A Midcourse Review of the Healthy People 2010: 21 Critical Health Objectives for Adolescents and Young Adults

Findings from the Midcourse Review 

In 2007, Healthy People 2010 data sources were assessed to measure progress on the 21 Critical Health Objectives, as part of the overall Healthy People 2010 midcourse review [5]. This review offers a useful snapshot of trends in key areas of adolescent health. Although notable progress has been made in a few areas, most others either show minor improvement or are falling further from the 2010 target (Table 1).

Implications for adolescent health policy 

This review points to the need for increased efforts on behalf of adolescents and young adults. Identifying national priority objectives is a first step in creating policy to improve adolescent health. These objectives can guide public and private agencies in prioritizing resources allocation. However, there is no federal infrastructure in place with specific responsibility or authority to improve adolescent health across all of the 21 CHO outcome areas. Indeed, it is difficult to identify basic information about the many existing, often single-issue, youth-focused programs scattered across the federal government [7], [8]. Young adults, who fare worse on most traditional indicators of adolescent health, have received even less focus at the national level [9].

The limited national support for adolescent health is not for lack of expert policy recommendations. Numerous adolescent health policy reports, consensus statements, research syntheses, and position statements offer recommendations for improving adolescent health[3], [10], [11], [12], [13] Recommendations come from developmental perspectives (e.g., policies should promote healthy function and development, as well as prevent and treat problems) and ecological approaches that emphasize the need to engage diverse sectors and use multilevel strategies, rather than rely solely on individual-level interventions to change behavior. Recommendations also advocate for population-based policies rather than categorical approaches that focus on specific health issues. As with U.S. health policy generally, adolescent health has been approached categorically: infrastructure and funding streams focus largely on specific issues, such as teen pregnancy or substance use [14], [15].

Factors underlying the U.S. political process pose challenges to translating these comprehensive recommendations into policy. Political change happens incrementally. The separation of powers and many interest groups make a piecemeal approach the national norm. The patchwork of federal, state, and local jurisdiction over various policies affecting health also impedes sweeping, comprehensive reform [16], although this dynamic has also fostered state and local initiatives that have influenced national policy. Although a large literature shows that health problems disproportionately affect people of lower socioeconomic status, including adolescents [17], the poor in the U.S. have little political power to advocate for policies to improve their well-being, relative to the poor in most other industrialized countries [18]. As a result, health issues touching middle class activists are often more likely receive policy attention [18], contributing to the nation’s categorical approach to health policy.

Despite these obstacles, there have been several significant public health successes in the past several decades, including some that benefit adolescents specifically. Schroeder and Isaacs [19] identified factors common to these successes, including highly credible scientific evidence, dedicated advocates/champions, public media campaigns, and effective laws and regulations. Reflecting factors discussed above, successes have occurred for specific issues, rather than populations. Single-issue approaches have become increasingly comprehensive, involving many sectors and addressing many levels of influence.

Efforts to reduce tobacco use among all Americans illustrate a comprehensive approach, as well as the importance of dedicated champions and overwhelming evidence on the harmful effects of tobacco. Tobacco use has declined dramatically in the United States since the 1960s [20]. Indeed, this is one of the few critical health objectives showing an encouraging trend. In addition to educating the public on the dangers of tobacco, legislative and regulatory initiatives include imposing excise taxes, promoting smoking cessation programs, reducing exposure to advertising, and banning smoking in many public spaces [20]. Local and state leadership played a key role in undertaking policy change [18], [19]. Recognizing the early age of tobacco addiction, many initiatives aim to prevent smoking initiation in adolescence, for example, through health education programs and restrictions on tobacco advertising in youth-oriented media [20]. Adolescents have clearly benefited from the societal commitment to reducing tobacco use, suggesting that single issue, society-wide interventions can improve adolescent outcomes for at least some of the key areas addressed by the critical health objectives.

Progress in the area of motor vehicle injury shows that state and local initiatives can have considerable influence. Grass roots movements, such as Mothers against Drunk Driving and Students against Drunk Driving, helped change public attitudes and fuel significant changes in state and national policies to deter drunk driving among drivers of all ages [19]. Policies focusing on minors have led to reductions in crash fatalities. These include “zero alcohol tolerance” laws that make it illegal for those under age 21 to drive with any measurable amount of alcohol in their blood [21], and state graduated drivers’ license (GDL) programs, which phase in driving privileges such as night-time driving and driving with multiple passengers [22]. The two CHOs for motor vehicle fatalities have not improved because these objectives include young adults, but the rate has decreased for 16-year-olds, who are subject to GDL programs [22]. In addition to public health and safety advocates, the insurance industry has also supported states’ efforts to enact GDL programs [23], [24].

In addition to political factors discussed above, those engaged in efforts to reduce adolescent pregnancy must contend with conflicting views of privacy, parental rights, and civil rights [16] as they pertain to the charged topic of adolescent sexual activity. Despite the often polarized national discourse, the adolescent pregnancy rate decreased 34%, the largest salutory change of any of the 21 CHOs. A recent analysis by Santelli et al. [25] argues that the decline is mostly attributable to improved contraceptive use, rather than decreases in sexual activity. Evaluation research to date has not demonstrated the federal “abstinence-only unless married” programs to be effective [26]. In the absence of effective national policy, it is logical to examine state policy, bearing in mind the many cultural and social influences on sexual and contraceptive behavior [27], [28]. Although careful not to infer causality, a report from the National Campaign to Prevent Teen Pregnancy highlighted initiatives in three states whose declines in teen pregnancy exceeded the 13% national decline from 1996 to 2002. In these states, initiatives enjoyed strong support from state governors, and used multilevel and multisectoral approaches. In California, which experienced a 21% decline, efforts included a media campaign, school-based education, statewide support for several types of community-based programs (e.g., siblings and male-involvement programs), and increased access to clinical services through Family Pact [29], the family planning initiative of the state’s Medicaid program [30]. This multifaceted approach has been sustained for over a decade by governors and state legislators of different parties.

Many in the adolescent health field advocate for a population-based approach. However, change in U.S. health policy typically occurs in specific areas, when a combination of factors comes together to engender political will to undertake broad multisectoral and multilevel initiatives. Although many aspects of the U.S. political landscape make sweeping reforms difficult, national policy change has often resulted from state and local leadership. Political discourse on adolescent health is shaped by differing notions of how issues of individual rights apply to adolescents, who, while legally minors, engage in adult behaviors that may jeopardize their health. The challenge is to make adolescent health issues, especially those that most affect the poor, compelling to the general public.