Investing in the Health and Well-Being of Young Adults (2015)

6

Public Health

When their health, safety, and well-being are viewed from a developmental life-course perspective, young adults are at elevated risk of morbidity and mortality in a surprising variety of ways compared with adolescents and older adults. What makes this surprising is that conventional wisdom suggests young adults ought to be in peak physical condition, given that they are beyond the pitfalls of adolescence and not yet experiencing the declines of aging. The vulnerability is even greater among those of lower socioeconomic position and from racial and ethnic minorities, who are exposed to greater risks and dangers than their more advantaged peers and lack safety nets to protect them (NIHCM, 2007). Policy makers and practitioners have recognized that the health, safety, and well-being of adolescents can be enhanced—during adolescence and thereafter—by basing policy and practice on an integrated understanding of this distinct period of development. A key conclusion of this report is that the health, safety, and well-being of young adults can similarly benefit from bringing a life-course perspective to bear on public health policies and programs and on the delivery of health care.

As chronic health conditions become the key health challenge for the 21st century, community-based prevention efforts will increasingly become an important focus for both the public health and health care delivery systems. It is important to recognize the mutually reinforcing connection between effective population-level and individual-level interventions. At the same time needs for treatment are reduced through prevention, public health activities can help increase the effectiveness of health interventions. In fact, Milstein and colleagues (2011) estimate that if protective public health interventions were integrated with coverage and care approaches, in 10 years they could save 90 percent more lives in the United States and in 25 years 140 percent more lives than could be saved through coverage and care approaches without such interventions (Milstein et al., 2011).

This chapter addresses policies and programs undertaken by the public health system (public agencies and their partners at the national, state, and community levels) aimed at reducing the incidence and prevalence of disease and injury among young adults. The next chapter addresses the

delivery of health care services for young adults, including both preventive services and treatment delivered by primary care physicians and other health care providers. The chapter begins with a brief overview of public health perspectives and activities. After highlighting the public health issues associated with young adulthood, we then review the literature on the effectiveness of public health initiatives, particularly those targeting health and safety problems with elevated prevalence among young adults, and summarize features of public health interventions that have been successful in reducing the risk of morbidity and mortality among young adults. Next we give special attention to the potentially pivotal role of mobile digital media and social networking as vehicles for public health interventions. We then turn to the role of public health policies, such as those related to the purchase of alcohol and tobacco, in protecting the health, safety, and well-being of young adults. In the next section, we look at the extent to which state and federal public health programs focus on those issues most salient to young adults, and on how these programs can be improved and better coordinated to best address these issues. The final section presents conclusions and recommendations.

OVERVIEW OF PUBLIC HEALTH PERSPECTIVES AND ACTIVITIES

The mission of public health has been defined as “organized community efforts aimed at the prevention of disease and promotion of health. It links many disciplines and rests upon the scientific core of epidemiology” (IOM, 1988, p. 41). Figure 6-1 shows how the different sectors involved, while acting individually, also work together as a public health system in pursuing health goals. Moreover, contemporary public health activities are grounded in an ecological approach that takes account of cross-level influences on individual health behaviors and conditions, including the natural, social, and built environments and the contributions of other government agencies or sectors—such as transportation, environment, economic development, and education—that influence population health (IOM, 2011, 2012b; Sallis et al., 2008). Similarly, public health interventions encompass a wide array of policies and programs, ranging from tax policies to media campaigns.

Although broad action on multiple determinants involving diverse public and private actors is needed to achieve the greatest effects on population health, the governmental public health infrastructure serves an essential coordinating role and, in many contexts, service delivery and regulatory roles (IOM, 2011). In the context of ensuring the health, safety, and well-being of young adults, we focus here on the 10 essential activities of state and local public health agencies listed in Box 6-1, which have become widely accepted in the field (IOM, 2011).

FIGURE 6-1 The intersectoral public health system.
SOURCE: IOM, 2011.

The leadership role of public health agencies should not be regarded as synonymous with a directive role. When public health was focused primarily on infectious disease control, its activities often were based on coercive legal authority. However, as the scope of public health has broadened to include preventing chronic disease, promoting healthy communities, and reducing or even eliminating health disparities, collaborative and facilitative approaches have become predominant. Greater attention is being paid to mobilizing and engaging important stakeholders, including community-based organizations, in promoting public health. This multisectoral approach is based on the premise that local agencies and organizations have a better understanding of the local context in which public problems can be studied and solutions can be developed, executed, and sustained (Israel et al., 2008; Minkler and Wallerstein, 2008; Ramanadhan et al., 2012).

It must be noted that the list of essential public health services today would also include ensuring equity within and across different population groups. Despite tremendous investments in research, planning, and deployment of public health strategies and their success, it has become clear that the benefits of these programs are accruing unequally across socioeconomic and racial/ethnic groups (Spalter-Roth et al., 2005). The challenge of erasing persistent health disparities has been the subject of extensive attention in recent years (IOM, 2002, 2012c), and the contributing social and individual factors are now better understood. These factors—which include social class, race and ethnicity, social and economic policies, racism, geography, housing, and communication inequalities, among many others—appear to explain why certain groups experience greater adversity due to risk conditions and also are often unable to take advantage of programs and policies that should ameliorate such conditions (IOM, 2011). A great deal of this work has focused on either childhood poverty or the experience of adults, with much less attention to young adults. But it is clear that any efforts to address health disparities will have to account for the experience of this important age group, as the effects they experience are likely to last for several decades.

PRIORITY PUBLIC HEALTH ISSUES FOR YOUNG ADULTS

Some recent reviews of young adult health have pointed to encouraging trends, such as decreases in rates of suicide, gonorrhea, and cigarette use¹ (Mulye et al., 2009; Park et al., 2006, 2014). However, the mortality rate for young adults aged 20-24 is 93.5 per 100,000, compared with

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¹ Although use of cigarettes is declining, the use of other tobacco products, such as electronic cigarettes, may be increasing (King et al., 2013).

60.8 among older adolescents (aged 15-19) and 17.4 among younger adolescents (aged 10-14), showing a substantial increase with age (CDC, 2014a). Young adults are at greater risk for short- and long-term impacts on health and have worse health outcomes than adolescents in many areas (Park et al., 2014). Overall, as compared with other age groups, young adults have the highest rate of death and injury from motor vehicles, homicides, mental health problems, sexually transmitted infections (STIs), and substance abuse (Neinstein, 2013). Yet in general, most of the leading causes of illness and death among young adults are largely preventable (Mulye et al., 2009).

Important developmental changes occurring during young adulthood can promote or compromise health and well-being (Harris et al., 2006; Mulye et al., 2009; Neinstein, 2013). Most young adults are transitioning from direct parental supervision to living on their own, which can create a period of vulnerability to unsafe and unhealthy behaviors. Many young adults need help coping with stressful circumstances in school or on the job, and a significant subset are at risk of experiencing acute emotional distress and the onset of major mental disorders (Garcia, 2010). These conditions can, in turn, impact education and workplace achievement in the short term as well as throughout life. There are also profound health and well-being consequences for young adults who have children (as discussed in Chapter 3). Moroever, risk-taking behaviors associated with morbidity and mortality across the life span tend to emerge or peak during young adulthood, with important immediate and long-term health consequences (Park et al., 2006, 2014). For example, use of tobacco and low levels of fitness and poor nutrition increase the probability of developing diseases such as cardiovascular and pulmonary disease and cancer later in life (Santelli et al., 2013). The collective impact of these problems is noticeable at the public health level, where little change in risky behavior has occurred over the past decade. And while in some ways, young adults appear relatively healthy, many public health concerns for young adults remain inadequately and ineffectively unaddressed (Park et al., 2006, 2014).

For the past 30 years, Healthy People has set the national objectives for improving public health. Healthy People 2020 focuses more on adolescents and young adults as compared with previous decades (Koh et al.,

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^* Quotations are from members of the young adult advisory group during their discussions with the committee.

2011). Based on guidance from national experts, Healthy People 2020 identifies 41 “core indicators for adolescent and young adult health,” which concentrate on individual outcomes, as well as systems that influence health for these populations.² The indicators span seven domains: health care (health insurance coverage, well care, immunizations), healthy development (adult connection, graduation, sleep, transition planning³), injury/violence prevention (motor vehicle crashes, riding with a drinking driver, graduated driver licensing laws, homicide, exposure to violence, physical fighting), mental health (suicide rate and attempts, depression, treatment), substance abuse (marijuana use, binge drinking, treatment), sexual and reproductive health (pregnancy prevention, STIs, HIV, reproductive health services), and prevention of chronic disease (oral health, hearing, obesity, physical activity, tobacco) (HHS, 2012a). Although all of the indicators are important for the health, safety, and well-being of young adults, this chapter focuses on an illustrative selection of public health challenges that are related most specifically to the health, safety, and long-term well-being of young adults and that pose substantial public health burdens—motor vehicle injuries; homicide and nonfatal assaultive injuries; sexual assault and intimate partner violence; mental health disorders and suicide; substance abuse; sexual and reproductive health; and chronic disease prevention, including decreasing obesity, reducing tobacco use, and increasing immunizations. Box 6-2 presents key findings on the public health challenges for young adults.

In addition, race, ethnicity, sex, sexual identity, age, disability, education, socioeconomic position, and geographic location all are associated with the health and safety of young adults (Mulye et al., 2009). Among both adolescents and young adults, certain populations have higher rates of risky behaviors, such as unhealthy eating, lack of physical activity, unprotected sexual activity, substance use, and unsafe driving (Park et al., 2014). Some examples are presented in Box 6-3. Major gender differences exist, as well as considerable ethnic and racial disparities, with non-Hispanic black and American Indian/Alaska Native young adults faring worse in many areas (Park et al., 2014). As Box 6-3 shows, many statistics are worse for certain populations than for others, but it is important to note that the differences go both ways. For instance, black males have a higher homicide rate than white males in this age group (100.3 versus 11.4 homicides per 100,000), but the reverse is true for the use of marijuana between early adolescence and young adulthood (Chen and Jacobson, 2012; Smith and Cooper, 2013).

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² See http://www.healthypeople.gov/2020/learn/Draft_Core_Indicators_Web.pdf (accessed October 22, 2014) for a full list of indicators.

³ Transition planning refers to individuals with special health care needs whose health care provider has discussed transition planning from pediatric to adult health care.

PUBLIC HEALTH INTERVENTIONS FOR YOUNG ADULTS

Public health interventions include a broad array of activities, such as informing or educating the targeted population about risks, persuading them to reduce risk, creating incentives or disincentives to encourage them to adopt healthy or safe behaviors, and modifying the environment to reduce exposure to risks or to promote or facilitate safe or healthy behaviors. Exposures include not only environmental toxins and dangerous products but also adverse social experiences, such as racism, violence, and social threats or health risks resulting from poor living and working con-

ditions. To the extent that individual behaviors play a causal role, recent public health approaches go beyond changing those behaviors to focus on mobilizing and engaging different sectors to create an environment that facilitates and sustains behavior change, as well as on changing public health practice and policies. These interventions can target the whole population of a community or specific subpopulations thought to be at elevated risk. They can be deployed separately or used in combination, creating synergy. Tools may also include legal requirements or prohibitions. All of these approaches have been used, with varying degrees of success, to address the

significant problems identified above that threaten the health, safety, and well-being of young adults, although previously, the focus was primarily on changing individual behavior rather than altering the broader context and environment.

When a multilayer approach is implemented—for example, to reduce the incidence of unsafe driving due to either alcohol use or distracted driving—the likelihood of success is greater (Park et al., 2006). The ecological model or approach assumes that individual behaviors are products of influence at multiple levels, including intrapersonal, interpersonal, organizational, community/built environment, and public policy (Bronfenbrenner, 1979; Sallis et al., 2008). Moreover, a critical assumption is that behaviors are outcomes stemming from interactions across levels and that the context in which behaviors occur can exert significant influence on individuals (Bronfenbrenner, 1979; Sallis et al., 2008). With respect to risky behaviors, for instance, young adults working in the construction industry are likely to be socialized to a different set of norms and practices than those attending 4-year colleges. As an example, the greater use of tobacco among blue-collar workers may be attributable to a lack of knowledge and social supports at the individual level and perhaps to fewer restrictions on smoking in the workplace (Sorensen et al., 2004). Ecological approaches draw on a variety of theories and are robust when applied to specific behaviors. While these approaches have been used for some time, rigorous research has just begun to explore the mechanisms explaining the outcomes of multilevel interventions. In this section, we summarize the evidence base on public health interventions in selected priority areas to illustrate what is known.

Goals of Public Health Interventions

Promoting change in public health is a complex endeavor in terms of both the outcomes expected to result from a campaign and the context in which campaign messages are disseminated and received (Randolph and Viswanath, 2004). Health outcomes vary considerably, including changes in cognition, attitudes, beliefs, affect, salience, preferences, behavioral intentions, and behaviors at the individual level. A campaign may focus on the initiation of new behaviors, such as beginning to eat healthfully or engaging in physical activity (Snyder et al., 2004). In the case of risky behaviors, such as unsafe sex and use of tobacco, alcohol, or illicit drugs, one goal is to deter initiation, but a second stage can be directed at those who may not have been deterred or preventing relapse in the case of tobacco or drug use. Other campaigns may reinforce positive health messages, promoting maintenance, whether of healthy eating or physical activity (Atkin and Rice, 2012). The temporality of campaign effects is another critical consideration, ranging from short-term effects (e.g., influenza vaccination) to longer-term

effects, such as maintaining healthy lifestyles in youth, the effects of which may last well into adulthood (Marcus et al., 2006). The idea of deferring immediate rewards to reap future well-being, such as by stopping smoking in youth to protect oneself from cardiovascular diseases or cancer in adulthood, is a challenging message to communicate, particularly to adolescents and young adults (Hoek et al., 2013). Finally, aside from the effects of an intervention on individual behavior, public health campaigns may aim to shape social norms and to promote, advocate, and instill changes at the institutional and community levels (Holder and Treno, 1997; Hornik, 2002; Hornik and Yanovitzky, 2003; Viswanath and Finnegan, 2002).

In the following sections, we briefly review public health campaigns and other interventions in some of the priority areas discussed earlier.⁴ We then offer a distillation of lessons learned from these campaigns.

Tobacco Use

Using tobacco can cause cancer and heart and lung disease and can affect fetal well-being (Viswanath et al., 2010b). Tobacco use is estimated to cost 480,000 lives per year as a result of cancer in at least 18 different organ sites and other chronic diseases, such as cardiovascular and chronic obstructive pulmonary diseases (HHS, 2014c; Viswanath et al., 2010b), yet it is one of the most preventable causes of mortality and disease in the United States. Not surprisingly, public health interventions attempting to dissuade people from initiating tobacco use, as well as promoting cessation among users, have received considerable attention.

Tobacco control interventions are an outstanding example of multilevel approaches whereby interventions at one level have been aided by interventions at other levels (NCI, 2008). At the societal and community levels,

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⁴ To review the interventions focused on young adults that are discussed, we conducted an extensive search of the literature using PubMed and a number of search terms derived from the priority areas specified in Chapter 5, including the combined terms “young adult,” and “intervention.” Additional search terms included “African American,” “Latino,” and “low income” to capture a more diverse sample. A secondary search was conducted using “young adult” and “intervention” in the Cochrane Review Database. Searches were restricted to articles published between 2009 and 2014, although reviews that included individual articles before this date were included. Other inclusion criteria were (1) reported findings of an intervention (those reporting only protocols or cost analyses were excluded); (2) inclusion of samples of healthy individuals that were not pregnant or diagnosed with cancer, diabetes, or another chronic condition; and (3) inclusion of samples of young adults aged 18-25 (articles including ages above or below this range were considered only if they were review articles or studies in which the mean age was within this range). The search was not exhaustive; reference lists were not searched for other relevant articles, and other search terms could have been used to identify additional articles. Priority was given to articles that were systematic reviews or emphasized population-level strategies.

evidence shows that comprehensive tobacco control programs, including tax increases, public smoking bans, media campaigns, youth access restrictions, and cessation programs, have reduced the prevalence and intensity of tobacco use (HHS, 2012b; IOM, 2007). At the individual level, media campaigns have focused on promoting knowledge of risks resulting from tobacco use and denormalizing tobacco use behaviors. The focus on individual behaviors is complemented by drawing attention to the deceptive practices of the tobacco industry; offering cessation supports in different institutional settings; promoting support for increased taxes on tobacco; and at the policy level, placing restrictions on marketing, advertising, and using tobacco in different localities, such as the workplace and restaurants (HHS, 2012b; IOM, 2007).

While a large body of work addresses tobacco control interventions among teens and adults (NCI, 2008), interventions focused specifically on young adults have been somewhat limited. A Cochrane review examined the impact of mass media campaigns on smoking prevention among young people (under age 25) (Brinn et al., 2012). Media were defined broadly to include television, radio, newspapers, billboards, posters, leaflets, and booklets. The review examined 7 of 84 studies that met the inclusion criteria and found that they were conducted systematically, drew on sound theories and research-informed interventions, and used extended campaigns to ensure exposure. Brinn and colleagues (2012) report modest evidence that mass media interventions could be successful in the prevention of smoking among young people. In a review of 25 studies examining the effectiveness of multicomponent interventions in reducing smoking uptake among young people, Carson and colleagues (2011) report that one intervention generally was successful in reducing smoking in the short term, and nine showed significant long-term effects. Improvements also were seen in changes in intentions to smoke (six of eight interventions), improved attitudes (five of nine), risk perceptions (two of six), and knowledge of tobacco use (three of six).

In contrast, short-term and/or single-component interventions are less likely to be successful. Villanti and colleagues (2010) conducted a systematic review of 14 studies of interventions promoting smoking cessation among young adults in the United States. The interventions focused on

young adults aged 18-24 and were conducted in multiple settings, including universities, a community college, an airforce basic training unit, a quitline, and a rural community. Interventions were delivered either through interpersonal channels, such as peer coaches, counselors, and health educators, or a computer website. The authors report limited support for the efficacy of the interventions, although brief interventions with an extended dose via telephone or electronic media were somewhat effective. Villanti and colleagues (2010) recommend using standardized measures and interventions that take the smoking trajectories among young adults into account and are conducted among diverse population groups.

The use of electronic media, such as telephone quitlines and text messaging, to promote cessation of tobacco use has drawn the attention of several researchers. The Internet and social media hold considerable promise in promoting cessation. Sims and colleagues (2013) compared the effectiveness of cessation counseling through quitlines with a group receiving only mailed self-help material. They report only short-term effects among the group receiving counseling on the telephone. On the other hand, Brown (2013) reviewed eight studies assessing the impact of technology-based interventions that included tailored texts, emails, counseling, and a discussion board on tobacco use among participants aged 18-30 and found that in at least four studies, there was significant 7-day abstinence in the intervention group.

Similarly, Skov-Ettrup and colleagues (2014) report on a randomized controlled trial involving 2,030 daily smokers aged 15-25. The intervention arm received tailored text messages on self-efficacy, beliefs about smoking, and topics chosen by the user, whereas the control group received only generic messages. While there were no significant differences between the two groups in self-reported cessation, the researchers report higher rates of quitting among those in the tailored messaging group who used the text messages. That is, when the participants actually used the messages, the desired effects were much more likely to occur.

This review highlights four points when it comes to tobacco control interventions among young adults. First, comprehensive tobacco control strategies have had a demonstrable effect in reducing the prevalence and intensity of consumption at the population level (HHS, 2012b; IOM, 2007). Second, more focus is needed on developing and testing effective interventions targeting young adults, especially at a time when new tobacco products are being introduced at a rapid pace. Third, most of the interventions appear to have been carried out in colleges or white collar settings, and more effort needs to be made to include population groups of diverse racial, ethnic, and socioeconomic backgrounds. Last, the new information and communication technologies hold considerable promise in promoting tobacco control, but remain underexplored.

Alcohol Use

Alcohol consumption carries a risk of adverse health and social consequences and is the third leading cause of death in the United States (CDC, 2010). It can have a major impact on individuals, families, and communities that can have cumulative effects, contributing significantly to costly social, physical, mental, and public health problems. Alcohol use is associated with both short- and long-term health risks. Short-term risks, most often caused by binge drinking, include injuries, violence, risky sexual behaviors, miscarriages, and alcohol poisoning (CDC, 2014b). Long-term risks include neurological, cardiovascular, psychiatric, and social problems; cancer; liver diseases; and gastrointestinal problems (CDC, 2014b).

Most public health interventions targeting alcohol use by young adults have focused on college students. Paschall and colleagues (2011a,b) conducted a randomized controlled trial in 30 universities where freshmen were delivered an intervention designed to reduce alcohol use and binge drinking. The intervention was delivered over the Internet in two doses and covered such topics as alcohol laws, policies, and risks; setting personal goals; and dealing with friends with alcohol problems. A booster session was delivered 30-45 days later. Limited reductions in alcohol use and binge drinking occurred immediately following the intervention, but the effects did not persist until the second assessment, in the spring semester (Paschall et al., 2011a,b). In another Web-based screening and intervention program targeting college students aged 17-24, Kypri and colleagues (2014) found that intervention group students receiving personalized feedback and information correcting misperceptions of alcohol use among their peers reported only minimal effect. Both of these Internet-based studies show that use of the Internet alone may not be the most effective intervention strategy with respect to outcomes.

Similar modest effects were found by Moore and colleagues (2013) in a cluster randomized trial of students in residence halls in Wales, United Kingdom. The intervention focused on correcting misperceptions about the drinking behaviors of peers in order to reduce alcohol consumption. Messages were delivered through nonmedia channels such as posters, coasters,

meal planners, and stickers. There were no significant effects on perceived norms or alcohol consumption between the groups, although there were some other modest effects.

On the other hand, a more broad-based community organizing approach focused on changing the environment with respect to high-risk drinking behavior among college students in North Carolina showed positive outcomes (Wolfson et al., 2012). The intervention encompassed campus-community coalitions; action plans; community organizers in each school; and promotion of environmental strategies, including awareness, enforcement, and policy. It also involved correcting misperceptions about alcohol use and limiting exposure to pro-alcohol messages. The intervention had a significant impact on decreasing consequences due to students’ own drinking, such as requiring medical treatment, getting a driving under the influence/driving while intoxicated ticket, and being taken advantage of sexually, as well as on alcohol-related injuries caused to others. No differences, however, were seen in actual drinking behavior.

Many environmental policy interventions have been effective in decreasing drinking and driving and motor vehicle crashes that involve alcohol among young adults (Hingson, 2010). However, it has been found that for policies to be effective, they need to be put into action and enforced at the local level (Hingson, 2010). It also has been found that multicomponent college-community approaches among college students that incorporate a legal component can decrease alcohol use and drinking and driving (Hingson, 2010).

Three main lessons can be drawn from this review. First, most interventions addressing alcohol use problems among young adults appear to have been conducted among college students, with virtually little or no focus on noncollege youth. Second, single-component approaches (e.g., only promotion or policy) or those using a single channel (e.g., television) are not effective, while a multipronged approach focusing on both the environment and individual behaviors may be more effective. Schulenberg and Maggs (2002) point out that binge drinking at college campuses is multiply determined and held at high rates by a number of pillars ranging from community standards to students’ assumptions about their rights to party. Addressing just one of these pillars is insufficient because the others will pick up the slack and keep the rates high. Third, multimodal community-wide interventions, including legal enforcement, have been shown to reduce drunk driving and alcohol-involved crashes among young adults.

Chronic Disease Prevention

Many interventions for chronic disease prevention center on maintaining a healthy lifestyle and focus on prevention of weight gain, weight loss,

healthy eating, and physical activity. Obesity increases the risk of chronic illness and is associated with reduced quality of life and adult success, as well as substantial human and societal costs (IOM, 2012a). Individual effects include illness (e.g., cardiovascular disease, diabetes, hypertension), disability, social ostracism, discrimination, depression, and poor quality of life (IOM, 2012a). Moderate amounts of daily physical activity are recommended for people of all ages both to remain healthy and to improve health. A decline in physical activity is one of the lifestyle changes that can occur during young adulthood.

Many studies have targeted the transition to college, most often using the college setting to recruit participants and deliver intervention components. In one example, undergraduate health classes were used to administer a goal-setting intervention. Participants who wrote if-then statements about healthy eating goals significantly increased their fruit and vegetable consumption relative to participants assigned to a general goal-related task (Chapman et al., 2009). Likewise, over a 15-week period, a college class-based intervention involving 80 students that met three times per week, emphasizing healthy choices and in-class activities, also significantly increased the consumption of fruits and vegetables among participants (Ha and Caine-Bish, 2009). And a sample of college freshmen who were administered an alternative-reality game during a college health education course significantly increased their physical activity compared with controls, although both groups gained a significant amount of weight over the study period, suggesting that other factors in the college experience were impacting weight changes (Johnston et al., 2012).

Online sources also have been used to influence healthy behaviors and weight loss, again in a college setting. For example, Gow and colleagues (2010) administered an intervention using an Internet classroom tool, finding that participants who received the intensive 6-week intervention with feedback on their weight had significantly lower body mass index than controls. The authors note that the combination of monitoring, feedback, and education had a stronger effect on behavior than each component separately. In another study, an Internet-based curriculum that provided 10 online lessons focused on healthy eating and physical activity to students across eight universities significantly increased fruit and vegetable intake and physical activity, with positive, lasting effects being seen over the course of 15-month follow-up (Greene et al., 2012). In another study, however, although an intervention using texts, emails, and a smartphone application led to decreases in body weight and increases in physical activity and healthy eating among the intervention group, no significant differences were observed relative to the control group (Hebden et al., 2014).

Reviews of weight loss interventions among young adults have shown mixed results. Interventions combining diet, exercise, and motivation con-

sistently show weight loss among young adults, although because of the varied components of these interventions, determining what elements are the most effective is problematic (Poobalan et al., 2010). Another review of 37 studies found that university course-based interventions often resulted in weight loss, with many self-monitoring interventions showing positive results as well (Laska et al., 2012). However, both reviews highlight the need to develop and evaluate rigorous weight gain prevention interventions focused on young adults that fully reflect the rapidly shifting life circumstances of this age group and incorporate more diverse populations.

Studies in this area have shown varying degrees of success. Many of the researchers acknowledge that an environmental approach is necessary to fully address the range of issues faced by young adults as they transition into making their own health-related choices, including pressure to engage in certain harmful behaviors.

Prevention of Sexually Transmitted Infections/HIV

STIs are infections that are transmitted primarily through sexual contact. Although they are largely preventable, they remain a significant public health concern, and some have the potential to cause serious health problems, especially if not diagnosed and treated early. The consequences of untreated STIs often are worse for young women than for young men, even though the yearly number of new infections is roughly equal among them (51 percent and 49 percent, respectively) (CDC, 2013c). Although HIV transmission is generally preventable, there is no vaccine or cure. As a result, HIV continues to be a major public health concern.

Several strategies have addressed STI and HIV prevention among diverse samples of young adults across a number of settings, often focusing on increasing condom use and decreasing risky sexual practices. In their sample of U.S. university students aged 18 and older, Norton and colleagues (2012) found that participants exposed to a 60-minute DVD addressing motivation, information, and behavioral skills with respect to increasing condom use and decreasing risky sexual practices changed these behaviors more when the topic was prevention of STIs or unplanned pregnancy than when it was HIV prevention.

Community-based participatory research was used to create a culturally congruent HIV prevention intervention, AMIGAS (Amigas, Mujeres Latinas, Inform andonos, Gui andonos, y Apoy andonos contra el SIDA [friends, Latina women, informing each other, guiding each other, and supporting each other against AIDS]), for young Latina women living in Miami, Florida, modeled after the evidence-based SiSTA (Sistas Informing Sistas about Topics on AIDS) program for African American women (DiClemente and Wingood, 1995; Wingood et al., 2011a). Within the

AMIGAS intervention, Latina health educators delivered four interactive group sessions emphasizing cultural and gender pride, the importance of healthy relationships, HIV knowledge, and how experiences unique to Latina women may increase HIV risk (Wingood et al., 2011a). At the 6-month follow-up, program participants reported significantly more consistent condom use, greater self-efficacy for negotiating safe sex, greater HIV knowledge, and fewer perceived barriers to using condoms compared with controls.

Several studies have targeted African American young adults in various community- and technology-based settings for the reduction of HIV risk behaviors. Aronson and colleagues (2013) developed a pilot intervention with 57 participants that used community-based participatory research partnerships among students, university faculty, and community partners to create a retreat for young adult African American men in which to discuss safe sex, followed by reinforcement messages via electronic media over the course of 3 months. Average number of sex partners and condom errors decreased significantly among participants, with the authors attributing much of this success to the high level of engagement with community partners. In a pilot study by Kennedy and colleagues (2013), a theory-driven, single-session condom promotion program delivered to 18- to 24-year-old African American men recruited from neighborhoods bordering urban community centers significantly increased condom use, perceived condom availability, and positive reasons to use condoms compared with a comparison group that received a general health curriculum. Results suggest that this brief, culturally appropriate prevention program may reduce risky sexual behaviors among high-risk youth from urban communities.

An HIV intervention for young African American women at Planned Parenthood in Atlanta, Georgia, used two computer-based 60-minute interactive sessions also modeled after the SiSTA program (DiClemente and Wingood, 1995; Wingood et al., 2011b). The intervention significantly increased knowledge of HIV prevention, condom self-efficacy, and condom use in participants compared with a control group that received a small-group session on general health topics (Wingood et al., 2011b). Another intervention with low-income African American young women at high risk for HIV used smartphones to stream a soap opera highlighting HIV risk reduction (Jones et al., 2013). Although no statistically significant differences were seen between the intervention and control groups, participants who viewed the videos found them engaging and wished to continue receiving them, prompting further research on how to reach this population on a popular messaging platform.

International studies also have shown success. A Dutch Web-based study involved a tailored intervention for young adults that used a virtual clinic with motivational interviewing, participant-specific feedback, and educational models. Significantly higher condom use and maintenance re-

sulted from the intervention compared with general feedback or treatment as usual (Mevissen et al., 2011). A study in India found that a workplace-based PowerPoint, video, and training session significantly increased positive perceptions of condoms and knowledge of proper wearing techniques among males aged 18-30 (Ray et al., 2012). The authors emphasize that simply providing knowledge may not be sufficient, and that a range of education on behavior, perception, and skill may be needed with this group.

In sum, many interventions targeting STI or HIV prevention saw success when they focused on topics most relevant to young adults; included culturally competent, tailored materials; and introduced skill components along with this tailored feedback.

Human Papillomavirus (HPV) Vaccination

HPV vaccination, recommended for females under 26 and males under 21, entails a series of three shots that protect against HPV infection and HPV’s associated health problems, such as cancer and genital warts (CDC, 2014c). Brief intervention techniques highlighting the benefits of HPV vaccination have been shown to increase positive perceptions of the vaccine and increase vaccination intention and reception. For example, Kester and colleagues (2014) recruited a sample of 18- to 26-year-olds at a minority health fair. Intervention group participants received a 5- to 10-minute small-group presentation on HPV infection, detection, and treatment; additional information sources; and a list of locations where the vaccine could be received. Participants had higher HPV knowledge scores and vaccination intention compared with controls.

HPV education also has been delivered to university populations in school computer labs. Intentions to be vaccinated increased significantly among women viewing an HPV website that provided information tailored to their specific perceived barriers to vaccination compared with women who viewed standard information (Gerend et al., 2013). Short videos also were used by Hopfer (2012), with intervention groups watching videos narrated by peers, medical experts, or both, while another arm reviewed a generic video or HPV website or received no message. HPV vaccination nearly doubled among the participants who watched the combined peer-expert video compared with controls; however, these results were not found for the peer- or expert-only videos, highlighting the importance of the communication source and suggesting that peer messages that normalize medical expert messages may play a crucial role in vaccination.

Direct provision of information about HPV and HPV vaccination may be a simple and effective way to motivate young adults to initiate HPV vaccination (Kester et al., 2014). Tailoring this information to ameliorating or removing specific barriers may enhance the effectiveness of this approach (Gerend et al., 2013).

Sexual Assault and Intimate Partner Violence

Black and colleagues (2011) found that nearly 1 in 5 women and 1 in 17 men reported experiencing rape at some point in their lives (Black et al., 2011). Approximately 1 in 20 women and men (5.6 percent and 5.3 percent, respectively) had experienced sexual violence other than rape.

Several interventions have sought to address sexual assault by providing girls and women tools needed to prevent these acts from occurring. One study focused on the transition of young adult women to the college environment, enlisting their mothers to participate with them the summer prior to their freshmen year (Testa et al., 2010). Mothers in the intervention condition were advised to complete a workbook on alcohol safety with their daughter before the start of school, with participants in the enhanced intervention condition also receiving a workbook chapter on college dating. Both intervention conditions were correlated with decreased incapacitated rape levels during the first year and increased communication among mothers and daughters, which predicted fewer drinking episodes, leading to lower sexual victimization rates involving alcohol.

Another study delivered an intervention for women to promote group responsibility, environmental awareness, and safe personal conduct as groups of college-aged students crossed the border to patronize Tijuana bars. The program led to a significant decrease in reports of sexual victimization (Kelley-Baker et al., 2011). Other strategies have focused on both men and women. A Web-based intervention for college students who were in longer-term relationships advised them on problem solving, communication techniques, and ways to enhance positive relationships, with weekly reminders to employ these skills (Braithwaite and Fincham, 2009). Intervention participants experienced improved mental health and relationship outcomes that continued over time, although anxiety, physical assault, and aggression grew worse before they ultimately improved.

Despite these findings, a meta-analytic Cochrane review of education- and skill-based interventions designed to reduce violence in the context of relationships and dating among youth aged 12-25 found no evidence of a significant effect on relationship violence episodes or on attitudes toward violence (Fellmeth et al., 2013). The 38 interventions included in the review were predominantly educational, and components were delivered in such settings as college classrooms, dorms, and fraternity halls, with sample populations ranging from coed to all-male or all-female. Intervention strategies included group discussions, videos of dramatic vignettes, role playing, problem solving and communication skills, and discussion of rape myths. Despite a trend found in increased knowledge about relationship violence, there was no evidence that these strategies improved participants’ attitudes, actions, or proficiency with respect to violence in relationships. The authors

highlight that the existing evidence relates primarily to determining changes in attitudes and knowledge, and that interventions both across communities and within families may be needed to reduce relationship violence. Further studies with longer-term follow-up and validated, standardized measures also are required to maximize the comparability of results (Fellmeth et al., 2013).

Mental Health Conditions

Mental health and substance use disorders are public health concerns for numerous reasons. First, they can cause death through the act of suicide. Mental health and substance use disorders also affect families and harm individuals by reducing their ability to achieve social, educational, and vocational goals; increasing the potential for further impairment and compromised functioning throughout life; and imposing costs related to extra care requirements and social disruption (NRC and IOM, 2009; Patel et al., 2007), as well as lost productivity (Birmbaum et al., 2010; Kessler et al., 2006). Of all types of illnesses, moreover, mental health and substance use disorders cause the greatest burden of disability in young adults (IOM and NRC, 2013). Furthermore, given the age of onset of behavioral health conditions, preventing or addressing mental and behavioral health needs in this period of life has the potential to reduce lifelong impact, since many fewer new cases occur after age 24 (Kessler et al., 2005). Timely mental health intervention can reduce morbidity and increase long-term health and well-being.

In addition, although not a psychiatric disorder, the experience of stress is pervasive in young adults (APA, 2013). Compared with older adults, young adults experience greater levels of daily stressors (Stawski et al., 2008) and perceive their lives as more stressful (Scott et al., 2013). One of the benefits of maturity appears to be coping better with stressful situations (Luong and Charles, 2014; Price and Dunlap, 1988; Schilling and Diehl, 2014). Even among young adults, the youngest struggle more with stressful events than their slightly older counterparts (Jackson and Finney, 2002). Psychological stress can contribute to the onset of mental illness (Blazer et al., 1987;

Corcoran et al., 2003; Kendler et al., 1999; Muscatell et al., 2009), and its relationship to physical health is well established (McEwen, 2008; McEwen and Gianaros, 2010).

Although mental health treatment is available and effective (HHS, 1999; NIH, 2009; NIMH, 2000), young people, especially young men and young indigenous and ethnic minorities, are reluctant to obtain professional care for problems relating to mental health (Edlund et al., 2012; Gulliver et al., 2010; Rickwood et al., 2007; Wu et al., 2007). Other studies have found that only about 18-34 percent of young people with depression and anxiety disorders seek professional help (Guilliver et al., 2010). Friends and family members rather than health professionals are preferred sources of help (Rickwood et al., 2007). Likewise, Wu and colleagues (2007) found that approximately 4 percent of full-time college students, 7 percent of part-time college students, and 6 percent of nonstudents aged 18-22 with an alcohol use disorder had sought help within the past year. Gayman and colleagues (2011) found that only about one-third of young adults with a substance use disorder had ever sought help; those in whom the onset of the disorder occurred at 18 or older were less likely to have sought help than those whose onset occurred earlier.

Perceived barriers to young adults’ seeking help for behavioral health disorders include stigma and embarrassment, difficulty recognizing symptoms or the need for treatment (i.e., lack of behavioral health literacy), a preference for self-reliance, and lack of confidence that their insurance will pay for treatment (Cellucci et al., 2006; Eisenberg et al., 2007; Gulliver et al., 2010; van der Pol et al., 2013). Perceiving the need for help or being encouraged by family, friends, or others to seek help increases the likelihood of help seeking (Caldeira et al., 2009).

The mental health literacy of young adults is not high (Farrer et al., 2008). Studies in Australia found that fewer than 50 percent of 12- to 25-year-olds could identify depression, and only about 25 percent could identify psychosis (Wright et al., 2005). Rates of recognition are lower in young men than in young women (Cotton et al., 2006). Lack of mental health literacy is regularly given as one of the explanations for missed opportunities to intervene with individuals with serious mental illness (Gulliver et al., 2010; IOM, 2004; Jorm, 2012).

As noted, the stigma attached to having a behavioral health disorder is one important impediment to help seeking by young people, and reducing stigma also is one of the major policy approaches proposed for reducing levels of unmet need for mental health services (HHS, 1999). Public stigma is the reaction of the general population toward a condition; self-stigma is the internalized impact of public stigma, and thus the prejudice people with behavioral health conditions turn against themselves (Corrigan and Watson, 2002); and personal stigma is the reaction

of an individual. All three forms of stigma can reduce willingness to seek behavioral health services (Eisenberg et al., 2009; Held and Owens, 2013), with some evidence suggesting that personal stigma may be a stronger disincentive than public stigma for college students (Eisenberg et al., 2009; Lally et al., 2013). Personal stigma also may pose a barrier to help seeking by reducing recognition of the impact of symptoms and thus the need for help (Schomerus et al., 2012). Generally, however, the specific roles of the various forms of stigma in help seeking are not well understood, specifically in young adults with behavioral health conditions. Many of the studies of public and self-stigma and help seeking in young adults examined these issues in general populations, most of whom did not have a behavioral health disorder.

One study illustrates the potential for unexpected and counterproductive consequences of public service announcements designed to reduce stigma; the announcements actually increased self-stigma and reduced help seeking in individuals with depression (Lienemann et al., 2013). In addition, help-seeking intentions have been studied much more thoroughly than actual help seeking. Thus, any public health campaign to reduce the stigma of behavioral health conditions and encourage help seeking for these conditions should be informed by research aimed at understanding the impact of stigma and of various types of public service announcements on help-seeking behavior in a wide range of young adults with behavioral health disorders.

A further impediment to adequate treatment of behavioral health disorders in young adults is that they are more likely than older adults to drop out of treatment once they have started (Edlund et al., 2002; Hadley et al., 2001; Sinha et al., 2003).

The onset of many mental health conditions during the young adult years has prompted a range of strategies aimed at preventing or treating mental health conditions in this population. A review of community-based prevention and early intervention programs found that the majority of interventions for young adults focus on strategies employing cognitive-behavioral therapy (CBT), which has shown the most reliably positive outcomes for treatment of anxiety or depression (Christensen et al., 2010). A later review focused on technology use among 18- to 25-year-old college students found that of diverse strategies employing the Internet, video, and audio, Internet-based strategies using CBT may be particularly useful for targeting anxiety, and to a lesser extent depression (Farrer et al., 2013). The authors conclude that the use of technological interventions targeting certain mental health problems holds promise for students in university settings, although more research is needed to assess the use of technology for other specific mental disorders. A review of 15 interventions targeting prevention of suicide and self-harm among 12- to 25-year-olds found highly

limited evidence regarding effective interventions for young adults experiencing suicide attempts, deliberate self-harm, or suicidal ideation (Robinson et al., 2011). While the authors acknowledge that CBT may show some promise, more methodologically rigorous trials of this approach are needed (Robinson et al., 2011).

Motor Vehicle Safety

Motor vehicle safety is a major concern for young adults, particularly since, compared with adolescents and adults aged 26-34, young adults (aged 18-25) are more likely to be injured or die in motor vehicle crashes and have more motor vehicle crash-related hospitalizations and emergency room visits (Neinstein, 2013). Historically, actions to prevent motor vehicle crashes and resulting injuries and deaths have taken an ecological approach, including multiple levels of influence such as policy designed to increase seat belt use. Indeed, the most notable road safety campaigns have promoted and enforced seat belt use (Dinh-Zarr et al., 2001) and have used enforcement campaigns to increase their use (Wakefield et al., 2010). For example, the Click It or Ticket program in North Carolina was associated with an increase in seat belt use from 63 percent to 81 percent and lower rates of highway deaths and injuries (Williams et al., 1996). Increasingly, states also are passing laws banning texting while driving, and in some cases any use of cell phones by drivers under age 18, to address distracted driving, a significant factor in motor vehicle crashes (NHTSA, 2014).

Law enforcement and repeated short-term mass media exposure appear to be important components of effective motor vehicle safety campaigns (Elder et al., 2004; Morrison et al., 2003; Salzberg and Moffat, 2004; Williams and Wells, 2004). The power of mass media also has been harnessed for drinking and driving campaigns. A social norms–based campaign delivered through television, radio, print, and theater advertisements in Montana reduced normative misperceptions about the frequency of drunk driving, increased designated driver use, and decreased drinking and driving rates among 21- to 34-year-olds within the intervention region (Perkins et al., 2010). Another social marketing approach targeting drunk driving

in Seattle, Washington, also saw success. A campaign delivered through messaging at taxi stands, at points of alcohol purchase, and in mass media significantly increased the use of designated drivers and taxis among the heaviest drinkers aged 21-34 (Rivara et al., 2011).

Despite the promising results of these campaigns, they may have unintended effects if inappropriate message formats are used. A group of college students that viewed fear-based public service announcements on distracted driving (such as talking on a cell phone, texting, or eating) reported significantly higher intentions to engage in the distracting behaviors after viewing the videos, indicating a boomerang effect (Lennon et al., 2010). The authors caution that fear-based messages may encourage young adults to behave in the opposite way from what is advocated in the message.

Many states are using graduated driver licensing (GDL) systems. Yet the results of a recent study indicate that some of the lives saved by GDL among 15- to 17-year-old novice drivers are offset by associated increases in fatal crashes among 18- to 19-year-old drivers (Fell and Romano, 2013). The reasons for this finding are unclear. It could be due to (1) novice 18- to 19-year-olds beginning to drive without the protective framework of a GDL program as a result of delaying licensure in the “good” GDL states⁵; (2) increased risk taking behaviors by 18- and 19-year-old drivers (e.g., impaired driving, late night driving, driving with teen passengers, lack of seat belt use, distracted driving); and/or (3) lack of exposure to risky situations (e.g., late night driving, driving on high-speed roads) among 18- to 19-year-old drivers in the good GDL states because of the protection from these situations when they were 16 and 17 years old (Fell and Romano, 2013). Further research is required to clarify the finding that those who seek a license in their young adult years actually endanger themselves even more as they lack the checks and family oversight of younger drivers.

Most individual-level driving safety interventions currently focus on educating novice drivers during the high school years as they gain their permit for the first time, often involving parents (Ramirez et al., 2013; Zakrajsek et al., 2013) and working within driver education classes (Zakrajsek et al., 2013). Relatively fewer studies have focused on the driving behaviors of young adults, using various tactics to reduce risky and distracted driving behaviors. An in-car education program involving 23 young men with a history of challenging driving behavior provided coaching sessions and in-car

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⁵ The Insurance Institute for Highway Safety rated a GDL law “good” if it had five or more of the following components: minimum learner’s permit age, mandatory waiting period before applying for an intermediate license, minimum hours of supervised driving, minimum age for an intermediate license, nighttime restriction, passenger limitation, and minimum age for full licensing (Fell and Romano, 2013).

feedback by a monitoring system. The program significantly improved driving skills in the intervention group, leading to positive changes in tailgating and unofficial races with other cars (Tapp et al., 2013). However, other studies with young adults have not shown the same success during actual time on the road. For example, teaching strategies using computer-based training modules to prevent distraction led to a decline in the intervention group’s willingness to engage in distracting activities and an increase in perceived risk, but no benefits were seen when the car was in motion (Horrey et al., 2009). Furthermore, a 20-hour prevention program for youth with multiple traffic citations showed no significant change in high-risk traffic behaviors and traffic citations compared with the control group, highlighting the need for further development of behavioral interventions to address high-risk driving behaviors (Nirenberg et al., 2013).

In summary, successful campaigns promoting motor vehicle safety have combined mass media messaging with legal enforcement, often engaging social networks to amplify the message and change norms. Single-component approaches and short-term campaigns have limited impact on intended outcomes.

Multiple Risk Behaviors

In addition to interventions addressing one or a set of related risk behaviors, there may be merit in multicomponent interventions that target various risk behaviors (Jackson et al., 2012). Such interventions may reflect the environmental approach needed to address the multiple transitions young adults experience, and may help focus on building resilience to adversity during these transitions by addressing multiple domains of risk and protective factors (Jackson et al., 2012). For example, a brief intervention among college students consisted of a one-on-one consultation featuring gain- and loss-framed messages tailored to students’ specific behaviors, followed by a goal-setting session. This intervention led to significant increases in health-related quality of life, fewer days of poor spiritual health, moderate exercise, and fewer days of driving after drinking compared with controls (Werch et al., 2010). Brody and colleagues (2010) focused on the period leading into the young adult years among African American students in rural counties who were in the past year and a half of secondary school, using a family-based intervention to increase the ability to cope with life stressors associated with the transition to adulthood. The intervention was found to buffer stress and increase resilience, leading to significant decreases in risk behaviors such as marijuana use, alcohol use, and risky sex among the intervention group compared with controls.

Lessons Learned

Although strategies and findings vary by priority area, some overall conclusions can be drawn from this brief review. First, the available evidence provides grounds for systematically investigating the potential utility of multifaceted health and safety campaigns targeting young adults. Single-component interventions focusing on one level, in general, have limited, short-term effects. Evidence of effectiveness as measured by health or safety outcomes at the population level (rather than solely by modification of individual-level beliefs, attitudes, or intentions) is weak for stand-alone interventions in many of the domains with particular application to young adults. By contrast, in the few health areas in which multilevel interventions have been used, the positive effects tend to be larger and long-lasting. Most community-based campaigns have used media but also sought to mobilize different sectors to create environmental and policy supports to facilitate healthy behaviors. Such intersectoral mobilization is exemplified by campaigns on tobacco use, HIV, and youth abuse of alcohol (Ramanadhan et al., 2012; Valente et al., 1993), among other areas. Law enforcement and repeated short-term mass media exposure also appear to be important components of motor vehicle safety campaigns.

Second, the most successful interventions have been those that involve comprehensive, multilevel community initiatives using ecological approaches to influence changes at the individual, organizational, and societal levels, sustained over time through a variety of channels and venues. Community and stakeholder engagement is critical to the sustained effectiveness of interventions. Many successful public health campaigns include such approaches as community-engaged social change and community-based participatory research (Koh et al., 2011; Minkler and Wallerstein, 2008).

Third, and related to the first two points, the most robust effects have been seen in those areas in which policy makers and researchers have collaborated to address the problem and evaluate interventions and, as a result, in which the most experience and evidence have been accumulated.

Fourth, a major limitation of current studies of young adults is that they have largely involved samples of university students. The focus on this population does not fully represent how young adults who do not attend college experience the transition after high school. Given the inequalities between youth and young adults from different socioeconomic and racial and ethnic groups, more information on how to develop and deploy robust interventions among noncollege youth are sorely needed. In particular, rigorous trials using standardized measures are needed so behavioral outcomes can be compared across groups.

This point is related to a broader concern—that public health campaigns that are media based or include a media component are less likely

to benefit people from disadvantaged socioeconomic and racial and ethnic groups, a phenomenon characterized as communication inequalities (IOM, 2006; Link and Phelan, 1995; Viswanath, 2006; Viswanath et al., 2013). The reasons for these health campaign inequalities are many, including a lack of access to media; a lack of attention; the complexity of the messages and practices recommended; and the economic, environmental, and social barriers to acting on messages. These inequalities in campaign effects offer a partial but robust explanation for the challenges encountered in attempting to eliminate or ameliorate health inequalities so well documented in the literature (Kawachi and Berkman, 2001; Link and Phelan, 1995; Marmot, 2013; WHO, 2001). It is worth noting, however, that these gaps are less likely to be seen when public health interventions and media campaigns focus explicitly on using strategies to reach different social groups, including minorities and those of lower socioeconomic position.

SOCIAL MEDIA AND THE HEALTH OF YOUNG ADULTS

Social media play an increasing role in curating information and driving audiences. Among those aged 18-29, for example, 97 percent use the Internet, 98 percent have a cell phone, and 83 percent have a smartphone, although income, urbanicity, and education are strongly associated with this phenomenon (Fox and Lee, 2014). More than 70 percent of Internet users use social media, with this number rising to 84 percent among those aged 18-29 (Duggan and Smith, 2013).

At the same time, a steady erosion in audiences for traditional media has occurred. In a Pew survey of online news consumption, for example, 39 percent of respondents reported getting news online—19 percent from social media, 16 percent from email, and 8 percent from podcasts (Pew Research Center, 2013). More germane, 60 percent of those in younger age groups rely on digital sources for their news. And more than one-third of youth aged 18-24 get their news from social media. Ownership of mobile devices, such as mobile phones and tablets, has actually increased news consumption, with people accessing information from multiple platforms (Pew Research Center, 2014). In line with this phenomenon, social media have emerged as key platforms for participation and engagement, particularly among youth.

In light of this dramatic transformation in information and communication technologies and their adoption among youth, it is important to explore the implications of these developments for public health. Social technologies afford new opportunities to reach out to and stay connected with young adults. Social and mobile media, in particular, provide a variety of contexts through which young adults can learn about, contribute to, and engage with developing narratives about public health. These media amplify

points of connection with young adults, and they enable broad, rapid, and convenient access to information and a variety of relational interfaces.

The empirical evidence for successful deployment of social media to promote health is nascent, and much of the literature is replete with commentaries and speculation. As these media become more ubiquitous, however, they increasingly are being incorporated into interventions. As the leading social networking site in the United States (Duggan and Smith, 2013), Facebook has been used to promote a number of healthy behaviors among young adults (Carrol and Kirkpatrick, 2011), but with mixed results. Exposure to a Facebook page delivering STI prevention messages to young adults in the community, for example, resulted in increased condom use at 2 months postintervention, although these results were not sustained at 6-month follow-up (Bull et al., 2012). In another study involving college students, using the private message function of Facebook to deliver social norms feedback successfully corrected misperceptions about drinking, reducing the amount and frequency of alcohol consumed postintervention and at 3-month follow-up (Ridout and Campbell, 2014). Enrollment in a Facebook group had no significant effect on increasing physical activity among a group of female undergraduate students (Cavallo et al., 2012). However, Napolitano and colleagues (2013) found significantly greater weight loss among college students exposed to a Facebook Plus intervention group (access to a weight loss–focused Facebook page plus goal setting, self-monitoring, and social support) compared with Facebook-only and control groups. This finding suggests that weight loss material delivered through a social networking platform alone may not be sufficient to effect changes in behavior.

A systematic review of the use of online social networks for interventions focused on weight loss and physical activity among participants of all ages found that 9 of the 10 articles included in the review reported significant improvements in these behaviors, albeit with small effect sizes (Maher et al., 2014). However, a meta-analysis by Williams and colleagues (2014) found no effects of the use of social media on weight or physical activity levels, citing problems with recruitment, retention, and poorly reported methods among reviewed studies. A systematic review of sexual health interventions among young adults also revealed a lack of evidence for the impact of social media on behavior. While interventions using social media or

text messages were found to significantly increase knowledge of STIs among samples of young adults, the evidence for impact on reducing sexual risk behaviors and increasing STI testing was mixed (Jones et al., 2014). Studies emphasize that this field of research is in its infancy, and future studies need to use high-quality research methods and large samples and determine how behavior change can be sustained over time to fully understand the promise of this widely used resource for health behavior change.

Based on experiences from other fields and data from current use, it is possible to formulate some hypotheses about the use of social media for public health interventions. We emphasize that these are hypotheses only that warrant more systematic testing in further research.

First, unlike traditional mass media, social technologies afford two- and multiway communication among audiences, especially when the members know each other or share some common interests. The open-ended opportunity for engagement may facilitate personal contributions or the tailoring of campaign content, which is known to result in a stronger impact on outcomes.

Second, social media may allow public health campaign planners to take advantage of the memetic potential for virality embedded within socially oriented technology. Several contemporary health campaigns are premised on the engagement principle, with the Avatars Anonymous project being an example of how health avatars can be personalized to convey health messages more effectively (Wood, 2014). Unlike traditional media, which access people as passive interlocutors, social and mobile media provide opportunities to turn passive audiences into active content producers. By “flipping” traditional roles, social and mobile media suggest new ways of engaging the target audience with public health campaigns. Because of its potential for engagement, the flipping model has become popular in redesigning educational experiences. In the health care and public health sector, the Flip the Clinic model,⁶ supported by the Robert Wood Johnson Foundation, is an example of interactive learning and active engagement with routine health care processes. Whether “flipping,” in either classroom

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⁶ See http://fliptheclinic.org/about (accessed October 22, 2014) for details on the Flip the Clinic project.

or clinical settings, is more effective than traditional approaches has yet to be empirically documented.

Third, the storytelling tradition is embedded in a range of cultures, and commercial advertisers often have resorted to this strategy to sell products and services. In social change programs, including those focused on health, narratives and exemplars are frequently used to promote change. Narratives offer both negative and positive examples of influence on health behaviors. Several studies have documented, for example, that exposure to depictions of tobacco use in movies is strongly related to both initiation and sometimes continued smoking among youth in the United States (Dalton et al., 2009; NCI, 2008) and young adults and adults in India (Viswanath et al., 2010a). On the other hand, narratives have also been used to help smokers quit smoking (Strecher et al., 2008). Using social and mobile media to support storytelling invites others to connect with the stories emotionally through the process of adding to, remixing, and reproducing them. This sustained loop of engagement could potentially create a sense of community supportive of health and well-being, a key element in new public health strategic directions.

Fourth, social and mobile media augment points of connection among people, networks, and information. They connect disparate and overlapping networks in ways that sustain existing and enable new connections. In this way, they offer networked “neighborhoods” more accessible to a variety of people than physical places where people traditionally have convened.

Overall, use of social and mobile media appears to hold promise for reaching young adults with public health campaigns. However, the effectiveness of these new technologies in fulfilling this promise has yet to be established. Studies indicate that going beyond the provision of information to include skill-based components may yield the greatest success (Jackson et al., 2012).

PROTECTIVE PUBLIC POLICIES FOR YOUNG ADULTS

Legislatures and public health agencies often adopt protective policies focused on young adults. They may do so for a variety of developmental

and behavioral reasons. For example, some risky behaviors that are permitted for adults pose a heightened risk to young people because of the shortsightedness, impulsivity, or other deficits in mature judgment and decision making that often characterize this age group. Legal restrictions are designed either to delay these behaviors until young people mature or to allow a transition period for training and experience. Legal permission to use alcohol and tobacco, to drive a motor vehicle, and to use firearms offers the most pertinent examples.

A key policy issue in all these contexts is where the line should be drawn in formulating these “wait” rules. As discussed in Chapter 2, some of the key policy-relevant features of adolescence, including sensation seeking, impulsivity, and shortsightedness, persist into the early 20s, and there are of course substantial individual variations above and below 18. Although 18 may be a sensible point at which to demarcate the generic “age of majority” for most legal purposes, drawing this line in each setting ultimately requires contextualized value judgments. In the present context, protecting young people from taking unreasonable risks must be balanced with respecting their right to direct their own lives. Cognitive and emotional factors that may affect the maturity of judgment exercised by adolescents and young adults will vary in different social contexts, as will the health and safety consequences of setting the “legal age” at one point or another. It may be sensible to draw the line lower in some health and safety contexts (e.g., obtaining a license to operate a motor vehicle) and higher in others (e.g., lawful access to alcohol) (Bonnie and Scott, 2013; NRC and IOM, 2004).

In recent years, the trend in the United States has been to take a more protective stance toward older adolescents and young adults, a trend that is reinforced by the prolonged transition to economic and social independence described in Chapter 2. In the public health context, this trend is most clearly evident in legislation setting the minimum age for purchasing alcohol, marijuana, and tobacco, and heightened by increasing concern about commercial targeting of young people by manufacturers of these products.

Age of Purchase for Alcohol, Marijuana, and Tobacco

After the repeal of Prohibition in 1933, the vast majority of states set the minimum drinking age at 21. However, when the national voting age was set at 18 by the 26th Amendment in 1971, 29 states changed the drinking age to 18, 19, or 20, which led to a dramatic increase in motor vehicle fatalities related to alcohol among 18- to 20-year-olds (Wagenaar and Toomey, 2002). Many states then raised the minimum age to 21, and a robust literature showed that alcohol-related fatalities declined. In 1984, Congress induced all states to restore the minimum age to 21 by threatening to withhold a percentage of highway funds from noncompliant states (NRC

and IOM, 2004). Subsequent studies showed significant decreases among young people in fatal and nonfatal motor vehicle crashes and alcohol-related crashes and arrests (NRC and IOM, 2004). In a comprehensive report published in 2004, the National Research Council (NRC) and the Institute of Medicine (IOM) proposed a strategy for reducing underage drinking and driving based on the idea that, in a world where alcohol is so widespread and aggressively promoted, reducing drinking by adolescents and young adults is a “collective responsibility.” Parents and other adults must take the law seriously instead of accepting the idea that teen drinking is a rite of passage to adulthood (NRC and IOM, 2004). Moreover, given the widespread availability of alcohol and easy access by underage drinkers, minimum drinking age laws must be enforced more effectively, along with social sanctions. The effectiveness of underage drinking laws could be enhanced through such approaches as compliance checks, server training, zero tolerance laws, and GDL laws (NRC and IOM, 2004).

Notwithstanding the NRC and IOM report’s reaffirmation of the wisdom of setting the minimum drinking age at 21, political efforts are occasionally launched to reduce the minimum drinking age to 18 or 19. Yet a recent literature review reinforces the point that establishing 21 as the minimum drinking age has decreased “alcohol-related traffic crashes and alcohol consumption among youth, while also protecting drinkers from long-term negative outcomes they might experience in adulthood, including alcohol and other drug dependence, adverse birth outcomes, and suicide and homicide” (Dejong and Blanchette, 2014, p. 113). The U.S. Task Force on Community Preventive Services recommends implementing and maintaining a minimum drinking age of 21 based on strong evidence for the effectiveness of doing so, which includes a median 16 percent decrease in underage motor vehicle crashes in states that increased the legal drinking age to 21 (Shults et al., 2001).

The alcohol experience appears to have guided policy makers in states that have chosen to legalize marijuana, where the age of purchase has uniformly been set at 21. Although marijuana policy has been highly controversial since the 1960s (Bonnie and Whitebread, 1974), recent developments have fundamentally changed the regulatory landscape and are likely to have profound effects on the epidemiology of marijuana use (IOM, 1999). The voters of California legalized medical use of marijuana in 1996, and analogous laws have been enacted by more than 20 other states (NCSL, 2014).

Colorado and Washington voters approved initiatives legalizing recreational marijuana use for people over 21 in 2012 and directing state legislatures to license the cultivation and distribution of marijuana and impose taxes on marijuana transactions (American Psychiatric Association, 2014). Although the cultivation, distribution, and possession of marijuana for either medical or recreational purposes remain illegal under federal law,

the U.S. Department of Justice has promulgated enforcement guidance to the U.S. Attorneys. That guidance allows for declining to enforce the Controlled Substances Act against persons who comply with the requirements of state law as long as the conduct allowed by the states does not endanger overriding federal interests, such as preventing “distribution of marijuana to minors” and “drugged driving and the exacerbation of other adverse public health consequences associated with marijuana use” (Cole, 2013).

Many questions remain unanswered about the effects of marijuana, especially when used in high-potency preparations. Public health concerns focus on the onset of dependence during adolescence and young adulthood, possible damaging neurodevelopmental effects, and increased risk of psychosis in psychologically vulnerable youth (Volkow et al., 2014). A key question raised by the legalization debate is how different approaches to legalization are likely to affect the prevalence and patterns of marijuana consumption and the extent to which marijuana will be used as a substitute for alcohol. However marijuana policy unfolds, the committee assumes that policy makers will take meaningful steps to discourage its use among youth below the age of purchase, which is nearly certain to be at least 21, and that state and federal public health agencies will establish the surveillance systems necessary to monitor patterns of consumption and the effects of policy changes on the public’s health.

The age of purchase for tobacco products also has come under scrutiny. Until the 1990s, the minimum purchase age (typically 16) varied substantially from state to state and was rarely enforced anywhere. In 1992, Congress enacted legislation (known as the Synar Amendment) tying state eligibility for substance abuse prevention and treatment block grant funds to enforcement of youth tobacco access laws, and reports published by the surgeon general (CDC, 1994) and by the IOM (1994) 2 years later highlighted the importance of reducing youth initiation of smoking as a priority component of state tobacco control. In 1996, the U.S. Food and Drug Administration (FDA) promulgated its Tobacco Rule, establishing a federal minimum purchase age of 18 and restricting tobacco advertising and promotion targeting adolescents (Redhead and Burrows, 2009). Although the Supreme Court invalidated the Tobacco Rule in 2000,⁷ Congress revived it in the Family Smoking Prevention and Tobacco Control Act of 2009,⁸ and the FDA reissued the rule in 2010. While codifying 18 as the federal minimum age of purchase, Congress authorized the states to adopt a higher minimum purchase age and directed the FDA to assemble an expert panel to assess the public health implications of increasing the minimum purchase

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⁷Food and Drug Administration, et al. v. Brown & Williamson Tobacco Corp., et al. 529 U.S. 120, 2000.

⁸ Public Law 111-31, 111th Cong. (June 22, 2009).

age for tobacco products. At the FDA’s request, the IOM has convened a panel to assess the effects of raising the minimum age to 19, 21, or 25, and the panel’s report is expected in 2015.

Advertising and Promotion of Alcohol, Marijuana, and Tobacco

Recent consideration of marijuana legalization has drawn attention to the challenge of designing a regulatory structure that will adequately protect the public health (American Psychiatric Association, 2014). The shortcomings of current regulatory approaches to alcohol and tobacco are mentioned prominently in the policy debate (Bonnie, 2014), and attention has focused particularly on the effects of advertising and promotional activities targeting young adults. While a review of the effects of advertising and promotion on young adults is beyond the scope of this study, a substantial body of research has accumulated on the exposure of young adults to alcohol advertising, the increasing number of tobacco promotions targeting young adults, the intertwining of alcohol and tobacco advertising, and the rapid acceleration of marijuana advertising in Colorado (Pacula et al., 2014; Richardson et al., 2014; Sepe and Glantz, 2002; Smith and Foxcroft, 2009).

IMPROVING AND COORDINATING PUBLIC HEALTH PROGRAMS

This section examines state and federal public health programs to ascertain whether and to what extent they focus on key issues, such as those presented earlier in Box 6-2, that are relevant for young adults. Although relatively good epidemiological surveillance data are available for many of these issues, information is rarely adequate for evaluating the effectiveness of programs and policies specifically for young adults. This is the case because, while a variety of public health programs and policies have been implemented to improve overall population health, specific data have not been available on whether they have adequately reached young adults and with what effects, or subanalyses of this particular age group have not been conducted. As discussed in Chapter 2, young adults have developmentally distinct characteristics that may require strategies different from those used for children, adolescents, or older adults. Additionally, programs and policies often have been shaped by the needs of distinct groups, as well as resource limitations, resulting in the development of specific eligibility requirements—for example, those at greatest risk of HIV/AIDs. The consequence has been a siloed approach to population health that fails to reflect the fact that the same young adult may be engaged in multiple risk behaviors, such as substance abuse and unprotected sexual activity.

Coordination of State and Local Public Health Programs

The IOM’s influential report on the future of public health (IOM, 1988) identifies three core functions performed by state and local public health departments: (1) assess the health of the community (assessment), (2) lead and promote evidence-based policies that are in the public’s interest (policy development), and (3) ensure the availability of community and personal health services that are viewed by constituents as appropriate and necessary (assurance). Building on that foundation, recent IOM reports (e.g., IOM, 2011) have endorsed a list of the 10 essential public health services displayed earlier in Box 6-1, which provide the foundation for state and local public health systems that play a lead role in ensuring the delivery of public health services (IOM, 1988, 2003).

The U.S. public health system is made up of 51 state,⁹ 2,794 local, and 565 American Indian and Alaska Native tribal public health agencies (Hyde and Shortell, 2012; NACCHO, 2009). The scope of these agencies’ duties and authorities and the agencies’ organizational structure vary among states (IOM, 2003). Virtually all state public health agencies provide immunizations, conduct infectious disease control and reporting, provide health education, and maintain health statistics (IOM, 2003). At the local level, local health departments are involved in various activities related to public health, such as population-based primary prevention services, immunization, and maternal and child health services. Research describing how these services are delivered is limited (Hyde and Shortell, 2012).

Funding for public health services at the state and local levels comes from a mix of federal, state, local, and private monies. In 2008, about 50 percent of state agency funding came from federal grants, contracts, and cooperative agreements; 24 percent from state general funds; and 26 percent from other sources (ASTHO, 2009). At the local level, in 2007, 25 percent of funds came from local contributions, 20 percent from state contributions, 17 percent from federal pass-through funding, 15 percent from Medicaid and Medicare reimbursements, and 11 percent from fees (NACCHO, 2009). Sources of funding vary widely at both the state and local levels, and agency activities are typically fragmented and siloed, depending on the funding stream. For example, many grantees of the federal Title X Family Planning Program administered by the Office of Family Planning face numerous challenges impacting their ability to provide family planning services because of management and administrative burdens, including funding limitations and increasing supply costs, as well as difficulty coordinating and managing multiple funding sources at the federal, state, and local levels (IOM, 2009). In addition, funding for public health infra-

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⁹ Including the District of Columbia.

structure is chronically inadequate and tends to decrease during recessions, eroding the capacity of local health departments to provide essential community services (NACCHO, 2014a). Since 2008, local health departments have lost 48,300 jobs as a result of layoffs and attrition, and 36 percent of the population currently lives in a jurisdiction affected by budget cuts (NACCHO, 2014a).

Nonetheless, all state and local public health programs deal at some level with many of the public health priorities for young adults described in this chapter, including tobacco control, obesity prevention, injury prevention, and prevention of unprotected sexual activity. However, fragmentation of organizational structures contributes to inefficiencies and gaps in the performance of the core public health functions, weakening responses to the needs of young adults (among other groups). For instance, the administration of different funding streams, each with its own priorities, eligibility requirements, and scope of work, carried out with little coordination or integration, results in programs reaching some groups of young adults but not providing a comprehensive approach when they are reached, while other young adults may not receive any of the services they need. Thus, for example, young adults may have access to reproductive health services offered through health departments, but may not receive screening for obesity and diabetes. These lost opportunities to take a more comprehensive approach contribute to unevenness in service provision. Furthermore, given the resources available, many young people may not have had the opportunity to access health services—either because their local jurisdiction does not make services available; because eligibility requirements preclude their access to care; or because they lack information about available resources, such as screening for STIs through public health clinics.

States have recognized the importance of integration of services for adolescents, and many state public health agencies have created adolescent topic areas or designated state adolescent health coordinators to help coordinate health programs and policies bearing on the health, safety, and well-being of adolescents (SAHRC, 2012). For example, a number of states have developed comprehensive adolescent health plans to help bring together different funding streams. Most public health departments have had an adolescent health coordinator position over the past 20-30 years, and these coordinators were initially supported directly as part of the Title V Maternal and Child Health (MCH) Block Grants to States Program. Many coordinators continue to work within Title V programs; as state funding and public health structures have changed, however, many are now funded through other divisions within public health agencies, such as family planning and chronic disease divisions.¹⁰ As of June 1, 2014,

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¹⁰ See http://nnsahc.org/images/uploads/1-_AHC_Overview.pdf (accessed October 22, 2014).

all states except Alaska, Montana, North Dakota, Tennessee, Utah, and Virginia and the District of Columbia had an adolescent health coordinator in place (SAHRC, 2014). The coordinators’ position and role vary greatly by state with respect to their responsibilities and areas of focus, but all are committed to improving the health, safety, and well-being of adolescents (NNSAHC, 2012). In 2012, 54 percent of state adolescent health coordinators had worked in adolescent health and 66 percent in public health for more than 11 years, and 20 percent for more than 20 years. Most take a broad approach to their work, with 64 percent focusing mainly on youth development, 52 percent on general adolescent health, and 38 percent on building health systems for adolescents; more than one-third have engaged adolescents in some way in their work (NNSAHC, 2012).

Very few states have implemented a similar approach for young adults, although some have extended the adolescent health coordinator’s role to include young adults. One example is Maine, whose program encompasses ages 10-24 and focuses on the issues of health service access and education and youth development, with the vision that all the state’s youth will be healthy, safe, and respected (King, 2014). In Texas, beginning in fiscal year 2015, contractors will be able to serve young adults up to age 24 in their programs. Contractors must select at least one of eight risk areas (motor vehicle safety, juvenile delinquency, substance abuse, dating violence, obesity, mental health issues, HIV/STIs, and access to care) on which to focus their activities. They are also required to facilitate a Youth-Adult Council (ages 12-24) to help guide their program development and incorporate a positive youth development framework.¹¹

Two statewide innovations merit careful review and consideration by other states. In Colorado, the public health department convened Colorado 9to25, a partnership of more than 200 organizations, to promote the health, safety, and well-being of youth aged 9-25 (see Box 6-4). And in Maryland, the governor convened an interagency activity—the Transition Age Youth Initiative—to focus on the transition needs of young adults with intellectual disabilities or behavioral health problems (see Box 6-5).

Federal Public Health Programs

Compared with state and local government agencies, the federal government has a limited role in delivering public health services. “Nevertheless, it plays a crucial role in protecting and improving the health of the population by providing leadership in setting health goals, policies, and standards, especially through its regulatory powers” (IOM, 2003, p. 111),

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¹¹ Personal communication, Carol Harvey, Office of Title V & Family Health, Texas Department of State Health Services, July 17, 2014.

as well as in supporting research. It also contributes operational and financial resources necessary to increase the effectiveness of the public health infrastructure at the federal, state, and local levels (IOM, 2003).

Although few federal programs specifically target young adults, many programs can be utilized to improve the health, safety, and well-being of this population. Table 6-1 illustrates the broad range of current federal public health programs that affect young adults, although, as discussed below, specific data on how many young adults are being served by these programs are not readily available. This table is not exhaustive, but is intended to provide examples within various categories of public health (e.g., substance abuse, reproductive health).

Many programs specifically target adolescents (e.g., the U.S. Department of Health and Human Services’ [HHS’s] Adolescent Pregnancy and Prevention Grant Programs) or mothers and children (e.g., HHS’s Services

Grant Program for Residential Treatment for Pregnant and Postpartum Women). While young adults meet some of these programs’ age eligibility requirements, evidence of whether tailoring has been used in the delivery of care or services has not been formally documented. One notable exception is incorporated as part of the National State-Based Tobacco Control Program, which aims to prevent adolescents and young adults from initiating tobacco use. It is also likely that some other programs, such as the family

planning services provided under Title X funding, which target primarily younger adults (51 percent of Title X clients are in their 20s), may use approaches best suited to young adults (Fowler et al., 2012).

Recently, the National Prevention Council released its Annual Status Report, which describes how federal government departments are collaborating in cross-sector efforts addressing prevention and health.¹² Many of these strategies may impact the young adult population, but the report

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¹² See http://www.surgeongeneral.gov/initiatives/prevention/2014-npc-status-report.pdf (accessed October 22, 2014).

TABLE 6-1 Selected Federal Public Health Programs Relevant to Young Adults

describes only one effort specifically targeting young adults—the launch of HHS’s partnership with the American College Health Association and the University of Michigan, which supports the Tobacco-Free College Campus initiative. This initiative resulted in increasing the number of designated smoke-free campuses from 774 to 1,342. The rest of the programs included in the report do not specifically mention young adults, although several federal public health programs (e.g., the Maternal and Child Health Services Block Grant Program, the Ryan White HIV/AIDS Program, Federally Qualified Health Centers) deal with many of the key issues impacting young adults listed earlier in Box 6-2 (see Box 6-6). A similar pattern can be seen at the state and local levels, where, as discussed earlier, numerous public health programs are relevant to young adults.

NOTES: ACF = Administration for Children and Families; CDC = Centers for Disease Control and Prevention; DoD = U.S. Department of Defense; DOT = U.S. Department of Transportation; FDA = U.S. Food and Drug Administration; HHS = U.S. Department of Health and Human Services; HRSA = Health Resources and Services Administration; na = not available; NHTSA = National Highway Traffic Safety Administration; SAMHSA = Substance Abuse and Mental Health Services Administration.

^a For most programs, three fiscal years of funding is available in the Catalog of Federal Domestic Assistance.

^b See http://hab.hrsa.gov/data/reports/funding.html (accessed October 22, 2014).

The committee found that in most cases, the number of young adults being served by each federal program is not reported as a separate category, reflecting the fact that young adults are not consistently identified as a group with their own set of health conditions, risk factors, and needs. Nor is evidence available on whether programs tailor their efforts to different developmental ages and whether these modifications result in improved outcomes. Moreover, age data are reported differently for each program. As noted throughout this report, young adults should not automatically be combined with adolescents and older adults in public health programs. Breaking down data collection and analyses by adolescents, young adults, and older adults, as well as by gender and race/ethnicity, wherever possible, would help in assessing whether strategies and interventions are

being modified for different developmental age groups, whether diverse eligible populations are actually being served, and what outcomes are being achieved by age group.

Finally, the federal Maternal and Child Health Bureau has established an Adolescent and Young Adult Health Program. This program is designed “to promote comprehensive healthy development, health, safety, and well-being of adolescents and young adults . . . by strengthening the abilities of

[Title V programs] as well as of public health and clinical health professionals, to better serve these population groups, which range in age from 10 to 25 years” (HRSA, 2014a). The program is an example of a formal effort to recognize young adults as a separate population with their own needs. However, it represents only a small component of public health systems’ response to the needs of this population. Where necessary, new data collection efforts, disaggregated by these age groupings and other identifiers, are warranted to support improvements in public health programs and

campaigns aimed at improving the health, safety, and well-being of young adults.

Preventive Care Opportunities Under the Affordable Care Act

The Patient Protection and Affordable Care Act (ACA) includes numerous provisions intended to increase access to preventive health care, focused at both the individual and population levels. The architects of the ACA recognized the need for population-level investments that can help modify the environments that are the contexts for public health, as well as reinforce the act’s individual preventive focus. The ACA increases incentives for adminstering preventive care and financially supports primary prevention initiatives of communities and public health agencies. The Prevention and Public Health Fund (PPHF), for example, while not specifically focused on young adults, is used to support community and clinical prevention programs, strengthen the public health infrastructure and workforce, and expand public health research and tracking efforts (APHA, 2013). Yet while the ACA includes commitments to prevention, through both an emphasis on the provision of clinical preventive services (see Chapter 7) and the PPHF, the federal government’s public health investment would need to be doubled to address current public health needs (IOM, 2012b).

In fiscal year 2012, under the auspices of the PPHF, $401.1 million was set aside to fund community prevention activities proven to reduce health care costs and improve health behaviors. These funds support such initiatives as the Community Transformation Grant (CTG) program, administered by the CDC (APHA, 2012). The CTG program is “designed to address the behavioral, physical, social, and environmental risk factors associated with chronic diseases, such as tobacco use and exposure to secondhand smoke, poor screening systems for disease risks, and lack of access to healthy food and safe environments for physical activity” (Hennrikus, 2013, p. 16).

Ultimately, the CTG program is anticipated to impact 40 percent of the U.S. population (Hennrikus, 2013). CTG grants fund evidence-based programs that address major causes of chronic disease, such as heart disease, diabetes, and cancer, in communities, and promote tobacco-free living, physical activity, healthy eating, services to prevent and control high blood pressure and high cholesterol, social and emotional wellness, and healthy and safe environments (Hennrikus, 2013). State and local government agencies, tribes and territories, and nonprofit organizations are eligible for CTG funds. Thus far, the CTG-funded programs have been implemented in an array of sectors, such as health care, education, and transportation. In 2011, $103 million was distributed among 36 states to 61 state and local government agencies, tribes and territories, and nonprofit organizations for

the implementation of evidence-based programs (CDC, 2013a; Hennrikus, 2013). Although many of these programs are likely to improve the contexts in which young people live, their impact on contributing to improved population-level outcomes among young adults cannot be known absent the improvements in data collection and analysis discussed above.

CONCLUSIONS AND RECOMMENDATIONS

Policy makers and practitioners have recognized that the health, safety, and well-being of adolescents can be enhanced, during adolescence and thereafter, by basing policy and practice on an integrated understanding of this distinct period of development. A key conclusion of this report is that the health, safety, and well-being of young adults can similarly benefit from bringing a developmental perspective to bear on public health policies and programs and on the delivery of health care (discussed in Chapter 7). The literature reviewed in this chapter also makes the following points clear:

• The effects of interventions—especially those that include only one component, focus on only one level, and are brief in duration—generally are small and not sustainable. On the other hand, multipronged and reinforcing approaches that target and are tailored to individual behaviors and their social, environmental, and legal contexts and are implemented over a period of at least several years generally are more successful and their effects more sustained.
• Approaches that promote collaboration and participation among multiple stakeholders create the right environment for individual change and foster health-related social change.
• The use of mobile digital media and social networking to implement interventions shows considerable promise, although evidence for the effectiveness of this approach remains to be developed.
• The notable success of some multilevel public health campaigns targeting older adolescents and young adults provides a solid foundation for developing and fielding innovative community initiatives that combine health messages with environmental interventions addressing cross-cutting health and safety challenges for young adults.
• Public health campaigns that are media based or include a media component are less likely to benefit people who are educationally or economically disadvantaged or are from racial and ethnic minorities, as well as young adults who are not in college.
• Formulating an integrated approach to public health policy and practice focused on young adults will require improvements in

• the data assembled for surveillance and research, as well as better coordination of federal and state public health programs.

• A major aim of policies focused on improving population health should be to incorporate screening and prevention into primary health care and other health settings for young adults, as well as social settings where at-risk groups congregate (e.g., STI screening in bars or nightclubs).
• The importance of identifying and rectifying health disparities among young adults has received little attention in the design and administration of public health programs, as well as in intervention research.
• Few state or local programs have attempted to coordinate or integrate programs for young adults, although innovations to this end have been undertaken in a handful of states.
• Several recent federal initiatives reflect a nascent effort to promote and support policies and practices reflecting an integrated understanding of young adulthood.

State and Local Coordination Efforts

No states have addressed the needs of young adults aged 18-26 in a large-scale way. Under the new Adolescent and Young Adult Health Program funded by the Health Resources and Services Administration and administered by the MCH Bureau, states and localities will be encouraged to expand care beyond adolescents. To advance this transformation, the committee makes the following recommendation:

Recommendation 6-1: State and local public health departments should establish an office to coordinate programs and services bearing on the health, safety, and well-being of young adults. If a separate office is not established for young adults, these responsibilities should be assigned to the adolescent health coordinator.

The committee is mindful that many state and local public health agencies are underfunded and have limited capacity to take on new responsibilities. Elevating the visibility and importance of young adults may also require additional training and skill development for staff. The committee regards this recommendation as requiring a change in orientation to shape an array of activities that will respond to the documented pressing needs of this population. Aside from bringing together the necessary expertise on the development and needs of young adults, improved coordination of young adult programs and services can also be expected to identify gaps in

existing services and opportunities for new services and allow more efficient allocation of resources.

Once an office for coordinating programs and services for young adults is created or linked to an existing office, an evaluation program will be important. Evaluation will provide processes and tools that can be applied to obtain accurate, reliable, and credible data to address program performance questions. Data collection needs to be feasible for health departments and other organizations, which are unlikely to have the resources for elaborate measurements of populations, polices, and environments. Better data will lead to better comparisons across time and may lead to better benchmarks. There are a variety of ways to accomplish this (see the American Evaluation Association’s Guiding Principles for Evaluators¹³ for examples).

Colorado 9to25, described earlier in this chapter, highlights the potential synergies of a multisectoral model of community mobilization focused on young adults (or adolescents and young adults). The U.S. Department of Education’s Promise Neighborhoods and the U.S. Department of Housing and Urban Development’s Choice Neighborhoods are analogous initiatives. Building on these models, state public health agencies (or local agencies with adequate staff and authority) should convene multistakeholder initiatives potentially called “Healthy Transitions to Adulthood,” as stand-alone activities or a component of already-existing community initiatives. The coalition should reach out to all local organizations with a stake in the healthy, successful development of young adults, including large employers, residential and nonresidential colleges and universities, community colleges, other providers of vocational training, faith-based organizations, and health care systems. A broad scope of activities might be undertaken by such coalitions, encompassing the entire range of transitional tasks in young adulthood and the range of outcomes associated with health and well-being. Young adults should play a pivotal role in these efforts from the outset.

Recommendation 6-2: Each community should establish a multistakeholder private-public coalition on “Healthy Transitions to Adulthood,” with the goal of promoting the education, health, safety, and well-being of all young adults. State or local public health agencies should take the lead in convening these coalitions. The coalitions should include young adults; colleges and universities; providers of career and technical education; employers; youth organizations; nonprofit organizations; medical specialties providing primary care to young adults; and other community organizations serving, supporting, or investing in young adults. These initiatives should mobilize public and private engagement and support; set priorities; formulate strategies for reaching all groups

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¹³ See http://www.eval.org/p/cm/ld/fid=51 (accessed October 22, 2014).

of young adults who need services and support; and design, implement, and evaluate prevention activities and programs. Initiatives should also incorporate the valuable input of young adults in shaping their scope and activities to ensure that there is traction among those initiatives aimed at improving their health, safety, and well-being.

The committee is aware of the difficulty of initiating multisector community mobilization efforts and understands that many such efforts do not succeed. However, the creative energy that can be brought to bear on such an initiative provides a solid basis for optimism. Some states may choose to build on the efforts they have devoted to adolescents, extending the purview of those efforts to recognize the importance of the transition into adulthood. The intent is not to dilute existing efforts to improve adolescent health, but to recognize the importance of the young adult years within the life course and the necessity of investing in this particular age group as well.

Finally, once a Healthy Transitions to Adulthood coalition has been formed, stakeholders should be identified and an evaluation process designed with their input so that the evaluations will meet the goals of all stakeholders.

Community Transformation Grants

The CTG program’s 5-year measurable performance goals are to decrease all of the following by 5 percent: death and disability due to tobacco use, the rate of obesity through nutrition and physical activity interventions, and death/disability due to heart disease and stroke (CDC, 2013a). While the first two of these areas clearly are congruent with the needs for prevention among young adults, it is not feasible to ascertain how many young adults have benefited directly from these investments to date. As illustrated by Box 6-2, moreover, many priority issues for young adults are not addressed by the CTG program. Since these national investments are currently being made, however, the CTG program presents an opportunity to deal with at least some of the issues that are important for young adults.

Reducing tobacco use is a key issue because smokers who quit before the age of 30 will reverse much of the damage to their health due to tobacco use (HHS, 2012b). Therefore, although much of the focus is appropriately on reducing the initiation rate for tobacco use among people under age 18, the young adult years also are critical for reducing lifelong rates of tobacco use. Similarly, weight gain during young adulthood may be one of the most important determinants of cardiovascular and cancer risk factors, so this time period is critical for reducing rates of obesity through both improved nutrition and physical activity.

Recommendation 6-3: Recipients of Community Transformation Grants—including state and local government agencies, tribes and territories, and nonprofit organizations—should incorporate specific targets for young adults in their plans to reach the 5-year measurable performance goals in the areas of reducing death and disability due to tobacco use and reducing the rate of obesity through nutrition and physical activity interventions.

As communities consider the types of public health interventions they could implement to support young adults, they might make use of two resources—CDC’s The Guide to Community Preventive Services¹⁴ and the New York Academy of Medicine’s Compendium of Proven Community-Based Prevention Programs.¹⁵ These resources identify particular programs that have succeeded in reducing obesity and related diseases, including heart disease, hypertension, diabetes, and some forms of cancer—all issues that pose a risk for young adults. Communities also might consider other examples of approaches for impacting young adults. In the area of obesity prevention, for example, HHS, the U.S. Department of Agriculture, the U.S. Department of Defense, and the U.S. Department of Veterans Affairs are engaged in ensuring that federal programs and facilities meet the Dietary Guidelines for Americans.¹⁶

Key Areas for Research

Given existing gaps in the current public health infrastructure for young adults, research is needed in several key areas to inform public health policies and programs:

• The effectiveness of multilevel interventions in achieving health outcomes, including how to connect with difficult-to-reach young adults. More research is needed to understand the impact of multilevel interventions, including public health campaigns and initiatives, on prevention and the amelioration of risk factors among young adults. Multidisciplinary researchers can review lessons learned as well as evidence in other relevant areas, such as the use of social marketing for other populations. Most of the young adult population is involved in some type of system (e.g., college, community college, military services), but active outreach to those not connected to these communities, or marginalized in other ways, is

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¹⁴ See http://www.thecommunityguide.org/index.html (accessed October 22, 2014).

¹⁵ See http://healthyamericans.org/report/110 (accessed October 22, 2014).

¹⁶ See http://fasinfat.org/national-prevention-strategy (accessed October 22, 2014).

• needed. There is limited evidence on these difficult-to-reach populations and on what strategies may be most effective in engaging them so they are better able to recognize and care about the potential risks they create or encounter.

• The influence of social media on health outcomes. The dramatic shift to reliance on information and communication technologies and the significant uptake of social media by young adults point to the promise of harnessing this form of communication to better connect this population with health-related content. The nature of social media may allow for a rich, interactive learning environment that can both engage youth and tailor content directly to their perceptions, barriers, and needs. The capability for two-way communication may further engage young adults and may turn passive audiences into active participants. But despite the promise of media for connecting young adults with both health information and resources in their communities, more research is needed to determine how best to integrate this platform into health interventions. Those conducting such research will need to use high-quality research methods and large samples, understand what other resources may be needed to supplement social media content, and determine how behavior change may be sustained over time.
• Better understanding of how social determinants, mechanisms, and trajectories contribute to health disparities among young adults, including within different groups. The preponderance of research involving young adults often focuses on college campuses, particularly for priority areas such as alcohol and tobacco consumption. However, the focus on this population fails to fully represent how young adults who do not attend college experience the transition after high school, and thus may obscure how those from different socioeconomic and racial and ethnic groups may be impacted by this transition. More research on how to develop and deploy robust interventions among noncollege youth in diverse community- and work-based settings is sorely needed, including rigorous trials using standardized measures so that behavioral outcomes can be compared across groups. Furthermore, studies with diverse groups may benefit greatly from partnerships with community organizations to increase reach, promote sustainability, account for cultural factors, and tailor the content of interventions more effectively to the needs of the target group.
• Better understanding of the impact of the advertising and promotion of alcohol, tobacco, and marijuana on the health, safety, and well-being of young adults. Research is needed to assess the impact, singly and in combination, of the promotion and advertising of al-

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