Health promotion for adolescents: preventive and corrective strategies against problem behavior KLAUS
This paper, in its first part, gives an overview of research on “problem behavior” in adolescence. Adolescence is considered to be a stage in life characterized by more experimentation, exploration, risk-taking, and rebellion than any other stages. Many health-damaging behaviors (drug consumption, precocious sexual activity, riskful driving, aggressive behavior, etc.) have important psychosocial functions in adolescents’ developments. Some of these behaviors can be signals of “stress”, defined as a bio-psycho-social state of tension resulting from a variety of stressors which confront adolescents daily in modern industrial societies. In the second part of the paper, the implications of this research for strategies of intervention are discussed. The systematic analysis distinguishes between different stages in the process by which problem behavior emerges and separates “preventive” from “corrective” forms of intervention. Additionally, the analysis differentiates between the dimensions targeted by the measures: interventions addressed toward individual behavior (“personal resources”) on the one hand, and living conditions (“social resources”) on the other hand. The resulting types of intervention approaches are illustrated with examples and discussed in view of how appropriate they are for health promotion in adolescence. Implications for “social policy for adolescents” are discussed.
In adolescence, many personal behaviors contribute to morbidity and mortality: smoking, heavy drinking, using illegal drugs, precocious and unprotected sexual activity, no regular participation in sports and exercise, riskful driving, aggressive and other forms of behavior that Richard Jessor (1984) has called “problem behavior”. Adolescence, obviously, is a stage in the life span characterized by more experimentation and exploration, risktaking and rebellion than is the case in other stages. Although experimentation with health risks is normal in adolescence, parents, teachers, and youth + Reprint requests should be addressed Intervention FRG.
to Klaus Hurrelmann, Research Center “Prevention and and Adolescence”, University of Bielefeld, POB 8640, D-4800 Bielefeld,
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Association for the Psychiatric Study of Adolescents
consequences that adolescents’ lives. As Richard Organisation, the shaping
in his plenary
to the World
in May 1989, has pointed out, adolescence of health in adulthood and in later life.
is a key lifestage for At the same time,
adolescence is in itself a stage of high risk for morbidity and mortality. Poverty, ubanization, rapid social change, and the decline of traditional social supports and controls have exacerbated such health risks in several subgroups of the adolescent population of various countries, both industrialized and non-industrialized. Consequently, to change personal behaviors from healthdamaging to health-promoting ones is a main target of intervention strategies. Traditionally, counseling
this has been done by providing programs.
the limits of this approach
seen: they do not take into account the social and psychological motivations and functions of health-damaging behavior, because they neglect the social context
of the behavior.
HEALTH In recent
we have to rethink
it into the more comprehensive
IN MXJLESCENCE health is used as a comprehensive
defining a physical and mental state in which processing inner and outer reality in a productive
an individual and satisfying
approaches social factors
is capable of manner. This
psychological the formation
personality. Socialization is understood as the process of the emergence, formation, and development of the human personality in dependence on and in interaction with the human organism on the one hand, and the social and material environment on the other (Featherman and Lerner, 1985).
The notion of the “healthy personality” According to this concept, a healthy personality does not form independently from society in any of its functions or dimensions but is continually shaped in a concrete, historically conveyed lifeworld throughout the entire length of the life span. The lifelong interplay between biological, psychological, and cultural/societal potentials and constraints determines the indi-
vidual’s state of health. In contrast to the viewpoint in medicine, the comprehensive definition of health proclaimed here emphasizes the integration of well-being into all of the dimensions of daily life. Self-responsible behavior and self-regulation are regarded as essential factors in the development of a healthy personality. Thus, health-conscious and health-promoting lifestyles can only be expected when the prerequisites for such factors are available. Health, therefore, is both a personal and a collective variable: “Health describes the objective and subjective state ofwell-being that is present when the physical, psychological, and social development of a person is in harmony with his/her own possibilities, goals, and prezlailing living conditions. Health is impaired when demands that arise in one or more of these areas cannot be coped with by the person in his/her respective stage of life. The impairment may be mamfest in symptoms of social deviance, psychological disorder, orphysicalphysiological disease” (Hurrelmann, 1989, p. 5).
Thus, health is composed of physical, psychological, and social aspects which influence each other reciprocally. Health is closely connected to individual and collective value systems and behavior patterns which are manifest in personal lifestyles. It is a state of equilibrium which must be continuously maintained during the life course. It is not a state of well-being that is passively experienced, as suggested by the purely physical definition within classical medicine: instead, it is the result of actively pursuing the establishment and maintenance of a social, psychological, and physical capacity for action. Social, economic, ecological, and cultural living conditions thereby form the framework with which the potential for health can develop. According to this concept, the state of health reJlects the subjective processing of and coping with physiological, psychological, and social conditions. Health is only possible when a person is able to establish constructive social relationships, is socially integrated, able to adapt his/her individual lifestyle to the changing aspects of the environment and thereby secure personal self-regulation, and act in accordance with the prevailing biogenetic, physiological and physical capacities. The modern theoretical approaches in social medicine, social psychology, social pediatrics, social pedagogy, social epidemiology, and medical psychology stress the interdependency of human development on the one hand, and the development of the social and physical environment on the other. The criterion of a “healthy” development is seen in the acquisition of social, psychological, and physical competencies which enable individuals to act adequately and develop an identity of their own, at the same time taking into account their needs and personality structures. The theoretical foundations of these approaches have been developed, among others, by Engel (1962), Levi (1971), Bronfenbrenner (1979), and Matarazzo, Weiss, Herd, Miller and Weiss (1984).
Ii. HURRELMANN Psychosocial
Modern youth research is increasingly making use of these theoretical models (Hurrelmann, 1989, p. 3.5). Health-enhancing as well as healthdamaging behaviors in adolescence are seen as part of the process of solving developmental tasks. Thus, risk behavior is a behavior that has to be understood as being functional: that is, it is instrumental, purposeful and goal-directed (Jessor, 1984). “Problem behaviors” such as cigarette smoking, getting drunk, engaging in unprotected intercourse, unhealthy eating habits, risk-taking activities, and illicit drug use can fulfil important functions for a young person, even though they are likely to compromise that young person’s health : “In this way, behavioral F-isk factors are dtfferent from otheF- kiFtds of tisk factors-they caFt have positive as well as Fregative coFtsequences. Healthcontpromising behaviors such as cigarette sFFtokiF?g,although placing the adolesenable that cent at Fisk for lung and heart disease, may simultaneously adolescent to attain importantpositive satisfactions such as beiFzgaccepted by the peel-group, orjust feeling more grown up, Otherficnctions that adolescent healthrisk behaviors may serve have emergedfrom a great deal of research: engaging iFt Fisk behaviors, e.g. using illicit drugs, caFr be a meaFrs of expressing opposition to adult authonty and conventional society; heavy alcohol use CLIFI be a copiFtg mechanism for dealing with frustratioFt aFtd anxiety; risky dn’ving or dn’nkitzg and driviFrg can affirm an importaFtt personal identity such as beiFtg “‘macho” OF cool; and Fisk behaviors catr be a way of attaiFtiFtg iFtdepeFrdeFzce froFFt pareFUn authority and taking personal control of one’s own life, e.g., by iFritiatiFrg sexual intercourse or by earl-v childbeaF_ing” (Jessor. 1989, p. 3).
Those patterns of behavior that can be considered as “problem behavior” are chosen because, in a specific social and personal situation, they provide a way of defining a public image and achieving social status. In many cases, they have their social context in the peer group, which is one of the most important reference groups in adolescence : “According to problem behavior theov, vulnerability to peerpressuF-e and the risk of substance abuse would be greater for adolescents who have fewer effectire coping strategies in their repertoire, fewer skills for handling social situations, and greater anxiety about social stituatioFts. I;‘or these adolesceFits, the range of options for achieving personal goals would be restricted at the sanre tinte that discomfoFt in interpersonal situations was high, motivating them to take echatevler actions they thought might be reasonable coping responses” (BotviFt aFtd Dusenbury, 1989, p. 8).
In other words: problem a bio-psycho-social
behaviors, in this respect, are signals of “stress”, of of tension resulting from a variety> qf stressful
“developmental tasks” (Coleman, 1989)) which confront adolescents daily in peer group, family, school, and work. Problem behavior emerges as soon as the personal as well as social resources are insufficiently developed in an adolescent’s life setting in terms of structure and profile. If the preconditions and foundations needed for self-efficacious and self-regulated behavior are lacking, the probability increases that physiologically, psychologically, and socially problematic forms of behavior will develop (Garmezy and Rutter, 1983 ; Peterson and Ebata, 1989). Whether or not specific constellations or stressful situations, events, and life situations (e.g., strain at school, difficulties in establishing peer-group relations, problematic school-to-work transition) lead to problem behavior depends first and foremost on the adolescent’s specific skills and abilities to cope with stressors. For example, if a discrepancy is perceived between action competencies and actions to be performed, the adolescent has to mobilize strategies to overcome the former. These strategies can be developed if and when there is the ability and readiness on the part of the adolescent to realistically perceive and assess his or her own action competencies and to identify as precisely as possible in which areas a discrepancy exists in relation to the competencies required. Following this diagnosis, in order to eliminate the discrepancy, strategies that are adequate to the situation then have to be implemented to correct and control individual action competencies on the one hand, and the situational demands for action on the other. The possibilities and patterns of constructing strategies for coping behavior are influenced, directly and indirectly, by the social and material living conditions. Social resources are important moderating factors that determine whether or not stress leads to problem behavior. These social resources can be defined in terms of the potential material, financial, informational, instrumental, emotional, cultural, and social stimuli, as well as support by the environment to the individual in a specific life situation (Thoits, 1983). This theoretical interpretation is supported by the results of the Bielefeld Study on Adolescence, which demonstrates that the main risk factors for drug, alcohol, and tobacco consumption and aggressive behavior, for example, are to be seen in (a) parents’ unfulfilled expectations of the adolescent’s school performance, (b) strong subjective strain due to scholastic demands, (c) experiences of failure in school, (d) difficulties in achieving recognition and integration into the peer group, and (e) relative material disadvantage in comparison with friends and peers. The occurrence of one or more of these risk factors correlates with a high probability that problem behaviors of the type mentioned will emerge (Engel, Nordlohne, Hurrelmann and Holler, 1987; Hurrelmann, Engel, Holler and Nordlohne, 1988; Hurrelmann and Engel, 1989a). In our study, aggressive delinquent behavior and drug consumption are
strongly associated with difficulties in the process of integration into peer groups. If adolescents are not successful in achieving an appropriate degree of acceptance from the peer group, and in establishing an undisputed social position within this group, and if they suffer from lack of popularity and recognition among their peers, a considerable insecurity in their social orientation and self-esteem results. Appearing to be at a disadvantage and to not be able to keep up with the peer group’s material (financial) standards serves as a decisive factor in the establishment of these types of problem behaviors. The strain and demands on adolescents in this respect are particularly high when emotional tensions with parents conflict with the peer group’s lifestyle. Those adolescents who report having conflicts with their parents in various areas of life are also those who have the highest risk of manifesting aggressive behavior and drug use (Engel and Hurrelmann, 1989). Results of this type are supported by several other IP~L~~I.~~~ grmdps (Jessor and Jessor, 1977; Bachman, O’Malley and Johnston, 1982; Siddique and D’Arcy, 1984; Butler and Corner, 1984; Elliot, Huizinga and Ageton, 198.5; Irwin and Millstein, 1986; Mechanic and Hansell, 1988). They show the importance of applying a comprehensive theoretical approach to explain problem behavior in adolescence. Many research results show agreement that problem behaviors have to be conceptualized as a syndrome (Botvin and Dusenbury, 1989), because there are consistently strong intercorrelations between different types of substance use (e.g., smoking, drinking, and drug use) and between different types of health compromising behaviors (e.g, substance use and precocious sexual behavior). These behaviors also correlate with indices of psychosocial risk, including environmental and personality variables such as: more friends’ models for deviant behavior, greater attitudinal tolerance for problem behavior, and independence being valued more highly than academic recognition; again this suggests a common underlying cause (Jessor, 1984). These results point to the fact that substance users differ from non-users on several behavioral dimensions, suggesting an underlying difference in values and ambition. For instance, individuals who use psychoactive substances are more likely than non-users to have poorer academic performance and engage in antisocial behavior, and are less likely to participate in organized extracurricular activities (e.g., sports or clubs). “These studies suggest that dizjerse health hehazio,s at-e injuenced more lq general styles of adaption that underlie daily routines and are socially and culturally rewarding than by specific motivations to he healthy. Much of the behavior associated with good health is integrated into complex behavioral repertoires that are sustained by interlocking networks of reinforcements. Smoking, alcohol use, exercise, and many other- health-related behaziors al-e components of pervasive cultural pattenls associated with religious and moral
orientations, educational lezlels, and the values and expectations of particular subgroups in the population” (Hansel1 and Mechanic, 1990, p. 78).
Thus, we face a complex set of factors which turn adolescence into a specific high-risk stage of life for health. In adolescence, the balance between health-compromising and health-enhancing activities is at stake. As Jessor has pointed out, the risk to health of engaging in health-compromising behaviors should probably be seen as a variable; at the same time its magnitude will often depend on the extent, the variety, and the intensity of the healthenhancing behavior engaged in by the adolescent: “Health risk in adolescence can refer to risk that is immediately consequential within adolescence (e.g., the risk from driving after consuming alcoholic beverages); to risk that has consequences for the post-adolescent period-that is, for adulthood and later l&e (e.g., the risk from obesity, orfiom a diet high in saturated fats); or to risks that include both present and remote consequences (e.g, the risk from becoming pregnant). It can refer to risk deriving from behacior (e.g., from cigarette smoking orfrom not using seat belts); to risk deriving from personality characteristics (e.g., risk from the sense ofpowerlessness orfrom having a strong need for independence and rebelliousness); to risk related to aspects of the enzlironment (e.g, the risk from contracting a sexually transmitted disease orfrom having adolescent hypertension); or to variable risks that depend for their consequences on the presence of certain situational factors (e.g., the risk from using marijuana just before drizjing), on gender (the risk from heavy drinking when pregnant), or on age (e.g, the risk from insufficient hours of sleep in early adolescence) ” (‘essor, 1984).
Measures carried out by public or private institutions, organizations, and associations are generally subsumed under the term “intervention”. As the discussion of research results in the previous section has shown, it is very important to distinguish between different stages in the emergence and development of symptoms of problem behavior which demand different intervention approaches. Therefore, in the following, I will roughly distinguish between two stages of intervention: intervention that attempts to prevent potential disorders in the (health) development of personality (“preventive or prophylactic intervention”), and the intervention that aims to reduce and if possible remove disorders already manifest (“postventive or corrective intervention”). The term preventive intervention is used to describe measures which are implemented before any symptoms of problem behavior are manifest. The aim is to avoid the personal and social conditions which are known to lead to
behavioral problems in adolescence. In this sense, they are anticipatory or “preventive” in the strictest sense of the word. In contrast, the term corrective intervention is used to describe measures which are employed after symptoms of stress are already manifest. In an attempt to strictly discriminate these measures from those of preventive intervention, the term “postventive intervention” could also be used. Corrective intervention, being directed toward problem behavior which is already manifest, uses appropriate measures in an attempt to check and reverse this behavior. Corrective intervention includes those measures which concentrate on preventing a consolidation and increase in problem behavior. Primarily, the aim is to reduce the consequences of problem behavior and its damaging side-effects in other areas of activity, as these can result in a “vicious circle” and in the establishment of a “social career” of deviance. The terminology chosen here is given preference over the terms “primary, secondary, and tertiary prevention” used in medicine (Caplan and Grunebaum, 1967), because it avoids an inappropriate inflationary use of the term “prevention”. However, distinct connections to medical terminology are apparent which are indicative of a common concept, inasmuch as measures are classified and defined according to their point of application in the process whereby problem behavior is manifest. Besides this differentiation between the stages in the process by which disorders and deviance emerge and develop, we can also differentiate between the effective dimensions targeted by the measures. This “target of intervention” can be divided into personal and social resources. The intervention is addressed toward the personal resources when the individual is the target of the activities, and where, for example, attitudes, behavior, action competence, and habits are to be influenced and modified. The intervention is directed toward social resources when ecological, material, and environmental factors are to be influenced. In this case too, the aim is to have a repercussive effect on the behavior of the individual (Hurrelmann, 1987; 1988). The acknowledgement given to interventions directed toward social resources has been completely unsatisfying in recent years. Most intervention activities have been focused directly on the individual behavior of adolescents, thereby neglecting the psychosocial functions of this behavior and its contextual relations. What we need, however, is a coordinated application of all the above-mentioned types of intervention if they are to be effective against health-impairing problem behavior. Interventions have to encourage and strengthen individual and social resources. In respect to individual resources, the emphasis is on promoting competence; in respect to social resources, the emphasis is on the promotion of networks. Intervention measures must be directed toward both poles of this relationship; they cannot be restricted to
changing individual factors alone. Having arisen in a social context-that of a concrete social and ecological environment-the individual’s capacity for action and coping can only be influenced and modified within this context. Such a context must be made the object of health-promotion policies for adolescents if these are to have a lasting effect (Heller and Swindle, 1983). If intervention concentrates only on the adolescent’s individual attempts to cope with developmental tasks and thereby avoids contact with the social basis of these attempts, it must remain ineffective or, at best, result in symptom displacement: the adolescent who drinks alcohol or smokes to relieve stress recognizes that such behavior results in impairments to health; as a consequence, he/she may possibly shift the conflict mechanism, become aggressive or depressive, acquire unhealthy eating habits, or seek refuge in other such behaviors that lead to long-term health impairments (Silbereisen, Eyferth and Rudiger, 1986). Promotion of individual competency and social resources must be viewed together, because as has been shown health depends on biological, psychological, socioeconomic, and natural living conditions, and on genetic disposition. Promoting personal and social resources entails endowing all adolescents with a greater degree of autonomy in organizing their living conditions, thereby enabling them to contribute toward their own health. In order to achieve a comprehensive sense of physical, mental, and social well-being, it is necessary for adolescents to be able to satisfy their needs, to recognize and achieve their hopes and dreams, and to deal with and modify their environment in a productive manner (Hurrelmann and Engel, 1989b).
COMPETENCE AND PROMOTING IN ADOLESCENCE
It is the aim of the following discussion to assess the limits and potentials of the different measures, to evaluate their advantages and disadvantages, and to give each measure its appropriate place in the overall ensemble of possible intervention strategies. By referring to the categorical discussion above, we can differentiate four “ideal types” of measures of intervention (see Figure 1). We now look at these four types of measures in detail.
Education, and particularly health education, being widely available, is a predominant mode of strengthening personal resources. Within industrial societies, the most important institutions for offering education are families,
preschool facilities, schools, vocational training schemes, and institutions of higher education and training. The term “health education” denotes the consciously planned, directive influence on individual personality development by means of another individual who is usually more knowledgeable and competent. In conveying knowledge, attitudes and skills by systematically initiating learning steps, health education aims at positively influencing the personality development of the recipient, strengthening his/her behavioral competency in various dimensions, and encouraging an autonomous process of acquisition by which an individual can have access to and adopt this competency. To give an example: the most widely used approach to drug abuse prevention over the years has been one which relies on the dissemination of factual information stressing the adverse consequences of substance use. Some approaches have attempted to emphasize and even to dramatize the risk associated with tobacco, alcohol, and drug use. The underlying assumption is that evoking fear should be more effective than an objective presentation of factual information. Other programs attack the problem of drug use from a moral perspective (Botvin, 1986). All approaches of these types only have a limited success, because they only
Personal resources (individual behavior)
Social resources (living conditions)
.4-type measures: Training individual competency
Health education Personal and social skills training Scholastic competence training Counseling
Improving social living conditions -
Improving the opportunity structure Creating possibilities for participation
-Treatment - Therapy
(Re-)Construction social networks
affect adolescents with a specific attitudinal structure and in other adolescents may even arouse curiosity. Therefore, recently, programs focusing on resistance skills and/or on personal and social life skills have been developed that pay primary attention to the psychosocial factors promoting substance use initiation : “The primary distinguishing feature of these approaches is that they typically include two or more of the following components: (1) general problem-solving and decision-making skills (e.g., brainstorming, systematic decision-making techniques); (2) general cognitive skills for resisting interpersonal or media influences (e.g., identifying persuasive advertising appeals, formulating counterargumerits);; (3) skills for increasing self-control and self-esteem (e.g., self-instruction, self-reinforcement, goal-setting, principles of self-change); (4) adaptive coping strategies for relieving stress and anxiety through the use of cognitive coping skills or behavioral relaxation techniques; (5) general interpersonal skills (e.g., initiating social interactions, complimenting, conversational skills); and (6) general assertive skills (e.g, making requests, saying So”, expressing feeling and opinions). These skills aregenerally taught by using a combination of instruction, demonstration, feedback, reinforcement, behavioral rehearsal (practice during class), and extended behavioral homework assignments” (Botvin and Dusenbury, 1989, p. 26).
These programs take into account that drug use is woven into a fabric of daily coping strategies. Accordingly, these measures are aimed directly at the psychosocial function that drugs have for adolescents. The aim is to offer direct help in establishing appropriate capabilities for coping with complicated and stressful life events and day-to-day situations. In order to be ultimately effective, however, it is imperative that functionally equivalent activities can be introduced; that is, behavior that is just as attractive and that receives as much attention as drug use, and which adolescents can accept as a consciously sought alternative with which to avoid drugs and their consequences and side-effects for health (Perry and Jessor, 198.5). In this respect, these programs have to be complemented with measures of type C. Other measures of type A will only be described briefly: (a) The results of the studies mentioned above have shown that many symptoms of health impairment are closely related to scholastic performance. Improving student performance in school through appropriate scholastic training can result in greater achievement and thereby neutralize an important cause of problem behavior. For this reason, advancement of social, intellectual, emotional, cultural, and psychomotoric competency within scholastic instruction is one of the most important intervention measures which can be applied within the context of school (Engel and Hurrelmann, 1989). (b) In addition to conveying scholastic knowledge and health skills