling, mental health coun-
seling, and health education, can target adolescents who rate themselves as not healthy or report poor health status.

Key words adolescents, health-related behavior, psychosocial functioning, self-rated health, Thailand.

Researchers frequently use a single-item measurement of self-
rated health (SRH) to assess survey respondents overall health
status.1 SRH is typically assessed in a simple, easy-to-obtain
fashion by asking individuals to rate their current health in such
qualitative terms as excellent, good, or poor.2 Single-item assess-
ments of SRH have consistently been found to be a valid measure
of physical health status in adults.3,4 Numerous studies have
found increased mortality3,5 for adults reporting their health as
poor and association with such risk behaviors as smoking,
physical inactivity, lack of sleep, overweight, and alcohol con-
sumption.6 In addition, SRH has also been shown to be one of the
best predictors of the use of health-care services.7 Idler and Ben-
yamini note that the validity of SRH as a measure of an individu-
als health status is so strong that this single item represents an
irreplaceable dimension of health status.3
Although SRH is one of the most widely examined measures
of health status among adults, it deserves more research attention
as a health indicator among adolescents.8 It has been speculated
that SRH in adults may principally reflect physical health prob-
Correspondence: Randy M. Page, PhD, Department of Health Sci-
ence, 221 Richards Building, Brigham Young University, Provo, UT
84602, USA. Email: randy_page@byu.edu
Received 2 May 2007; revised 5 December 2007; accepted
10 March 2008; published online 1 September 2008.
lems and limitations of physical functioning due to chronic and
acute conditions and mental health problems.9 In adolescents,
however, SRH may extend beyond symptomatology and be a
somatic expression of life distress.10 The assertion of an indicator
of distress in adolescents is strengthened by consistent findings
showing a relationship between SRH and social and economic
disadvantage.11 SRH appears to be a function of adolescents
overall sense of functioning12 and an important component of
what Zullig et al. term adolescent health-related quality of
life.13 Adolescents with type 1 diabetes who self-rated their
health as good or excellent were found to have shorter diabetes
duration, fewer hospitalizations, and better overall diabetes care
management than those with lower levels of SRH.14 SRH has
been found to be directly affected by family financial situation,
school achievement, self-esteem, and tobacco use in adoles-
cents,10 as well as positively associated with parental education,
positive self-image, feeling connected at school, and living in a
safe neighborhood.15 Other factors that appear to affect SRH in
adolescents include physical health problems and disability,2
childparent relationships,9 school achievement,16 female gen-
der,2 and higher body mass index (BMI).17 During adolescence,
personal health appraisals appear to more represent youths over-
all sense of psychosocial functioning than their physical func-
tioning.18 This tendency to relate general life difficulties to health

2008 Japan Pediatric Society


problems may reflect underlying patterns of expressing life dis-
tress in physical rather than psychological terms.
The purpose of the current study was to determine whether
specific measures of psychosocial functioning (loneliness, hope-
lessness, shyness, perceptions of social status) and health-related
factors (physical activity, sleeping habits, eating breakfast, and
overweight/obesity status) differ according to self-rating of
health in a sample of Thai adolescents. This provided an oppor-
tunity to extend research investigating SRH, psychosocial func-
tioning, and health-related factors in adolescents in general, but
also more specifically within a non-Western population of ado-
lescents. Despite the popularity of SRH in Western countries as
a useful public health tool, it has only rarely been used in Asian
countries.19
Methods
Sample and subject selection
The present subjects consisted of 2519 adolescents attending 10
coeducational secondary high schools in Chiang Mai Province,
Thailand. The selected schools represent a mix of rural and urban
and public and private schools. Administrative officials within
these schools agreed to have classroom teachers in selected
English or Ethics classes administer a survey instrument to their
students. Classes were selected by administrative officials on the
basis of their judgment of which classes were most representa-
tive of their student body and specific logistical concerns relative
to the administration of the survey.
The mean age of subjects was 16.2 1.33 years. Of the stu-
dents in the sample, 91.2% were in grades 1012 (656 10th
graders, 738 11th graders, and 900 12th graders) and 8.8% were
in grades 79 (40 seventh graders, 144 eighth graders, and 38
ninth graders). The sample consisted of 830 boys and 1662 girls
(27 students did not report gender). The higher number of girls in
the sample reflects the fact that considerably more girls are
enrolled in coeducational high schools in Chiang Mai Province.
Thus, the gender distribution in this sample reflects current
enrollment trends.
Survey instrumentation and data collection
The survey instrument included a single-item measure of SRH,
four measures that relate to psychosocial functioning (loneli-
ness, hopelessness, shyness, perceptions of social status) and a
number of health-related factors. The measure of SRH used was
the same as that used in the World Health Organization collabo-
rative health behavior in school-aged children study.20 The use
of a single-item measurement to assess SRH is consistent with
most research involving this indicator of overall health status.1
Another item from the WHO collaborative study included on
the survey instrument was a single-item measure of self-rated
happiness.
Loneliness was measured using the revised UCLA Loneli-
ness Scale (R-UCLA).21 Hopelessness was measured with the
Beck Hopelessness Scale.22 The Cheek and Buss Shyness Scale
was used to measure shyness23 and the MacArthur Scale of Sub-
jective Social StatusYouth Version was used to assess percep-
tions of social status.24 Health-related factors that were part of
Self-rated health 121
the survey included items addressing physical activity, sleeping
habits, eating breakfast, overweight/obesity status. These items
were largely modeled after the US Centers for Disease Control
and Preventions (CDC) Youth Risk Behavior Survey.25 Four
physical activity items were also summed to form a physical
activity summary variable (Physical Activity Index). Overweight
status was based on BMI (kg/m2) calculated from self-reported
height and weight. International cut-off points for BMI for over-
weight and obesity by sex and age were used to determine the
overall proportion of boys and girls in these two classifications.26
The Childhood Obesity Working Group of the International Task
Force on Obesity (IOTF) proposes these BMI cut-offs as an
international reference of overweight and obesity for children
and adolescents aged 218 years.27 An additional item on the
survey instrument was perception of physical attractiveness.
Survey instruments were distributed to students in class by
regular classroom teachers. Students were instructed orally and
with written instructions not to place their names on the survey
forms, that their participation was voluntary, and to answer the
questions honestly and accurately. Most students were able to
complete the survey in 1015 min. Upon completion, students
placed questionnaires in envelopes, that is, they were not handed
directly to school teachers or school personnel.
Analysis of data
Level of SRH served as the categorical independent variable in
the study. Subjects were grouped on the basis of their responses
as either very healthy, healthy, or not healthy. The dependent
variables were the measures that relate to adolescents psychoso-
cial functioning (loneliness, hopelessness, shyness, perceptions
of social status) and health-related factors (physical activity,
sleeping habits, eating breakfast, and overweight/obesity status)
that were included in the study. Analysis of variance (anova)
was used to test whether students with different levels of SRH
differed on dependent measures that were scaled in a continuous
fashion. 2 testing was done for dependent measures that were
scaled categorically. Descriptive statistics were also calculated to
determine means, standard deviations, percentages, and frequen-
cies of dependent measures according to SRH level. Statistical
tests were computed using SAS version 9.1 for Windows
(SAS Institute Inc., Cary, NC, USA).
Results
Table 1 displays SRH according to the gender of the survey
respondents. Boys and girls differed significantly on SRH (2
[2] 38.1, P < 0.0001), with a higher proportion of boys (23.2%)
than girls (12.6%) reporting their health as very high. The pro-
portion of boys (5.1%) reporting that they were not healthy was
similar to the proportion of girls (4.6%) making the same report
about their health status. Even though this variable is designed
to be analyzed categorically because there are only three
response options on this variable, we tested for a gender differ-
ence when treating it as a continuous variable. This showed a
significant gender difference in SRH (t [2438] 5.4, P < 0.0001),
with boys (mean, 2.18 0.5) scoring higher than girls (mean,
2.08 0.4).
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122 RM Page and J Suwanteerangkul

Table 1 Level of self-rated health by gender
Very healthy Healthy Not healthy
% (n) % (n) % (n)
Boys 23.2 (193) 71.7 (595) 5.1 (42)
Girls 12.6 (209) 82.8 (1370) 4.6 (76)
Boys and girls differed significantly on self-rated health
(2[2] 38.1, P < 0.0001).
Significant main effects (P < 0.05) of SRH level or 2 associa-
tion with SRH level were found for all of the dependent measures
among boys, except for perception of physical attractiveness and
overweight status. There were fewer significant main effects of
SRH level or 2 association with SRH on the dependent measures
among girls. Significant main effects (P < 0.05) with SRH level or
2 association with SRH level were found among girls for all vari-
ables except hopelessness, perception of social status (society),
eating breakfast, and obesity status. Main effects or 2 associations
among girls were not significant for hopelessness, perceptions of
social status, eating breakfast, or obesity status. These results,
along with descriptive statistics, are presented in Tables 2,3.
Discussion
While most of the boys (71.7%) and girls (82.8%) rated them-
selves as healthy, a significantly higher proportion of boys
(23.2%) than girls (12.6%) rated themselves as very healthy.
The more positive self-evaluation of health by boys than girls is
consistent with other research.12,28 Tremblay et al. speculated that
lower self-perceived health among girls may relate to concerns
related to reproduction, to higher levels of emotional distress,
and/or to greater preoccupation with other health matters,
appearance, bodyweight, and social relationships.29
In the present sample a fairly equal percentage of boys (5.1%)
and girls (4.6%) rated themselves as not healthy. Torsheim et al.,
using the identical item that we used to assess SRH, calculated
that across 27 European and North American countries, the
average percent of boys reporting not healthy was 4.6%, and
that of girls was 8.2%.20 They noted, however, that 11% of the
total variation in SRH was due to country differences and
determined that for 95% of the countries examined, the percent-
age reporting not healthy would fall between 1.4 and 14.4% for
boys, and between 2.5 and 23.2% for girls. Many factors may be
involved in explaining country and individual differences in
SRH such as socioeconomic status,28 inequalities in income
distribution,20 family income and worry about family finances,30
presence of a chronic condition or physical health problem,14
health behaviors,29 bodyweight and appearance concerns,29 social
relationships,29 school achievement,10 and psychological health
status18 (e.g., self-esteem, stress, depression).
The present results showed a pattern of psychosocial distress
or poor psychosocial functioning among the adolescents in the
sample who rated themselves as not healthy. These adolescents
scored higher on loneliness and shyness and lower on self-rated
happiness. Not healthy boys also scored higher on hopeless-
ness, while this difference was not significant among girls.
Vingilis et al. postulated that psychosocial functioning during
adolescence is a major factor shaping a young persons appraisal
of personal health status.18 They asserted that adolescents per-
sonal health appraisals may more represent youths overall sense
of psychosocial functioning than their physical functioning.
According to these authors, young people may tend to relate gen-
eral life difficulties to health problems and reflect underlying
patterns of expressing life distress in physical rather than psy-
chological terms. There is some evidence that adolescents give
greater emphasis to psychological functioning when reporting
health status than do adults.2 Adults may see psychological func-
tioning and physical functioning as two distinct constructs when
reporting health status, whereas adolescents may view health sta-
tus more in relationship to life distress. Clearly, the findings

Table 2 Psychosocial functioning and health-related variables for boys according to self-rated health

Continuously scaled variables Very healthy Healthy Not healthy Significance

(Mean SD) (Mean SD) (Mean SD)
Loneliness 38.6 7.5 39.9 7.6 45.0 9.1 F(2,760) 11.4, P < 0.0001
Shyness 15.5 6.4 17.3 6.2 19.4 6.2 F(2,783) 8.5, P 0.0002
Hopelessness 5.4 3.1 5.8 3.3 7.2 3.7 F(2,781) 4.8, P 0.0085
SSSsociety 5.9 1.6 5.6 1.5 5.2 1.4 F(2,710) 3.5, P 0.0308
SSSschool 6.3 1.5 6.1 1.6 5.4 2.0 F(2,710) 5.5, P 0.0044
Self-rated happiness 3.4 0.7 3.0 0.7 2.7 0.7 F(2,790) 23.6, P < 0.0001
Perception of physical attractiveness 5.2 1.7 5.0 1.6 4.8 1.8 F(2,800) 1.3, P 0.2739 (NS)
Vigorous physical activity 4.8 1.9 3.6 2.0 2.5 2.1 F(2,826) 32.8, P < 0.0001
Muscle strengthening activity 3.5 2.2 2.4 2.1 1.9 2.1 F(2,827) 19.8, P < 0.0001
No. sports teams played on 2.4 1.9 1.9 1.7 1.1 1.6 F(2,824) 10.6, P < 0.0001
Activity index 13.5 5.0 10.4 5.3 7.2 5.3 F(2,819) 35.7, P < 0.0001
Eating breakfast 4.2 2.7 4.2 2.7 2.8 2.5 F(2,824) 5.2, P < 0.0056
Categorically scaled variables % (n) % (n) % (n)
Overweight 8.8 (17) 11.4 (68) 19.1 (8) 2 (2) 3.7, P 0.1580 (NS)
Obese 1.0 (2) 2.7 (16) 9.5 (4) 2 (2) 9.6, P 0.0081
Usually get 78 h sleep a night 71.0 (137) 65.4 (388) 34.1 (14) 2 (2) 20.3, P < 0.0001
Usually get enough sleep 64.1 (123) 55.9 (332) 11.9 (5) 2 (2) 38.1, P < 0.0001
SSS, subjective social status.

2008 Japan Pediatric Society

 Self-rated health 123

Table 3 Psychosocial functioning and health-related variables for girls according to self-rated health

Continuously scaled variables Very healthy Healthy Not healthy Significance

(Mean SD) (Mean SD) (Mean SD)
Loneliness 36.8 6.9 38.1 7.0 40.3 8.7 F(2,1562) 6.4, P 0.0017
Shyness 17.2 6.3 17.7 6.2 20.0 5.8 F(2,1597) 5.7, P 0.0035
Hopelessness 4.8 3.1 4.8 2.9 5.2 3.2 F(2,1572) 0.6, P 0.5697 (NS)
SSSsociety 5.6 1.7 5.4 1.6 5.4 1.6 F(2,1505) 0.8, P 0.4400 (NS)
SSSschool 6.3 1.7 6.2 1.6 5.8 1.6 F(2,1504) 2.7, P 0.0682 (NS)
Self-rated happiness 3.3 0.7 3.0 0.7 2.8 0.7 F(2,1599) 15.8, P < 0.0001
Perception of physical attractiveness 5.0 1.4 4.9 1.3 4.4 1.4 F(2,1603) 6.8, P 0.0012
Vigorous physical activity 2.9 1.8 2.3 1.7 1.6 1.5 F(2,1651) 19.0, P < 0.0001
Muscle strengthening activity 2.0 2.0 1.4 1.7 1.0 1.6 F(2,1650) 9.7, P < 0.0001
No. sports teams played on 1.5 1.6 1.2 1.4 0.7 0.9 F(2,1634) 9.5, P < 0.0001
Activity index 8.5 4.4 6.6 4.2 3.4 3.5 F(2,1633) 28.4, P < 0.0001
Eating breakfast 4.3 2.6 4.3 2.5 4.1 2.6 F(2,1646) 0.3, P 0.7431 (NS)
Categorically scaled variables % (n) % (n) % (n)
Overweight 4.8 (10) 6.1 (83) 15.8 (12) 2 (2) 12.44, P 0.0020
Obese 1.4 (3) 1.2 (16) 4.0 (3) 2 (2) 4.3, P 0.1191 (NS)
Usually get 78 h sleep a night 73.2 (153) 61.3 (835) 44.0 (33) 2 (2) 21.7, P < 0.0001
Usually get enough sleep 64.1 (134) 49.6 (679) 32.9 (25) 2 (2) 25.4, P < 0.0001
SSS, subjective social status.

showing higher loneliness and hopeless scores (among boys) are
concerning in light of the fact that hopelessness and loneliness
are cognitive variables associated with increased risk for suicide,
along with low self-esteem, poor problem-solving skills, and
external locus of control.31,32 Shyness and lowered feelings of
happiness are also concerning because they indicate problems in
psychosocial functioning for a young person.
We used a subjective measure of socioeconomic status (SES),
the MacArthur Scale of Subjective Social Status,24 to assess the
relationship between subjective social status (SSS) and SRH.
This measure provides a youth-specific measure of SSS and,
according to its developers is useful for analyzing the effects of
social status on adolescent health. This measure addresses the
lack of a consistent effect of SES on adolescent health which
may be due to the fact that most analyses assessing SES and
health in adolescents use parental measures of SES, which do not
tap the adolescents emerging self-concept of social stratifica-
tion.33 The present findings, showing a relationship between SSS
and SRH among Thai boys, are consistent with the application of
this measurement tool within a large sample of US adolescents.24
Not healthy Thai boys placed themselves lower than other stu-
dents on the SSS scale measuring social status among their peers,
which asked respondents to evaluate themselves relative to other
people in their school in terms of respect, grades, social standing,
and having others to hang around with. In terms of the other
dimensions of SSS, society and community, we also found a
relationship showing lower rating of SSS among not healthy
boys relative to healthy and very healthy boys. An interesting
finding was that there was an association between SSS in boys,
but not among girls. Research utilizing these SSS scales in the
USA did not find differential relationships with SRH for boys
and girls.24 Goodman et al. noted that there is a weaker association
between adolescent health and social status/stratification in
the broader community and society, than there is for social
status among peers.24 West presents the idea that during
adolescence there is equalization in health status among differ-
ent SES groups, but differentials will emerge during adulthood
when SES becomes a more prominent determinant of
self-concept.34
In addition to psychological functioning, it has been sug-
gested that adolescents may use health-related behaviors such as
physical activity as a frame of reference for SRH.35,36 Because
previous research among North American and Western European
adolescents has linked physical inactivity with lower levels of
SRH,37,38 we hypothesized that we would find similar results for
the present sample of Thai adolescents between SRH and the
four specific items assessing physical activity that were exam-
ined. There was, in fact, a significant relationship for both boys
and girls. Very healthy adolescents were the most likely to
engage in vigorous physical activity, muscle strengthening activ-
ity, and play on sports teams as well as score higher on the physi-
cal activity index (sum of the physical activity items). The not
healthy adolescents were the least likely to participate in physi-
cal activity. Physical activity is an important lifestyle dimension
of adolescent health because it is associated with several health
benefits, including the prevention of overweight and obesity.39
Thus, it was not surprising that a higher percentage of not
healthy boys (9.5%) than other boys (2.7% for healthy, 1.0%
for very healthy) were above the IOTF BMI cut-offs for obesity
for children and adolescents aged 218 years.27 Also not surpris-
ing was that 15.8% of not healthy girls compared to 4.8% of
very healthy and 6.1% of healthy girls were above the IOTF
cut-off for overweight. Another interesting finding relating to
bodyweight, was that SRH was associated with perception of
physical attractiveness among girls, in that not healthy girls
rated themselves lower on physical attractiveness than other
girls.
The present study also found an association between SRH and
sleep habits. Only 11.9% of not healthy boys and 32.9% of not
healthy girls reported that they had enough sleep, compared to

2008 Japan Pediatric Society

124 RM Page and J Suwanteerangkul
55.9% of boys and 49.6% of girls reporting as healthy and 64.1%
of boys and 64.1% of girls reporting as very healthy. A similar
pattern was found with respect to the item assessing whether the
adolescents usually had 78 h sleep a night. For example, 71%
of very healthy boys responded that this was true of them while
only 34.1% of not healthy boys reported getting this much sleep.
These findings regarding sleep are not surprising in view of our
other findings showing association between SRH and psychoso-
cial distress (loneliness, shyness, self-rated happiness) among the
sample of Thai adolescents. Research by Fredriksen et al. showed
that sleep clearly plays a significant role in predicting depressive
symptoms and self-esteem during adolescence.40 Adolescent
moodiness, which often negatively influences coping skills and
relationships with peers and adults, has been linked to insufficient
sleep.41 Tiredness has also been linked with suicide ideation.42
A final finding of note in the present study was that not
healthy boys were less likely to have eaten breakfast in the past
week in comparison to their healthy and very healthy peers, frequently used in Western populations of adolescents, have not
while there was no association between SRH and frequency of
eating breakfast among girls. The lowered frequency of eating
breakfast among the not healthy Thai boys may be problematic
because research in Western nations shows that inadequate nutri-
tion (often complicated by skipping breakfast) likely negatively
impacts learning problems, because hunger affects adolescents
concentration and ultimately their ability to learn.43,44 Goodwin
et al. note that research into the relationship between adolescent
diets and SRH is presently limited and there is a need for more
research in this area.36 Their research suggests that dietary intake
of vegetables and awareness of fat consumption may be indica-
tors of health status in adolescents.
Clinical implications
The present findings have important clinical implications for
pediatric practice. The pattern of poor health risk demonstrates
the merit of using SRH in adolescent health assessment. SRH is
easy to obtain and simple to assess; and single-item assessments
of SRH appear to be valid measures of health status in adoles-
cents.3,4 When SRH assessment indicates that an adolescent is
not healthy, then pediatric practice interventions, such as health
counseling, mental health counseling, and health education,
should be considered for this adolescent. The present study dem-
onstrated a pattern of overall poor health risk for Thai adolescents
who self-rated their health as not healthy. Interventions that
appear to be needed for these adolescents include health promo-
tion programs that encourage physical activity, healthy body-
weight maintenance, healthy diet, and having enough sleep.
Psychosocial support interventions are warranted that deal with
such psychosocial issues as loneliness, hopelessness, shyness,
appearance and body image, and positive self-image.
Cultural implications
Cultural considerations must be taken into account when consider-
ing the results and implications of the present study. An important
Thai cultural ideal is choie choie or the maintenance of a consistent
minimization of overt display of feelings and concealment of such
feelings as anger, doubt, anxiety, or grief. Outward expressions of
2008 Japan Pediatric Society
feelings can be regarded as signs of ignorance or crudity, suggest-
ing that one has not yet learned how to control oneself. This cultural
hesitancy to share expressions of emotions may affect the degree to
which the adolescent responders in the present survey revealed
their true feelings on the survey measurements. McCarty et al.
stressed that Thai youth are taught to inhibit overt expressions of
their feelings, particularly when communicating with authority
figures or those who are older than them.45 Thus, from a cultural
standpoint it is plausible that Thai youth may be reluctant to report
themselves as not healthy or indicate feelings such as loneliness
or hopelessness even if in fact they have these personal feelings
about themselves. This cultural norm is much different from West-
ern culture that generally emphasizes open expression of feelings
and thoughts. Another Thai ideal that may cause reluctance to share
feelings is krengchai. Krengchai is extreme reluctance to impose
on others by overtly expressing personal feelings and wishes.
The psychosocial measures used in the present study, although
been validated in Asian adolescent populations and the constructs
they represent may have different cultural meanings. Loneliness,
shyness, and hopelessness may manifest differently in Thai cul-
ture than in other cultures. Shyness, for example, is often consid-
ered a negative trait in Western societies, but appears to have
different meanings in Asian societies. Chen et al. asserted that in
contrast to individualistic societies, shyness traditionally in Asian
(collectivistic) societies is more likely to be esteemed and valued
as a positive and adaptive trait and that shy children are accepted
by peers and well adjusted to the school environment.46
The fact that this research was conducted with Thai adoles-
cents is important. We believe that it is the first study reported in
the international literature of SRH among adolescents in an
Asian country. Similar to studies conducted among Western ado-
lescents, SRH also appears to be predictive of psychosocial func-
tioning, physical health status, and health-related behavior in
these Asian adolescents. This is an important finding given the
myriad of differences in culture, society, and lifestyle between
Thai adolescents and adolescents living in Western societies.
Additional research investigating SRH among Asian adolescents
is warranted, because this study is only a first step.
Sampling limitations
This study had important sampling limitations that need to be
addressed. The sample was composed of adolescents attending
10 coeducational secondary high schools in Chiang Mai Prov-
ince, Thailand. As such, it does not adequately represent all ado-
lescents in Thailand or in Chiang Mai Province. Chiang Mai
Province should not be construed to represent Thailand because
it is only one of 76 provinces. Further, although almost 90% of
Thai children attend primary school, only approximately 56%
attend secondary school. Thus, the students attending secondary
school clearly do not represent all adolescents in any locality in
Thailand. The present sample shows a clear selection bias toward
those enrolled in secondary school and does not reflect those not
enrolled. It is highly likely that there are important differences in
these two groups. Future studies of SRH in Thailand need to
include a wider range of Thai adolescents.

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2008 Japan Pediatric Society