The previous chapters of this report respond to the committee’s charge to review key questions related to the effective implementation of youth programs. In particular, Chapter 2 examines the literature on adolescent development through an optimal health lens to set the stage for the review of programs in Chapter 4. Chapter 3 looks at adolescent risk taking and its social environmental influences, and provides an overview of the current landscape of the three specific behaviors (alcohol use, tobacco use, and sexual behavior) targeted by the committee for our program review. Chapter 4 then responds to the central charge to this committee—to use the optimal health framework to analyze the core components of programs found to be effective in preventing unhealthy risk behaviors among adolescents.
This final chapter of the report synthesizes our findings and conclusions into recommendations and promising approaches for research, programs, and policies. In line with the charge in our statement of task to recommend (1) a research agenda incorporating a focus on optimal health for youth, and (2) improvements to the Office of the Assistant Secretary for Health’s (OASH’s) youth-focused programs, the three evidence-based recommendations presented in this chapter focus on the following:
- research on the effectiveness of core components of programs,
- updates to and expansion of data collection for the Youth Risk Behavior Survey (YRBS), and
- OASH programs.
We conclude with the following two promising approaches that, based on a broader examination of the contemporary research literature, represent significant opportunities for program improvement:
- policies and practices focused on inclusiveness and equity, and
- involvement of diverse youth in all decisions for youth programs.
The two recommendations that respond to our charge to provide a research agenda incorporating a focus on optimal health for youth address (1) research on the effectiveness of core components of programs, and (2) updates to and expansion of data collection for the YRBS.
Research on the Effectiveness of Core Components of Programs
RECOMMENDATION 5-1: The U.S. Department of Health and Human Services should fund additional research aimed at identifying, measuring, and evaluating the effectiveness of specific core components of programs and interventions focused on promoting positive health behaviors and outcomes among adolescents.
Our recommendation for further research on the core components of programs is supported by the systematic review and examination of the literature on core components in Chapter 4.
Identification of the core components of evidence-based programs (EBPs) is a relatively new yet promising approach in the field of implementation science. As described in Chapter 4, this approach emerged from concerns about implementation fidelity to manualized or “name brand” EBPs
for children’s mental health conditions when a large number of “generic” programs without the EBP label had shown effectiveness in the community. In an attempt to broaden understanding of the effectiveness, relevance, and availability of evidence-based treatments, clinicians and researchers began undertaking clinical trials that deconstructed EBPs in order to identify their “active ingredients” (Blase and Fixsen, 2013). One example comes from studies of cognitive-behavioral therapy (CBT), one of the most widely used and effective interventions for internalizing problems. Core components research on CBT has shown that exposure to a fear or stressor may be the most important component of this therapy for anxiety and traumatic stress (Seligman and Ollendick, 2011). Moreover, distilling treatments into their active components can help reduce the length of interventions, which in turn can increase treatment fidelity, compliance, and access for diverse populations.
More recent research on the core components of programs for adolescents has shown the utility of this approach with respect to not only mental health, but also opioid use disorder (OUD) and youth program management and quality improvement. For example, researchers at the Center on Addiction have been able to identify 21 core techniques focused on family psychoeducation, medication options, and shared decision making that are most effective for youth in OUD treatment (National Academies of Sciences, Engineering, and Medicine [NASEM], 2019a). With regard to program management and quality improvement, a team at the David P. Weikart Center for Youth Program Quality conducted a systematic review and meta-analysis to identify high-quality practices that could be used by youth workers to promote positive outcomes among youth in after-school programs. Applying the results of this research, they created the Youth Program Quality Assessment, which can be used to measure program quality and identify staff training needs (NASEM, 2019a).
Three main methods can be used to identify core components of programs (see Chapter 4). The first is the distillation and matching method (used by Boustani et al., 2015), which aims to identify the distinct techniques within a treatment that can be used to individualize services (Chorpita, Daleiden, and Weisz, 2005). The second method is the Delphi technique, which involves convening focus groups of experts to reach consensus on the most effective components of a set of treatments (Garland et al., 2008). The third method is meta-analysis and meta-regression (used by Hahn et al., 2015; Wilson et al., 2011; Tanner-Smith et al., 2015), which applies quantitative methods to analyze the relative effectiveness of program components (Lipsey, 2018).
While all of these methods can help identify common components of effective programs, not all are designed to test their effectiveness. To address the issue of effectiveness, several efforts have focused on implementing core
components approaches in practice settings and evaluating whether the use of these methods is associated with better outcomes. Examples include Chorpita et al. (2013, 2017) for children’s mental health; Smith et al. (2012) for after-school programs; and Lipsey (2008), Lipsey, Howell, and Tidd (2007), and Redpath and Brandner (2010) for juvenile delinquency. These examples show promise for core components approaches, but these approaches have not yet been validated for adolescent health behaviors and outcomes more broadly. Therefore, we recommend that the U.S. Department of Health and Human Services (HHS) fund research focused on further exploring the use of core components approaches to identify the components of effective programs that promote adolescent health and test whether those components do in fact result in better health outcomes. If so, these components could be used to develop shorter and more focused interventions that would be (1) less costly and require less facilitator training, which could lead to greater program fidelity, and (2) more accessible to diverse populations.
Updates to and Expansion of the Youth Risk Behavior Survey
RECOMMENDATION 5-2: The Division of Adolescent and School Health of the Centers for Disease Control and Prevention should
update and expand the Youth Risk Behavior Survey (YRBS) to include
- out-of-school youth (e.g., homeless, incarcerated, dropped out), and
- survey items that reflect a more comprehensive set of sexual risk behaviors with specific definitions; and
- conduct further research on the ideal setting and mode for administering the YRBS with today’s adolescents.
As described in Chapters 1 and 3, we chose to use the YRBS to describe trends in adolescent risk behavior because it (1) covers all three of our behaviors of interest, and (2) is the dataset used most often by the sponsor to evaluate youth risk behavior trends. However, our use of YRBS data in this report by no means suggests that these data are perfect. We therefore believe there are specific actions that the Centers for Disease Control and Prevention (CDC) can take to provide a more accurate picture of trends in adolescent risk behavior moving forward.
First and foremost, we recommend that the YRBS begin including out-of-school youth in the sampling design. Although the YRBS estimates that out-of-school adolescents represent only 3 percent of the adolescent population, other research suggests that this figure could be as high as 10.1 percent
(Brener et al., 2013; King, Marino, and Barry, 2018). This population is especially important because those adolescents who are not in school, particularly those who are homeless or incarcerated or have dropped out, have higher incidences of the risk behaviors addressed in this report and their related adverse health outcomes compared with those who are in school (Edidin et al., 2012; Freudenberg and Ruglis, 2007; Heitzeg, 2009; Kearney and Levine, 2012; Odgers, Robins, and Russell, 2010; Tolou-Shams et al., 2019; Wilson et al., 2011). An updated and expanded YRBS that captured data on these youth could help inform programs and interventions for these marginalized groups of adolescents.
Second, we recommend updating the sexual behavior items on the YRBS to reflect the variety of sexual behaviors in which today’s youth engage. The survey’s current sexual behavior questions are vague, referring to “sexual intercourse” without providing a clear definition of this term. Most of the subsequent questions also tend to focus on pregnancy risk, which further suggests that “sexual intercourse” refers only to penile–vaginal intercourse. This wording is inherently flawed for multiple reasons. First, today’s adolescents have different conceptualizations of sex and sexual activity relative to their counterparts in the past (Diamond and Savin-Williams, 2009). Accordingly, respondents may interpret “sexual intercourse” to mean any type of sex (vaginal, oral, or anal) and/or to include only consensual sexual activity, which can lead to biased estimates of the behavior of interest. Second, the emphasis on vaginal sex and pregnancy risk ignores the impact of sexually transmitted infections (STIs), whose incidence is disproportionately higher in adolescents and young adults compared with adult populations (CDC, 2018). Similarly, the focus on vaginal sex excludes LGBTQ adolescents, who are primarily at risk for STIs and may never engage in penile-vaginal intercourse. We therefore recommend that future YRBS cycles not only include a definition for “sexual intercourse,” but also ask about experiences of vaginal, oral, and anal sex in order to provide a more accurate picture of adolescent sexual risk.
Fortunately, the CDC does not have to start from scratch. Other nationally representative surveys, including the National Survey of Family Growth (NSFG), have successfully implemented these types of questions with adolescent populations. Appendix C shows the comparable items on the YRBS and NSFG, which can be used to identify appropriate oral and anal sex questions as well as example definitions for each of these behaviors.
Thus, by implementing the aforementioned changes to the sampling design and sexual behavior items, the YRBS will be able to provide estimates that are more (1) representative of the entire U.S. adolescent population, (2) precise, and (3) reflective of contemporary behavior trends. As a result, these data can be used to make sure that adolescent health programs
and interventions are reflective of the behavior trends and needs of today’s youth.
Finally, we recommend that the CDC conduct further research regarding the ideal setting and mode for administering the YRBS with contemporary cohorts of youth. As described in Chapter 3, the most recent evaluation of YRBS setting and mode effects was conducted in 2008 (Brener et al., 2013; Denniston et al., 2010; Eaton et al., 2010). However, the technological landscape over the last decade has changed significantly, particularly among adolescents. For example, as described in Chapter 2, 95 percent of today’s youth have a smartphone, ranging from 93 percent among those with a household income of $30,000 or less to 97 percent among those with a household income of $75,000 or more (Anderson and Jiang, 2018). As a result, a web-based survey mode may be more effective than paper-and-pencil instruments for today’s youth. Furthermore, if shown to be effective, a web-based survey could also make the YRBS more accessible to out-of-school youth, as described above.
This section of the chapter presents our recommendation for OASH programs. Specifically, this recommendation responds to the statement of task for this study by providing ways that OASH can use its role to foster the adoption of promising elements of youth focused programs in the initiatives it oversees, such as those focused on mental and physical health, adolescent development, and reproductive health and teen pregnancy.
RECOMMENDATION 5-3: The Office of the Assistant Secretary for Health within the U.S. Department of Health and Human Services should fund universal, holistic, multicomponent programs that meet all of the following criteria:
- promote and improve the health and well-being of the whole person, laying the foundation for specific, developmentally appropriate behavioral skills development;
- begin in early childhood and are offered during critical developmental windows, from childhood throughout adolescence;
- consider adolescent decision making, exploration, and risk taking as normative;
- engage diverse communities, public policy makers, and societal leaders to improve modifiable social and environmental determinants of health and well-being that disadvantage and stress young people and their families; and
- are theory driven and evidence based.
This recommendation is grounded in the findings from our systematic review and examination of core components papers presented in Chapter 4. Although we reviewed programs targeting individual behaviors (e.g., substance use, sexual behavior), application of the optimal health framework revealed an important and heretofore neglected area of investment: broadening the focus of OASH-funded programs to teach skills that, if learned successfully, underlie and impact health and well-being across the life course (see Klingbeil et al., 2017). Specifically, evidence shows that integrating and coordinating funding for programs that focus on social-emotional learning and positive youth development would be more effective in targeting adolescent health behaviors and related outcomes relative to the fragmented approach taken in the past (Taylor et al., 2017; U.S. Department of Health and Human Services, 2018). Our review also showed the strengths of social-emotional learning programs initiated in early childhood and continued through adolescence (Taylor et al., 2017), particularly in demonstrating that the nature of the positive effects of such programs may differ across developmental stages (Dray et al., 2017).
It must be emphasized that this recommendation for universal social-emotional learning and positive youth development programs should not be taken as a suggestion that programs targeting specific health behaviors (e.g., substance abuse prevention, inclusive sex education) are not important. Rather, we view the more holistic programs recommended here as building a foundation of self-regulation, good decision making, social awareness, and relationship skills upon which other specific behavioral skills and services (e.g., understanding social norms around drugs, negotiating condom use, access to contraception) can be built.
This recommendation is also informed by our review of the literature on adolescent risk taking in Chapter 3, where we draw a critical distinction between healthy and unhealthy risk taking. Healthy risk taking is a normal and necessary part of adolescent identity development, providing adolescents with opportunities to explore their environments, practice decision-making skills, and develop autonomy. In contrast, unhealthy risk-taking behaviors are often illegal or dangerous, and may result in adverse health outcomes that impede adolescent development. Therefore, instead of conceptualizing all risk taking as negative, it is important to acknowledge its developmental purpose and provide opportunities for adolescents to take healthy risks that will help them learn, grow, and thrive.
Our recommendation for OASH programs also reflects the critical importance of reducing health disparities and promoting health equity by targeting the social determinants of health that disadvantage marginalized communities. As mentioned throughout this and other National Academies reports, marginalized adolescents (e.g., homeless, justice-involved,
estranged from their families, identifying as LGBTQ, having a disability), particularly those who are racially and ethnically diverse and/or from lower-income groups, need more resources relative to their peers from more advantaged backgrounds (Auerswald, Piatt, and Mirzazadeh, 2017; NASEM, 2017, 2019b). Moreover, when standardized programs are implemented in these communities, they often fail to meet the needs of the youth who are targeted. It is therefore critical that OASH programs continue to be developed and implemented with input and support from the communities they serve, as those insights will help identify the most pressing needs for the respective youth populations.
Finally, we recommend that these programs be theory-based and informed by scientific research evidence. Regarding the current research base, our review of programs in Chapter 4 indicates that effective approaches are more likely to be theory-based, to address social influences and norms, to incorporate cognitive-behavioral skills, and to consist of multiple components. However, recognizing that much of the research documented in the current scientific literature was not designed to evaluate the effectiveness of core program components, we recommend that these programs continue to evolve based on future research (see Recommendation 5-1). By continuing to rely on the most up-to-date scientific evidence, OASH will be better positioned to continuously improve the youth programs and initiatives it oversees.
As stated earlier, the committee’s ability to identify core components of programs was hindered by the limited number of studies in the literature that were designed to examine the effectiveness of specific components. However, in line with the charge in our statement of task to identify promising elements of youth-focused programs, we are suggesting two approaches that deserve meaningful attention in the design, implementation, and evaluation of adolescent health programs.
Promoting Inclusiveness and Equity
PROMISING APPROACH 5-1: Programs can benefit from implementing and evaluating policies and practices that promote inclusiveness and equity so that all youth are able to thrive.
Our first promising approach relates to OASH’s role in convening, coordinating, and driving policy and policy discussions. As mentioned in Recommendation 5-3, targeting the social determinants of health that disadvantage marginalized communities is critically important for reducing
health disparities and promoting health equity in adolescent health programs. However, beyond focusing programmatic efforts toward communities with the greatest need, all health education programs can benefit from implementing policies and practices that promote cultural inclusiveness and equity. In particular, programs need to address the structural inequities, including racism, sexism, classism, ableism, xenophobia, and homophobia, that lead to health inequities. When programs are not inclusive and equitable, they can be discriminatory, leading to worse overall outcomes that are both unfair and avoidable (NASEM, 2017; Williams and Mohammed, 2013). Thus, implementing these policies and practices in all programs can avoid the systematic and counterproductive exclusion of youth who may benefit from those programs.
As described by the CDC, an effective health education curriculum “incorporates learning strategies, teaching methods, and materials that are culturally inclusive” (2019). Such practices include (CDC, 2019, para. 13)
- using materials that are free of culturally biased information;
- incorporating information, activities, and examples that are inclusive of diverse cultures and lifestyles (such as genders, races, ethnicities, religions, ages, physical/mental abilities, appearances, and sexual orientations);
- promoting values, attitudes, and behaviors that acknowledge the cultural diversity of students;
- optimizing relevance to students from multiple cultures in the school community;
- strengthening the skills students need to engage in intercultural interactions; and
- building on the cultural resources of families and communities.
Importantly, beyond encouraging programs to adopt specific policies and practices that promote equity and inclusion, these aspects of programs need to be formally evaluated. Although our review of programs as documented in Chapter 4 yielded some evidence that a supportive and inclusive culture improves program effectiveness, the extent to which programs included in our review had such policies or used such practices was rarely if ever measured. We recognize, however, that the limited evidence from our review is due more likely to the constraints of our statement of task and our systematic review methodology than to the relevance of these policies and practices for youth programs.
A variety of resources and tools are available that can help organizations plan, implement, and evaluate culturally and linguistically competent policies and practices. For example, the National Center for Cultural Competence at Georgetown University provides an extensive literature and
a number of training and self-assessment tools that can be used to inform, monitor, and improve the cultural and linguistic competency of organizations and programs, particularly those that work with children and adolescents.2 By using these and other resources, OASH can promote program effectiveness by ensuring the implementation and evaluation of policies and practices focused on equity and inclusion in all of the initiatives it oversees.
PROMISING APPROACH 5-2: Programs can benefit from including youth of diverse ages, racial/ethnic backgrounds, socioeconomic status, rurality/urbanity, sexual orientations, sexes/genders, and disability/ability status in their decision-making processes.
Partnering with diverse youth in the development of policies and programs that impact their health and well-being is critical to ensure the success of these programs (OECD, 2017). Youth are experts in their own experiences and challenges (Wyatt and Oliver, 2016), and as discussed in Chapters 2 and 3, this particular generation has experienced a number of rapid technological and cultural changes that have affected not only how they interact but also how they access and process information about their health. Understanding these experiences is pivotal in creating policies that address and alleviate barriers to promoting their health.
If they become engaged in policy making, youth can openly express their preferences and needs. Evidence from community-based participatory research demonstrates that engaging target populations as full and equal partners ensures that their needs, preferences, and values are reflected in policies and programs designed to impact their well-being (Holkup et al., 2004; Murry and Brody, 2004; Wallerstein et al., 2015). Moreover, including youth from diverse age groups (early, middle, late adolescence), racial/ethnic backgrounds, socioeconomic status, rurality/urbanity, sexual orientations, sexes/genders, and disability/ability status from the very beginning of program development can help make these programs more acceptable and effective for the diverse groups they serve (Ford, Rasmus, and Allen, 2012; Mirra and Garcia, 2017; OECD, 2017; Powers and Tiffany, 2006).
Civic engagement of youth enhances the effectiveness of public policy; conversely, the success of programs and policies is undermined when researchers and policy makers do not authentically value the expertise of youth (OECD, 2017). Promoting participation by youth increases their ownership of policies and programs, which is essential for success, while
also building consensus on key policies. This participation can lead to more effective policy implementation and also strengthen the relationship between citizens and government (Partridge et al., 2018). Thus, engaging youth as experts can yield reciprocal benefits for youth, researchers, and policy makers (Zeldin, Christens, and Powers, 2013).
Given its role as a leader in adolescent health policy at the national level, OASH has a unique opportunity to engage with youth on the issues that affect them. By involving youth in its decision-making processes, OASH can capitalize on their knowledge and experiences to improve its youth-focused programs while also providing positive youth development opportunities for the young people involved in this process.
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