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Promoting Positive Adolescent Health and Well-Being, Thriving in the 21st Century: Implications for Research, Programs, and Policies

      Adolescence is an important and exciting period for young people to develop skills and gain experiences that help prepare them for a healthy and productive adulthood. Adolescents are also deeply impacted by their social, physical, and global milieus, and the mixed messages they often receive [
      National Academies of Sciences, Engineering, and Medicine
      Promoting positive adolescent health behaviors and outcomes: Thriving in the 21st century.
      ]. Although most adolescents transition through this period with little difficulty, some require additional support from prevention and intervention programs designed to promote healthy behaviors and outcomes. However, little is known about which specific program characteristic or “active ingredients” are actually making the difference. If we could identify these specific core components, we may be able to create and replicate effective adolescent health promotion programs that are also more accessible to diverse populations. Accordingly, the recent report published by the National Academies of Sciences, Engineering, and Medicine, Promoting Positive Adolescent Health Behaviors and Outcomes: Thriving in the 21st Century [
      National Academies of Sciences, Engineering, and Medicine
      Promoting positive adolescent health behaviors and outcomes: Thriving in the 21st century.
      ], aims to identify these core program and intervention components that are effective in improving adolescents' health behaviors and outcomes. The report also makes recommendations for future research, programs, and policies focused on optimal adolescent health.
      Based on the committee's charge to use an “optimal health lens” and the available literature, we used O'Donnell's definition of optimal health [
      • O'Donnell M.P.
      Definition of health promotion 2.0: Embracing passion, enhancing motivation, recognizing dynamic balance, and creating opportunities.
      ,
      • O'Donnell M.P.
      Definition of health promotion.
      ] that describes a “dynamic balance of physical, emotional, social, spiritual, and intellectual health.” This framework stresses the important influences of the physical and social environments, which for adolescents include peers, parents, schools, communities, society, and media. These influences and other social determinants such as poverty and discrimination can reduce or increase the likelihood of an adolescent engaging in unhealthy risk behaviors and/or having negative health outcomes.
      Unfortunately, the committee's review of adolescent health programs and interventions showed that few specifically evaluate the effectiveness of core program components. Nevertheless, several themes were extracted from the committee's review. Specifically, some effective programs use social-emotional learning and positive youth development approaches from childhood throughout adolescence. Rather than focusing on a specific risk behavior or health outcome, these effective programs build skills such as understanding and addressing social norms and helping youth develop negotiation and refusal skills that can apply more generally to optimal health and serve as a foundation upon which other specific behavioral skills and services can be built. Furthermore, programs that address social determinants of health and involve diverse youth, families, and communities are most effective at reducing health disparities.
      The committee presented three recommendations for research and programs. First, the committee suggested additional funding for research that identifies, measures, and evaluates the effectiveness of core components [
      • Blase K.
      • Fixsen D.
      Core intervention components: Identifying and operationalizing what makes programs work.
      ]. Too often adolescent programs are implemented and disseminated without regard to what works or are essential. Such research is sorely needed to inform the development and proliferation of effective programs and to inform funding priorities [
      U.S. Department of Health and Human Services
      NIH stage model for behavioral intervention development.
      ].
      Second, the report calls for updates to and expansion of the Centers for Disease Control and Prevention biennial Youth Risk Behavior Survey (YRBS), a nationally representative sample of in-school youth who are surveyed about their health behaviors [
      Centers for Disease Control and Prevention
      Youth Risk Behavior Surveillance System (YRBSS) overview. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Adolescent and School Health.
      ]. Although widely used to monitor risk behavior among youth, the YRBS does not obtain comprehensive information generalizable to all youth and all behaviors. As such, the report recommends that the YRBS be expanded to include out-of-school youth (e.g., youth who dropped out of school, homeless, and incarcerated youth), consider different and electronic modalities in which to survey a wider net of youth, and that additional items focusing on sexual risk behaviors (e.g., diverse sexual activity) with definitions be included.
      Finally, the report recommended that the Office of the Assistant Secretary for Health within the Department of Health and Human Services funds holistic, theory- and evidence-based, population-wide adolescent health programs that engage diverse communities. These programs should recognize that adolescent risk behavior is normative.
      The committee also noted two important and promising approaches that should be considered to best support optimal adolescent health. First, programs and policies need to promote inclusiveness and equity so that all adolescents are able to thrive. Critical to this approach outlined by the committee is that programs and policies need to address structural inequities including racism, sexism, classism, ableism, xenophobia, antisemitism, homophobia, and other forms of discrimination that lead to health inequities [
      National Academies of Sciences, Engineering, and Medicine
      Communities in action: Pathways to health equity.
      ]. When programs and policies are exclusive, inequitable, or discriminatory, they often lead to worse overall outcomes for adolescents, outcomes that are unjust and preventable [
      National Academies of Sciences, Engineering, and Medicine
      Communities in action: Pathways to health equity.
      ]. We believe to truly benefit from the inclusion of diverse populations and diverse perspectives, it is not enough to just have representation. All engaged must have an equitable share in the development and implementation of programs and policies.
      Second, research, programs, and policies can benefit from including youth of diverse ages, racial/ethnic backgrounds, socioeconomic status, rurality/urbanicity, sexual orientations, sexes/genders, and disability/ability status as active participants in their development, implementation, and evaluation. This concept is central to the slogan, “Nothing About Us Without Us!” which has been used to reinforce the philosophy that no policy should be decided by any representative without the full and direct participation of members of the group(s) affected by that policy. This slogan became popular initially through disability activism but has also been determined to be essential in the development of adolescent health programs and policy development [
      • Patton G.C.
      • Sawyer S.M.
      • Santelli J.S.
      • et al.
      Our future: A Lancet commission on adolescent health and wellbeing.
      ]. Adolescents are our future, and when meaningfully engaged, they have much to contribute. A teen present at the committee's public information-gathering session said it well, “And for me, what I think a thriving person in 2019 is when you're physically, mentally, and emotionally stable. I feel like you accept yourself for who you are and you're around people that support you emotionally and you can in return give that support back” [
      National Academies of Sciences, Engineering, and Medicine
      Promoting positive adolescent health behaviors and outcomes: Thriving in the 21st century.
      ].
      How can adolescent health care providers, scientists, policy makers, and others use the optimal health framework and needs identified in this report to help all adolescents thrive in the complex 21st century? Taking the core components approach outlined in the report may help us determine not only which characteristics of programs may improve an array of adolescent health behaviors and outcomes but also what components result in greater inclusiveness, equity, and authentic engagement of adolescents. Adolescent health is a multidisciplinary field that includes providers, public health professionals, researchers, policy makers, and others, all of whom have traditionally understood the importance of promoting meaningful inclusiveness and equity and the authentic engagement of adolescents [
      Society for Adolescent Health and Medicine
      Promoting equity and reducing health disparities among racially/ethnically diverse adolescents: A position paper of the Society for Adolescent Health and Medicine.
      ,
      Society for Adolescent Health and Medicine
      Racism and its harmful effects on nondominant racial-ethnic youth and youth-serving providers: A call to action for organizational change. A position paper of the Society for Adolescent Health and Medicine.
      ]. We should, therefore, continue to be engaged in implementing, evaluating, and disseminating policies, programs, and practices that address structural inequities such as racism and sexism and promote inclusiveness, equity, and youth engagement to show that these promising approaches are, indeed, evidence based.

      References

        • National Academies of Sciences, Engineering, and Medicine
        Promoting positive adolescent health behaviors and outcomes: Thriving in the 21st century.
        The National Academies Press, Washington, DC2020
        • O'Donnell M.P.
        Definition of health promotion 2.0: Embracing passion, enhancing motivation, recognizing dynamic balance, and creating opportunities.
        Am J Health Promot. 2009; 24: iv
        • O'Donnell M.P.
        Definition of health promotion.
        Am J Health Promot. 1986; 1: 4-5
        • Blase K.
        • Fixsen D.
        Core intervention components: Identifying and operationalizing what makes programs work.
        U.S. Department of Health and Human Services, Office of Human Services Policy, Office of the Assistant Secretary for Planning and Evaluation, Washington, DC2013
        • U.S. Department of Health and Human Services
        NIH stage model for behavioral intervention development.
        (Available at:)
        • Centers for Disease Control and Prevention
        Youth Risk Behavior Surveillance System (YRBSS) overview. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Division of Adolescent and School Health.
        (Available at:)
        • National Academies of Sciences, Engineering, and Medicine
        Communities in action: Pathways to health equity.
        The National Academies Press, Washington, DC2017
        • Patton G.C.
        • Sawyer S.M.
        • Santelli J.S.
        • et al.
        Our future: A Lancet commission on adolescent health and wellbeing.
        Lancet. 2016; 387: 2423-2478
        • Society for Adolescent Health and Medicine
        Promoting equity and reducing health disparities among racially/ethnically diverse adolescents: A position paper of the Society for Adolescent Health and Medicine.
        J Adolesc Health. 2013; 52: 804-807
        • Society for Adolescent Health and Medicine
        Racism and its harmful effects on nondominant racial-ethnic youth and youth-serving providers: A call to action for organizational change. A position paper of the Society for Adolescent Health and Medicine.
        J Adolesc Health. 2018; 63: 257-261