Public Health Approaches to Adolescent Health Beyond Disease and Illness

Abstract

Two seminal events provide a frame for public health approaches to adolescent disease and illness: the formation of the United States Public Health Service and the establishment of the World Health Organization. Within this framework, this chapter addresses contemporary public health approaches for adolescents beyond disease and illness. Next, contemporary public health efforts in the United States, now guided by a comprehensive set of goals and objectives called Healthy People including adolescent-specific content, are explored. Adolescent health issues, the unique needs of adolescents to improve their health, and the importance of adolescent public health are then outlined. Within that context, practical issues in public health practice focused on adolescents are detailed. Emphasis is placed on positive youth development, a youth-oriented strategy involving active youth participation as a public health approach.

Partially supported by MCHB Grant #T71MC00012.

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Introduction

Two seminal events provide a frame for public health approaches to adolescent disease and illness: the formation of the United States Public Health Service (USPHS) and the establishment of the World Health Organization (WHO). Within this framework, this chapter addresses contemporary public health approaches for adolescents beyond disease and illness. Next, contemporary public health efforts in the United States, now guided by a comprehensive set of goals and objectives called Healthy People including adolescent-specific content, are explored. Adolescent health issues, the unique needs of adolescents to improve their health, and the importance of adolescent public health are then outlined. Within that context, practical issues in public health practice focused on adolescents are detailed. Emphasis is placed on positive youth development, a youth-oriented strategy involving active youth participation as a public health approach.

Historical Framework to Public Health and Adolescent Health Psychology

The formation of the USPHS can be traced back to the Act for the Relief of Sick and Disabled Seamen of 1798 authorizing government-operated marine hospitals to care for American merchant seamen (U.S. Department of Health and Human Services, 2011). Although subsequent legislation broadened the scope of USPHS, it is important to note that the majority of seamen in 1798 were adolescents. At that time, sailors generally went to sea as boys, and by the time they were 16 years old they could be rated as seamen, but most left the sea in young adulthood (Lambert, 2011). With respect to adolescent psychology, Lambert noted, “the idea of being single, free of responsibilities and well paid would have made a career at sea obviously alluring” (Lambert, 2011). Thus, the earliest federal public health activity was largely a response to the health care needs of this population of adolescents. As noted in Box 1 the field of public health relevant to adolescents now includes seven essential activities (Centers for Disease Control and Prevention, 2011).

Box 1 Seven Essential Public Health Activities Relevant to Adolescent Populations (Centers for Disease Control and Prevention, 2011)

• 1. Monitoring their health status

• 2. Mobilizing community partnerships to identify and solve health problems

• 3. Developing policies and plans that support individual and community health efforts to improve adolescent health

• 4. Enforcing laws and regulations that protect health and ensure safety of adolescents

• 5. Assuring a competent public adolescent health care workforce

• 6. Evaluating the effectiveness, accessibility, and quality of personal and population-based health services

• 7. Conducting research related to new insights and innovative solutions to health problems

The WHO, established in 1948 as the international public health arm of the United Nations, defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (World Health Organization, 2011a). Thus, any discussion of adolescent health and adolescent health psychology must move beyond disease and illness to comprehensive well-being. The WHO defines adolescents as youth between 10 and 19 years old, accounting for 20 % of the world population, with 85 % of all adolescents living in developing countries (Global Health Council, 2011). As noted in Box 2, nearly two-thirds of premature deaths and one-third of disease burden in adults can be traced to conditions or behaviors that began in youth. Promoting healthy practices among youth that protect them from health risks is critical to the future of every country’s health and social infrastructure and to the prevention of health problems in adulthood (World Health Organization, 2011b).

In 2002, the UN General Assembly Special Session on Children recognized the need for the “development and implementation of national health policies and programmes for adolescents, including goals and indicators, to promote their physical and mental health” (World Health Organization, 2011b).

Box 2 World Health Organization: 10 Facts on Adolescent Public Health Issues

• 1. 20 % of people in the world are adolescents, and 85 % of them live in developing countries. Nearly 2/3 of premature deaths and 1/3 of the total disease burden in adults are associated with modifiable conditions or behaviors that began in youth, including tobacco use, a lack of physical activity, unprotected sex, or exposure to violence.

• 2. Young people 15–24 years old accounted for an estimated 45 % of new HIV infections worldwide in 2007.

• 3. About 16 million girls 15–19 years old give birth every year—roughly 11 % of all births worldwide—with the vast majority to adolescents in developing countries. Pregnancy-related death rates are much higher for adolescents than for older women.

• 4. Many children in developing countries enter adolescence undernourished, making them more vulnerable to disease and early death. Conversely, overweight and obesity—another form of malnutrition with serious health consequences—is increasing among young people in developed countries.

• 5. More than 20 % of adolescents experience some form of mental illness, such as depression, mood disturbances, substance abuse, suicidal behaviors, or eating disorders.

• 6. The vast majority of tobacco users worldwide begin during adolescence. More than 150 million adolescents use tobacco, and this number is increasing globally.

• 7. Alcohol consumption among young people reduces self-control, increases risky behaviors, and is a primary cause of injuries (including those due to road traffic accidents), violence (especially domestic violence), and premature deaths.

• 8. Among 15–19-year-olds, suicide is the second leading cause of death, followed by violence in the community and the family.

• 9. Unintentional injuries are a leading cause of death and disability in adolescents, with road traffic injuries, drowning, and burns the most common types. Injury rates among adolescents are highest in developing countries, and within countries, they are more likely to occur among adolescents from poorer families.

• 10. Many adolescent health challenges are closely interrelated and successful interventions in one area can lead to positive outcomes in other areas.

  (Modified from www.who.int/features/factfiles/adolescent_health/facts/en/index.html Accessed August 28, 2011.)

Healthy People: US National Adolescent Public Health Goals, Objectives, and Strategies

Healthy People 1990: Under the leadership of the Surgeon General Julius B. Richmond, Healthy People was established as a blueprint to improve the health of all Americans over a decade. With core concepts now considered axiomatic, it laid out a US national public health policy for the first time. Described as a document “to encourage a second public health revolution,” it reflected the first consensus among key stakeholders to focus on health promotion and disease prevention (CDC, 1989). A 1980 Surgeon General’s companion Report Promoting Health, Preventing Disease: Objectives for the Nation for the first time included an adolescent and young adult outcome—mortality reduction (Public Health Service, 1980). A pediatrician who appreciated the special needs of adolescents, Dr. Richmond, presciently wrote, “achievement of these objectives by 1990 is a shared responsibility, requiring a concerted effort not only by the health community, but also by leaders in education, industry, labor, community organizations and many others” (Public Health Service, 1980).

Healthy People 2000 and 2010: In its second iteration, Healthy People 2000, there was a focus to reduce disparities among populations, such as the higher rates of sexually transmitted infections (STIs) in adolescents and young adults compared to older adults. The third iteration, Healthy People 2010, shifted from reducing to eliminating disparities, especially as they existed within a population, such as the higher rates of STIs among African-American compared to White adolescents in the same age-group. In addition, for the first time, Healthy People 2010 included 21 “critical” national health objectives (CNHOs) across six domains for youth 10–24 years old: (1) mortality, (2) unintentional injury, (3) violence, (4) substance use and mental health, (5) reproductive health, and (6) prevention of chronic disease during adulthood. Following the end of the 2000–2010 decade, the first comprehensive study of the 21 CNHOs in Healthy People 2010 was recently published, with both encouraging and discouraging findings (Jiang, Kolbe, Seo, Kay, & Brindis, 2011; Kreipe, 2011).

Although mortality for 10–24-year-olds in the United States was reduced compared to baseline, disparities in deaths continued to exist, based on sex, age, race, and ethnicity in a consistently troubling pattern, with males exceeding females, older groups exceeding younger groups, and Blacks exceeding both Whites and Hispanics in mortality. With respect to mortality rates, White and Hispanic 10–14-year-olds and females 10–19 years old all met Healthy People 2010 targets, but 20–24-year-old mortality increased from baseline. This disturbing trend emphasizes the importance of focusing on young adults as an often overlooked population (Park, Mulye, Adams, Brindis, & Irwin, 2006).

The “Other” race/ethnic mortality category contains two small subgroups that reflect extremes of mortality rates. American Indian/Alaskan Native youth have the highest same-age mortality rate among all racial/ethnic groups for both males and females, while Asian/Pacific Islanders have the lowest (National Adolescent Health Information Center, 2006). Among American Indian/Alaskan Native youth, death rates due to motor vehicle crashes or to suicide are twofold greater than rates for the next highest group, non-Hispanic Whites (National Adolescent Health Information Center, 2006). On the other hand, as a group Asian/Pacific Islander youth have relatively low rates of substance and alcohol use (National Adolescent Health Information Center, 2006), providing possible insight into alcohol-related MVC death reduction. Researchers have identified cultural factors including an emphasis on family reputation, humility, keeping a low profile, negative community sanctions on excessive drinking and behavior, and the impact of moderate parental drinking practices in the Asian/Pacific Islander population (Williams, 1984/1985). Although such protective influences may be mitigated as families accommodate to and are assimilated into mainstream culture, studying low-risk populations may suggest specific interventions for high-risk populations.

Outcomes for two other objectives deserve special attention because they worsened over time. Rates for the STI Chlamydia and for overweight/obesity worsened markedly from baseline to 2010 targets. Among 15–24-year-olds, females attending family planning clinics experienced a −125 % deviation from the 2010 target to reduce Chlamydia rates, while females and males at STI clinics had a −34 % and −52 %, respectively, deviation (Jiang et al., 2011). Overweight or obesity in 12–19-year-olds increased by 62 %, representing a −115 % deviation from the 2010 target (Jiang et al., 2011).

In Healthy People 1990, smoking was the major target of health promotion and disease prevention, and obesity was only mentioned in relation to hypertension and cardiovascular disease in adults (Public Health Service, 1980). Gonorrhea was the primary STI; Chlamydia was noted as an agent causing newborn illness and did not become a reportable STI until 1995. Obesity has replaced tobacco as a public health priority for preventable mortality and morbidity among adolescents and young adults (Ogden, Carroll, & Flegal, 2008), and Chlamydia is now the most common STI in 15–24-year-olds, and becoming ever more so (Centers for Disease Control and Prevention, 2010a). Disparities are evident in both of these domains as well: obesity is higher among males than females, and among Blacks and Hispanics than Whites, and increases with age (Eaton et al., 2010).

Healthy People 2020: As a tribute to Dr. Richmond’s visionary leadership, Healthy People, now in its fourth iteration for the years 2010–2020, includes a new goal: “to improve the healthy development, health, safety, and well-being of adolescents and young adults,” (Healthy, 2020a) and two new topic areas: adolescent health and lesbian, gay, bisexual, and transgender health (Healthy, 2020b), each with special relevance to adolescent health. Another feature of Healthy People 2020 with respect to adolescent health psychology is a new focus on identifying, measuring, and tracking health disparities by examining the determinants of health, with a goal of achieving health equity by eliminating disparities and improving the health of all groups. Health disparity exists if, for any reason, a health outcome occurs to a greater or lesser extent between populations of adolescents. Because databases such as those analyzed for the comprehensive study of 2010 outcomes are limited to a narrow range of individual characteristics, such as sex, race, and ethnicity, other potential dimensions of disparity (e.g., sexual identity, disability, socioeconomic status, or geographic location) that may foster or impair an individual’s ability to achieve good health have had limited inclusion in public health policy development. These features are more difficult to measure, but compared to the standard individual demographics may be more responsive to interventions and have an even greater impact on adolescent health psychology.

Thus, a range of personal, social, economic, and environmental factors affect adolescent health status. To that end, Healthy People 2020 encourages the development of objectives that address the relationship between health status and biology, individual behavior, health services, social factors, and policies. An ecological approach—in which adolescents are seen to affect the environment and the environment affects the adolescent—requires a dual focus at both individual and population levels of adolescents (Kreipe, 2011). Because the determinants of health are interactive and dynamic, effective public health interventions must mirror these qualities. For example, the adolescent population is becoming increasingly ethnically diverse, with recent dramatic increases in the numbers of Hispanic and Asian American youth. The adolescent and young adult population is not only more diverse than the adult population, but becoming so more rapidly (National Adolescent Health Information Center, 2008). This is important because family structure both varies by racial/ethnic group (National Adolescent Health Information Center, 2008) and influences health outcomes. Meeting the goal of improving the healthy development, health, safety, and well-being of adolescents in the context of rapidly expanding diversity will require culturally effective public health practices and increased attention to disparate health and academic outcomes known to correlate highly with poverty, especially among adolescents from minority racial and ethnic groups (Healthy, 2020a).

The collaborative entity that has been responsible for overseeing national efforts to address adolescent health deserves mention. The National Initiative to Improve Adolescent Health (NIIAH, www.cdc.gov/HealthyYouth/AdolescentHealth/NationalInitiative) is led by two federal agencies collaborating with a variety of partner organizations and key stakeholders to mobilize activity directed at the adolescent health objectives in Healthy People. NIIAH has a national, state, and community focus and commitment to the health, safety, positive development, and well-being of adolescents, young adults, and their families. To improve health and safety outcomes, NIIAH addresses access to quality health, safety education, and health care, with attention to social determinants of, and the elimination of disparities in, health, safety, and well-being of adolescents and young adults and their families (CDC, 2011). Leaders in adolescent health have noted that emerging data indicate 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” (Jiang et al., 2011).

Thus, adolescent health psychology and public health activities intersect at both the individual and the population level. Readers are referred to the chapters in this book by Clements-Nolle (epidemiology), DiClemente (determinants of health-related behaviors), Leany (brain development), Dmitrieva (socioeconomical influences), and Coleman (processes of risk and resilience) for a more in-depth discussion of factors that must be appreciated to develop effective public health interventions with respect to adolescent health psychology.

Adolescent Health, Disease, and Illness Responsive to Public Health Approaches

A federal monograph on adolescent health services emphasizes that adolescent patterns of behavior determine young people’s health status both in the present and the future (National Research Council and Institute of Medicine, 2009a). Contemporary public health and social problems in America that either start or peak between 10 and 24 years of age include (1) homicide, especially among urban minority youth; (2) suicide, especially among suburban or rural youth; (3) motor vehicle crashes, including those caused by drinking and driving; (4) substance use and abuse; (5) smoking; (6) STIs, including human immunodeficiency virus (HIV), with the highest risk group being adolescent and young adult males who have sex with males; (7) teenage unplanned pregnancies; and (8) homelessness (Healthy, 2020a). Although these health threats are largely preventable, adolescents are in a developmental transition (no longer children but not yet adults) and sensitive to environmental influences (Mulye et al., 2009). As previously noted regarding the ecological nature of adolescent heath, disease, and illness, environmental factors, including family, peer group, school, neighborhood, policies, and societal cues, can either support or challenge young people’s health and well-being (National Research Council, 1993).

As documented throughout this book, adolescence is a critical life-course phase, with a variety of developmental tasks that must be successfully negotiated for an individual to transition to healthy adulthood (Kreipe, 2008). Also, many conditions linked to multiple environmental risks, as well as protective factors, covary with each other. Thus, adolescents who have good communication and connection with an adult are less likely to engage in risky behaviors (Resnick et al., 1997). Likewise, risky behavior is less likely in adolescents whose parents monitor their activities and provide safe opportunities for development (Aufseeser, Jekielek, & Brown, 2006). On the other hand, adolescents who live in poverty have poorer health and less access to health care (Larson & Halfon, 2010). With respect to school, academic skills are associated with higher rates of healthy behavior (Centers for Disease Control and Prevention, 2010b); high school graduation lowers the risk of health problems (Muennig & Woolf, 2007), incarceration, and financial instability (Sum, Khatiwada, & McLaughlin, 2009). Neighborhoods provide an important ecological context in adolescent health, with youth from areas with concentrated poverty being at particular risk for mental health problems, delinquency, and unhealthy sexual behaviors (Leventhal & Brooks-Gunn, 2004). An environmental factor of increasing concern, due to our lack of complete understanding regarding its potential for good or harm, is the media, with an increased risk of adolescents who are exposed to media violence, sexual content, smoking, and drinking alcohol engaging in them (Roberts, Henriksen, & Foehr, 2004).

Effective Public Health Policies and Programs Targeting Adolescent Health Problems

There are numerous examples of public health interventions targeting adolescents with specific health problems, each with a slightly different approach.

Graduated Driver Licensing and Tobacco Reduction Programs: Legislative approaches such as state-graduated driver licensing programs are highly effective (D’Angelo, Halpern-Felsher, & Abraham, 2010), while those limiting the sale of tobacco products are probably not as effective as media campaigns, such as “Reality Check” or the “Truth Campaign,” to reduce youth tobacco use by emphasizing that the tobacco industry manipulates adolescents to become addicted to nicotine with devious marketing and advertising strategies (American Legacy Foundation, 2011). See also the chapter in this book by Brook, Pahl, Brook, and Brown (smoking).

Adolescent Pregnancy Prevention Programs: Despite an overall decrease in US teen pregnancy rates over the past two decades, the rates continue to far exceed those in other developed countries. In 2010, the federal government established the Office of Adolescent Health within the Department of Health and Human Services, which is funding a broad, long-term research effort related to evidence-based teen pregnancy prevention programs across the country. This initiative supports replication of extant evidence-based programs as well as the study of promising programs to establish a firm scientific foundation of evidence of effectiveness in the real world. A thorough scientific review of interventions with an evidence-base of effectiveness is available at the Office of Adolescent Health website devoted to this topic (Department of Health and Human Services, 2010). Also see the chapter by Aruda (pregnancy) in this book for more information.

Violence Prevention Programs: Effective public health violence prevention programs generally fall into community-based or school-based interventions. Community-based strategies include those that focus on (1) parents and family designed to improve family relations by combining training in parenting skills, education about development and the factors that predispose youth to violent behavior, and exercises to help parents develop skills for communicating with their children and for resolving conflict in nonviolent ways; (2) home-visitation which brings community resources to at-risk families in their homes during regularly scheduled home visits, including providing psychological support and other services to help parents function more effectively; (3) social-cognitive skills development to equip adolescents with the skills they need to deal effectively with difficult social situations; or (4) mentoring, in which a young person is paired with an adult who acts as a supportive, nonjudgmental role model, has been shown to significantly improve school attendance and performance, reduce violent behavior, decrease the likelihood of drug use, and improve relationships with friends and parents (Thornton, Craft, Dahlberg, Lynch, & Baer, 2002).

School-based violence prevention programs fall into two categories: universal, in which programs designed to reduce or prevent violent behavior are delivered to all students in a classroom, or targeted, in which programs are delivered to all students in a grade or school in high-risk areas (e.g., with low socioeconomic status or high rates of violence or crime). A comprehensive review of such programs and independent meta-analysis found strong evidence that universal school-based programs decrease rates of violence and aggressive behavior among students at all grade levels, leading the federal Task Force on Community Preventive Services to recommend universal school-based programs to prevent or reduce violent behavior (Centers for Disease Control and Prevention, 2007).

Mental, Emotional, and Behavioral Disorder Prevention: Recognizing that mental disorders are among the most common causes of disability, Healthy People 2020 has an expanded focus on this issue with respect to adolescents (Healthy, 2020b). The current model framing these disorders emphasizes the interaction of social, environmental, and genetic factors across the lifespan, so that prevention efforts must entail an interdisciplinary, multipronged approach. Balancing risk factors that predispose youth to mental illness are protective factors that increase the likelihood of mental health. Highly informative is emerging evidence regarding brain development in adolescents and young adults (see Lany’s chapter on brain development) that provides a biopsychosocial framework to understand phenomenon in this domain. See also chapters in this book by Donohue, Urgelles, and Fayeghi (substance use); O’Mara, Lee, and King (depression and suicide); Grant (anxiety); and Gazke-Kopp, DuPuis, and Nix (behavior problems) for more details.

A recent National Research Council and Institute of Medicine comprehensive review of the prevention of mental disorders and substance abuse among youth identified multiple strategies shown to enhance their psychological and emotional well-being (National Research Council and Institute of Medicine, 2009b). Research including meta-analyses and numerous randomized trials demonstrate the value of the following:

• Strengthening families by targeting problems (e.g., substance use or aggressive behavior); teaching effective parenting skills; improving communication; and helping families deal with disruptions (e.g., divorce or death) or adversities (e.g., parental mental illness or poverty).

• Strengthening individuals by building resilience skills, cognitive processes, and behaviors (National Research Council and Institute of Medicine, 2009b).

• Preventing specific disorders (e.g., anxiety or depression) by screening individuals at risk and offering cognitive training or other preventive interventions. Given the 20 % prevalence of mental health conditions in adolescents, many of which are undiagnosed and untreated, an alternative approach could be to screen all adolescents at primary care visits (Columbia University Teen Screen^®, 2011; National Research Council and Institute of Medicine, 2009b).

• Promoting mental health in schools by offering support to youth who are under serious stress; modifying the school environment to promote pro-social behavior; developing students’ skills at decision making, self-awareness, and conducting relationships; and targeting violence, aggressive behavior, and substance use (National Research Council and Institute of Medicine, 2009b; University of California Center for Mental Health in Schools, 2011).

• Promoting mental health through health care and community programs by promoting and supporting pro-social behavior, teaching coping skills, and targeting modifiable lifestyle factors that can affect behavior and emotional health, such as sleep, diet, activity and physical fitness, sunshine and light, and television viewing (National Research Council and Institute of Medicine, 2009b).

Positive Youth Development Approach to Adolescent Health and Wellness

Background on Positive Youth Development (PYD): As noted above, past public health interventions have largely centered on early identification and treatment, or the prevention, of problems. This perspective focuses on harm reduction rather than health promotion. Healthy People 2020 identifies PYD as an emerging issue to prevent risk behaviors, but from the perspective of promoting healthy youth development (Healthy, 2020a). PYD interventions are intentional processes that provide all youth with the support, relationships, experiences, resources, and opportunities that lead to positive outcomes needed to become successful and competent adults (Bernat & Resnick, 2006). Addressing the positive development of young people facilitates their adoption of healthy behaviors and helps to ensure a healthy and productive future adult population (McNeely & Blanchard, 2009).

PYD is grounded in work related to resilience (see chapter by Williams in this book), enabling youth to have positive outcomes despite adversity. Characteristic features of such “resilient” youth include having a close relationship with an adult role model or caregiver, an “easy” temperament, pro-social friends and interests, and good language and reasoning skills (Werner & Smith, 2001). Once considered an intrinsic trait, research has demonstrated that resilience can be enhanced by externally applied interventions, and therefore an opportunity for a public health approach. Damon notes that the PYD approach envisions young people as resources rather than as problems for society, with an emphasis on manifest potentialities rather than supposed incapacities of young people (Damon, 2004). PYD acknowledges adversities and challenges, but resists viewing development as an effort to overcome deficits and risk. Thus, it aims to understand, educate, and engage youth in productive activities rather than to correct, cure, or treat them (Damon, 2004).

Definition and Key Features of PYD: Although many youth activities may be considered as “positive youth development” programming, there are several characteristic features, outlined in Box 3, that define key elements of PYD (Seligman, 2005). Positive youth development is a framework that guides communities in the way that they organize services, opportunities, and supports to help youth develop to their full potential (Dotterweich, 2011). Pittman notes that PYD emphasizes that problem-free is not fully prepared, and the need to move from “beating the odds” to “changing the odds” for youth to achieve well-being as an adult (Pittman, Irby, & Ferber, 2000). Effective PYD enhances the “5 Cs” of individual Competence, Connection, Confidence, Caring, and Character. From a public health perspective, PYD moves beyond disease treatment or prevention to optimal health and wellness.

Box 3 Characteristic Features of Positive Youth Development Programming (Seligman, 2005)

• 1. Promote bonding: youth emotional attachment and commitment to social relationships in the family, peer group, school, community, or culture

• 2. Foster resiliency: youth capacity to adapt to stressful events in healthy and flexible ways

• 3. Promote competencies: social, emotional, cognitive, behavioral, and moral

• 4. Encourage self-determination: youth ability to think for oneself and act consistent with those thoughts, related to the need for competence, autonomy, and relatedness

• 5. Foster spirituality: youth moral reasoning or commitment, or belief in a moral order

• 6. Develop self-efficacy: youth perception that goals can be achieved by one’s own action

• 7. Nurture clear and positive identity: youth internal organization of coherent sense of self

• 8. Foster belief in the future: youth internalization of hope and optimism about possibilities

• 9. Recognize positive behavior: positive social response to desired youth behaviors

• 10. Provide opportunities for meaningful pro-social involvement: youth presented with events and activities across social environments to encourage pro-social interactions

• 11. Establish pro-social norms: encourage youth to adopt healthy beliefs and clear standards for behavior through a range of approaches

Models of PYD: Three models of PYD deserve mention regarding reducing risks and promoting health. Communities That Care (CTC^® www.sdrg.org/CTCInterventions.asp) is a coalition-building program designed to help a broad-based group of community stakeholders to gather and process information about their community and apply PYD interventions to address their specific youth issues. Involving research findings from numerous disciplines, the CTC^® model establishes priorities with measurable, strength-based outcomes for a whole community. Although initially focused on reducing or preventing substance use, other positive outcomes have been noted (Catalano, Gavin, & Markham, 2010). A commentary by the CTC^® group in a recent Journal of Adolescent Health supplement framed PYD as a means to promote adolescent sexual and reproductive health (Hawkins et al., 1992).

The Search Institute (www.search-institute.org) was established to provide leadership, knowledge, and resources to promote healthy youth and communities. It focuses on cultivating 40 developmental assets^® associated with a young person thriving, dichotomized into 20 internal and 20 external assets, each divided into four categories that have 4–6 anchor points (Search Institute, 2011). Internal asset categories include commitment to learning, positive values, social competencies, and positive identity. A youth who is optimistic about her or his personal future is an example of a positive identity item. External assets, related to domains in which adults can play an important role, are grouped into the following categories: support, empowerment, boundaries and expectations, and constructive use of time. A youth perceiving that adults in the community value youth is an example of an empowerment external asset. Extensive research has shown that assets correlate positively with health-promoting behaviors, while the lack of assets correlates with a variety of risky health behaviors (Mannes, 2006). Not all assets have the same influence on health, however. The internal assets of being motivated to do well in school and of caring about one’s own school have a very powerful positive correlation with healthy behaviors and attitudes.

Finally, a PYD intervention deserving mention is Assets Coming Together (ACT) for Youth, a statewide academic-public health collaborative launched in 2000. With funding from the New York State Department of Health (NYS DOH) and its AIDS Institute, the initial focus of ACT for Youth was to reduce violence, abuse, and high-risk sexual behavior among youth through the creation of 11 Community Development Partnerships (later 12 Collaborations for Community Change). Two academic Centers of Excellence (COE) provided technical assistance, training, and other support to both the community partnerships and the NYS DOH. One COE, composed of four partners, now provides academic support and technical assistance about PYD to the NYS DOH, and evaluation and training for communities funded by the NYS DOH. In so doing, the COE connects PYD research to public health practice. Modeling a basic tenet of PYD that adults need to partner with youth in developing programs, ACT for Youth maintains an online presence (www.actforyouth.net), as well as a linked site for and by youth with input from PYD leaders in NYS DOH (www.nysyouth.net). This academic-public health-youth partnership is considered a “big picture” PYD-public health model for other states (Pittman, Martin, & Yohalem, 2006).

ACT for Youth: ACT for Youth is grounded in principles and practical issues detailed in the National Research Council/Institute of Medicine’s monograph Community Programs to Promote Youth Development (National Research Council and Institute of Medicine, 2002), and the subsequent Youth Development Handbook: Coming of Age in American Communities, edited by ACT for Youth leaders (Hamilton & Hamilton, 2004). It is one of the first sustained statewide PYD initiatives framed as a public health intervention (Birkhead, Riser, Mesler, Tallon, & Klein, 2006) in which social policy is translated into adolescent public health practice (Kreipe, 2006). Several features of ACT for Youth are notable: a formal Youth Development Team (YDT is a public-private, statewide partnership of leading agencies) providing early leadership grounded in a common, holistic vision (Carter et al., 2006); an emphasis on meaningful “youth engagement” (Schulman, 2006); policy-level support for PYD assuring that all youth-oriented programs funded by NYS have an evidence-based PYD orientation (Riser, Mesler, Tallon, & Birhhead, 2006); a long-standing mutually supportive relationship among the COE, NYS DOH and AIDS Institute, and communities; and a commitment to applying cutting-edge research to practice in the field.

NYS Youth Development Team: The vision of the YDT is for families, schools, and communities to partner in support of the development of healthy, capable, and caring youth. In the spirit of the WHO definition of health, the ultimate outcome is for young people to become healthy, caring, competent, and contributing adults, fully prepared to be parents, workers, leaders, entrepreneurs, and citizens of the future (Carter et al., 2006). Because transforming this vision into statewide practice requires committed actions (policy, funding, and training) at both the state and community levels, meeting this goal requires key stakeholders at all levels to address positive youth health outcomes through effective partnerships. Challenges to the process include ongoing consistent leadership, adequate resources to sustain efforts, marketing strategies, engaging ever-changing membership, buy-in and ownership of PYD, long-term integration of PYD into the fabric of organizations and agencies, positive local involvement, and maintaining collaborations with PYD a high priority for all stakeholders (Carter et al., 2006). Key elements and lessons learned from the first 5 years of the YDT guiding ACT for Youth (Carter et al., 2006) are adapted and detailed in Box 4.

Box 4 Key Elements and Lesson Learned from Statewide PYD Partnerships (Carter et al., 2006)

• Shared vision and leadership modeling PYD principles

• Common goals, definitions, and language unifying all activities

• Broad range of strategic partnerships, with authentic buy-in and minimal hierarchal structure

• Nonexclusive, diverse group of stakeholders who are also decision-makers

• Sustained commitment to PYD at all levels, requiring new connections, linkages, and resources

• Adaptability to approaches while maintaining fidelity to evidence-based public health models

• Partners recognize the relevance of PYD to their organization as well as the “big picture”

• PYD institutionalized at all levels as an evidence-based effective public health intervention

Youth Engagement: An essential, but often overlooked, element of PYD is the active engagement of youth by adults. As noted by Schulman—herself an adolescent when she authored an article on the concept—the terms “youth voice,” “participation,” “partnerships,” and “engagement” are often used interchangeably, but the underlying concepts are hierarchical (Schulman, 2006). Obtaining youth voice represents the lowest level of PYD interaction: the opinions of youth are sought, often after decisions have been made by adults, so that youth are asked to choose among a few preconceived ideas with little reciprocity. When youth are more valued as team members and become more actively involved in PYD, participation occurs as youth allocate their time and energy to community, school, and family activities (Schulman, 2006). As reciprocity deepens, participation transforms into partnerships when consistent, mutual relationships between youth and adults are formed, and values and power are shared. Engagement, the ultimate level of involvement, occurs when youth-adult partnerships feature a belief in, and commitment to, mutually meaningful, collective action, emanating from shared feelings of passion, excitement, and focus (Schulman, 2006).

A study of the outcomes of ACT for Youth related to youth participation concluded that (1) the Collaborations for Community Change modeled effective youth engagement, and through those efforts, youth participation was both visible and became a community-wide expectation. The voices of youth were reflected in local policy and programmatic agendas; (2) as youth participation became a visible norm in communities, ACT for Youth supported organizations creating youth engagement opportunities in community health; and (3) ACT for Youth built the capacity of adults (community leaders, practitioners, and citizens) to partner with local youth. By providing training, technical assistance, and logistical support, the collaborations helped communities involve youth in community planning and implementation of initiatives (Zeldin, Petrokubi, Collura, Camino, & Skolaski, 2009).

ACT for Youth: A Statewide Approach to Effect Community Change

An important and active public-private partnership bridging many sectors, the NYS YDT was created in 1998 by the NYS DOH and the NYS Office of Children and Family Services to promote PYD principles and strategies throughout health, human service, education, and other sectors across NYS. Within the NYS DOH, the Center for Community Health’s Bureau of Child and Adolescent Health and the AIDS Institute’s Bureau of Special Populations joined together to promote PYD in communities throughout NYS by supporting ACT for Youth with public health funds from a variety of federal and state sources (Riser et al., 2006). Redirecting these funds, all of which targeted ACT for Youth goals, into a single stream focused on PYD resulted in highly leveraged, efficient, and effective use of resources.

By bringing together partners who might not otherwise collaborate—but who experienced synergies in working together for a common adolescent health goal—ACT for Youth modeled PYD principles at the level of state government. That is, the NYS DOH provided services, opportunities, and supports emphasizing (1) positive outcomes, (2) individual development, (3) youth engagement with strategies aimed to involve all youth, (4) long-term commitment, (5) community involvement, and (6) collaboration (Whitlock, 2011). The sustained commitment to PYD by the NYS DOH has been demonstrated for more than 11 years in statewide policy and program development, supported by funding and other resources. The NYS DOH compiled guidelines for integrating PYD into Health Department Programs, outlined in Box 5 (Whitlock, 2011).

Box 5 Guidelines to Integrate PYD into Health Department Programs (Whitlock, 2011)

• Base program goals on a PYD approach

• Assure that everyone involved has a core knowledge base about PYD

• Offer practical assistance in putting the principles of PYD into action

• Promote PYD through funding decisions

• Encourage programs to offer meaningful opportunities and roles for young people

• Facilitate opportunities for programs to share successful strategies

• Integrate YD into prevention programs with the support of academic and research institutions

• Include YD outcomes in program evaluation activities

Trusting, Long-Standing, Mutual Relationships: An important element of ACT for Youth has been the commitment of resources, policies, and programs to PYD, as well as the presence of strong cross-sector relationships at the leadership level for more than a decade. The NYS DOH Adolescent Health Coordinator (also a leader at the Bureau of Child and Adolescent Health) in collaboration with the Director of the ACT for Youth COE (a developmental psychologist and social scientist based at Cornell University) and the Directors of the other partner organizations in the COE (the Division of Adolescent Medicine at the University of Rochester, the NYS Center for School Safety, and the Cornell Cooperative Extension of New York City) have developed trusting, mutual relationships that model the core elements of PYD programming. Having the same individuals lead this effort over time has required creative responses to challenges, such as three changes in NYS administration and two economic downturns. However, responding successfully to challenges with a commitment to disseminating and diffusing messages regarding PYD in a variety of ways (e.g., online messaging, webinars, publications, conferences, and trainings) has led to continued integration of PYD into statewide youth services, programming, policy, and funding, with national public health implications (Healthy, 2020a).

Commitment to Translating Research into Practice: Public health practice needs to be grounded by models with demonstrated effectiveness. Such evidence-based models are not stagnant, but require ongoing adaptations that maintain fidelity with the core features of a model. This translation is sometimes difficult for youth-serving agencies in the field that might be more action oriented than science driven. Early in ACT for Youth, a community group asked the COE for a program that could be taken “off the shelf and put to use.” The COE response was a quote from Bronfenbrenner (who coined the term human ecology): “the purpose of social science is not to answer questions, but to question answers.”

Academic partners at Cornell University and the University of Rochester, as well as leaders at NYS DOH, are guided by the scientific evidence base for PYD as they work with community groups focused on PYD public health interventions in real-world settings across the state. The resulting practical implementation of evidence-based models with fidelity in communities is evaluated by the academic partners focused on the same goals. Thus, ACT for Youth has included the creation of a PYD outcome tool for youth (Sabaratnam & Klein, 2006), the evaluation of community partnerships themselves (Surko, Lawson, Gaffney, Claiborne, 2006), and youth in participatory research and evaluation (Powers & Tiffany, 2006). The strength of these horizontal, cross-sector, practice-oriented partnerships informed by research regarding best-practices may explain the success of ACT for Youth as a public health approach (Zeldin et al., 2009).

Summary

The USPHS was founded more than 200 years ago largely to address the diseases and illnesses of adolescent seaman. Over the subsequent years, increasing public health attention in America was directed at the promotion of health and wellness, beyond the treatment or prevention of disease or illness. Worldwide there has also been increasing public health attention to adolescents, with the recognition of the tremendous burden borne by societies for adolescent morbidity and mortality—largely related to behaviors and therefore theoretically preventable. Due to the limited success of campaigns targeted at specific conditions, PYD has gained traction as a public health approach to adolescent issues. By combining an emphasis on positive features of youth within a developmental framework, the provision of what youth need to thrive, the involvement of broad-based coalitions of key stakeholders, and the active engagement of youth as partners in the process rather than mere recipients, this public health approach holds great promise, as noted previously (Whitlock, 2011) and in Healthy People 2020 (Healthy People, 2011a, 2011b). Continued research is needed to determine the elements of success in a variety of applications.