Promoting healthy behaviors among adolescents: a review of the resiliency literature.

Abstract: This article discusses the resiliency research on adolescent health behavior. A review of the resiliency research is provided. A conceptual framework provides a conceptual base to describe how the resiliency research may protect adolescents from engaging in negative health behaviors. In addition implications for planning, implementing and evaluating adolescent health promotion programs are also discussed.

**********

Research on adolescent involvement in health behaviors has primarily focused on risk factors that predispose, enable and reinforce engagement in high-risk health behaviors among adolescents (Perkins, Luster, Villarruel, & Small, 1998; Resnick, 2000; Scales & Leffert, 1999). In relation to adolescent problem behavior, risk based research proposes that risk factors are those conditions or variables present in an adolescent's life that may lead to negative health outcomes (Jessor, Van Den Bos, Vanderryn, Costa, & Turbin, 1995). Jessor et al. summarized risk factors as follows:

   Risk factors are conceptualized as increasing
   the likelihood of engaging in problem behavior;
   through direct instigation or encouragement
   (e.g., failure or frustration instigating
   a coping response, or models and influence
   from peers; through increased vulnerability
   for normative transgressions (e.g., low
   esteem); and through greater opportunity
   to engage in problem behavior (e.g., membership
   in an antisocial peer group) (Jessor et
   al., 1995, 924).

A substantial body of research associated with adolescent health risk behavior has focused on age, race, ethnicity, family structure, socioeconomic status, history of sexual abuse, low self esteem, alcohol use, peer relationships, depression and parenting styles (Murry, 1992; Santelli, Lowry, Brener, & Robin, 2000; Small & Kerns, 1993; USDHHS, 2000).

While risk focused research has provided important insights into negative causative factors associated with adolescent health behavior much less research has been conducted on the role that protective factors play in positively influencing adolescents against in negative health behaviors (Blinn-Pike, 1999; Jessor et al., 1995). Protective factors may have a direct effect on behavior and may moderate risk factors and help to protect negative health behaviors. Interest in the effects of protective factors on adolescent problem behavior is increasing (Jessor et al., 1995; Scales & Leffert, 1999).

Researchers have suggested that risk and protective factors must be treated orthogonally and not inversely (Figure 1). Jessor et al., (1995) have stated that protective factors should be examined separate from risk factors, not merely defined as an absence of risk or as low risk factors. Further, protective factors should be studied as a means to increase positive health behaviors among youth and not merely to reduce the risk of engagement in negative health behaviors. The Association of Maternal and Child Health Programs has stated that the role of health education within public health in addressing the health and well being of adolescents is changing to more closely examine protective factors in youth, families, schools and communities (Fine & Large, 2002). This approach may form a basis for developing adolescent health policies and programs that emphasize preventive and positive interventions that incorporate the development of assets and competencies in adolescents (Fine & Large, 2002).

[FIGURE 1 OMITTED]

This paper addresses the contribution of resiliency research toward understanding adolescent health. A conceptual framework provides a conceptual base to describe how protective factors may protect adolescents from engaging in negative health behaviors. Implications for planning, implementing and evaluating adolescent health promotion programs are also discussed.

OVERVIEW OF THE RESILIENCY RESEARCH

The concept of resiliency was originally developed in the field of developmental psychology (Blinn-Pike, 1999). Resiliency has been defined as:

   The process of, capacity for, or the outcome
   of successful adaptation despite challenging
   or threatening circumstances (Blinn-Pike,
   1999, p. 2).

The study of resiliency focuses on the strengths or assets that exist within individuals, communities, schools and families. Current research suggests that "assets" may buffer youth against negative health behaviors, such as sexual promiscuity, substance abuse, poor dietary choices, inadequate physical activity and anti-social behavior (Scales & Leffert, 1999). What makes a youth resilient to certain negative health behaviors is unique to that particular individual and the environment in which he or she lives. From an ecological systems theory view (Bronfenbrenner, 1979), an individual's resiliency is a product of an interaction between individuals, families and the social environment.

The earliest study by Emmy Werner examined resiliency among adolescents in the 1950s, and ended in the 1980s. Results for this study suggested that positive influences can mitigate high-risk behaviors. Werner (1998) observed that children who had been raised in poverty and considered "at risk" for engaging in negative behaviors; when positive factors such as a self efficacy, problem solving skills, presence of a caring adult or engagement in school were present in the lives of these children, they were less likely to be involved in negative health behaviors such as teen pregnancy, substance abuse and anti social behavior.

More recently Benard (1991) and Scales and Leffert (1999) have suggested that positive factors, such as time spent with a caring adult, bonding to school and community; good communication and problem solving skills and an ability to make and keep friends, positively influence youth away from engaging in negative health behaviors. These positive, protective factors can affect adolescent health behavior in two ways. First, protective factors may buffer or protect adolescents from harm by decreasing the likelihood that an adolescent will engage in a high-risk health behavior (Jessor et al., 1995; Resnick et al., 1997; Scales & Leffert, 1999). Second, protective factors may serve as moderators of risk because they modify the relationship between risk and problem behavior (Jessor et al., 1995). Resnick (2000) defined protective factors as "events, circumstances and life experiences that can help protect young people from harm" (p. 1). Jessor et al. (1995) described protective factors as follows:

   Protective factors are conceptualized as decreasing
   the likelihood of engaging in problem
   behavior; through direct personal or social
   controls against its occurrence (e.g., strong
   religious commitment or predictable parental
   sanctions); through involvement in activities
   that tend to be incompatible with or
   alternatives to problem behavior (e.g., activities
   with the family or with which groups);
   and through orientations towards and commitments
   to conventional institutions (e.g.,
   schools) or to adult society more generally
   (Jessor et al., 1995, 924).

Outlined in Table 1 are the different ways researchers have conceptualized the organization of protective factors over the past 20 years. For example Hawkins, Catalano, and Miller (1992) hypothesized that there is an interplay of a variety of specific protective factors during adolescence that influence adolescent health behavior. Hawkins and Catalano (1992) organized protective factors within four domains that include the individual/peer domain, the family domain, the school domain and the community domain. In the individual/peer domain protective factors include healthy beliefs and clear personal standards for behavior. In the school domain protective factors include bonding to school, such as opportunities at school for involvement educational and extracurricular activities and school rewards for positive behaviors. In the family domain protective factors include family attachment and family opportunities for involvement such as eating meals together, good communication with parents, and clear boundaries and parental expectations. And in the community domain protective factors include community rewards for positive behaviors, and community laws and norms that support and reinforce positive behaviors (Hawkins, Catalano, Kosterman, Abbott, & Hill, 1999; Hawkins et al., 2000).

Garmezy (1985) has summarized protective factors into three categories: 1) individual differences, such as self esteem, high self efficacy, and personal competencies, 2) family attributes, such as family support and affection, and 3) extrafamilial situations such as support from other adults and strong integration of the family into the community in which they live. Jessor et al. (1995) have conceptualized protective factors within three psychosocial systems: 1) the personality system such as positive orientation towards health and intolerant attitudes towards deviance, 2) the perceived environment system such as positive relations with adults, awareness for friends who model conventional behavior and provide a strong social influence, and 3) the behavior system such as involvement with prosocial behaviors like volunteering to work for a community service project and engaging in family activities such as spending recreational time with parents and participating in religious functions together.

Similar to the concept of protective factors, increasingly the concept of developing assets in individuals, families, schools and communities is gaining more credibility in the public health arena. Benson, Blyth, Deville, and Wachs (1997) created the Developmental Asset Model for youth, families and communities. This model is divided into 20 internal and 20 external assets. The 20 internal assets fall into three categories: commitment to learning, positive values, and social competencies (Scales & Leffert, 1999). The 20 external assets fall into four categories: support, empowerment, boundaries and expectations, and constructive use of time (Scales & Leffert, 1999). Benson et al. (1997) hypothesized that in order to be resilient to negative health behaviors youth must have internal and external assets present in their lives and that the more assets present in a youth's life the less likely they are to engage in high risk behavior such as sexual promiscuity, substance abuse or anti social behavior.

More recently in the resiliency research the concept of "connectedness" as a means to promote resiliency in youth is growing. Resnick et al. (1997) reported that parent-family connectedness, connectedness to school and some individual characteristics may protect adolescents from engaging in negative health behaviors. Fors, Crepaz, and Hayes (1999) found that parental monitoring and involvement, family communication, school connectedness, and positive sense of one's own future reinforced positive heath behaviors. Participation in religious services and sports as well as academic achievement has been found to increase resiliency from engagement in negative health behaviors (DuRant, Kahn, Beckford, & Woods, 1997; Stronski, Ireland, Michaud, Narring, & Resnick, 1999).

A CONCEPTUAL FRAMEWORK OF PROTECTIVE FACTORS

The factors that contribute to adolescent health behavior are complex and multidimensional. Multiple factors often interact simultaneously at the individual, family, peer and community level to impact an adolescent's health behavior (Small and Kerns, 1995). The concept of resiliency provides a strength-based environmental approach for understanding how a variety of factors may interact to create positive health outcomes for youth. Adolescents live within several different domains that include four main categories: 1) as an individual, 2) within a family, 5) interaction with communities such as in schools and neighborhoods and with peers, and 4) are affected by macrosystem factors such as values, norms and cultural beliefs. Within these differing environments protective factors operate simultaneously to impact adolescents' health behaviors. Figure 2 provides a conceptual framework of protective factors to explain how adolescent's health behaviors derive from interactions with different situations and conditions. The concept of protective factors illustrates that a combination of factors may relate to an adolescent's health behavior: how the adolescents were parented, what kind of neighborhood they live in, who their friends were, what kind of school they went to, what kind of students they are in school, and the values and norms of the community in which they are being raised (Rink & Tricker, 2003).

[FIGURE 2 OMITTED]

APPLICATION OF THE PROTECTIVE FACTORS FRAMEWORK TO ADOLESCENT HEALTH PROMOTION PROGRAMS

The resiliency research has demonstrated that multiple factors interact to influence the well being of adolescents. The resiliency research confirms the importance of a multifaceted approach to adolescent health promotion and the development of adolescent health promotion programs. Furthermore the identification of common protective factor themes at the individual, family, community and macrosystem level that promote resiliency in youth highlight the need for health educators to focus their programming efforts on some of these common protective factor themes. These protective factor themes include:

1) Developing interpersonal and intrapersonal skills among youth.

2) Promoting youth participation in the environment in which they live.

3) Emphasizing intergenerational relationships between youth and adults.

4) Establishing clear norms and expectations for youth.

5) Providing access to information and services for youth in their community.

6)Involvement in policy changes that support positive youth development.

Outlined below are suggestions for how health educators can apply these key protective factor themes to plan, implement and evaluate health promotion programs for adolescents.

Increase Interpersonal and Intrapersonal Skills. Health promotion programs for adolescents must include educational components that address increasing social skills, problem solving skills and communication skills in order to increase self esteem, self efficacy, and promote a positive sense of one's individual capabilities. Health Educators can evaluate the effectiveness of health promotion programs designed to increase interpersonal and intrapersonal skills by utilizing pre and post test techniques.

Promote Youth Participation. Engaging youth in real opportunities for involvement and leadership such as leading group discussions or functioning as peer role models provides opportunities for youth to increase their sociability with their peer group and adds credibility to the health promotion program among the adolescents. In addition utilizing a participatory action research approach to program evaluation by including adolescents in what kind of data to collect as well as the data collection process is a useful method of promoting youth participation in health promotion programs.

Emphasize Intergenerational Relationships. Research overwhelming emphasizes the need for access to caring adults and positive adult role models in the lives of youth as a means of buffering adolescents from engagement in negative health behaviors (Scales & Leffert, 1999). Health promotion programs that provide adolescents with access to adults and incorporates adult role models for youth to interact with enable adults and youth to view each other in a positive light and allows for adults to model prosocial behaviors. Evaluation of intergenerational programs for youth may include completing questionnaires or conducting semi structured interviews that describe the impact of intergenerational relationships in the lives of adolescents.

Establish Norms and Expectations. In order to successfully navigate through adolescence youth need clear norms and expectations established for them that provide them with a sense of what kind of behavior is expected of them. Establishing norms and expectations for youth provides them with and understanding of rules acceptable to the environment in which they live. Health promotion programs designed for adolescents should clearly identify what the norm and expectations are for the youth participating in the program as well as engage youth in supporting each other to uphold the program norms and expectations.

Provide Access to Information and Services. Health promotion programs designed to address the health challenges of adolescents would benefit from providing information on services available to youth in their community. By doing so adolescents access services and programs themselves or with their family members that provide them with additional opportunities for involvement. Simple process objectives, such as the number of materials distributed, the number of adolescents referred to services, or the number of adolescents actually seen for services, may be used to evaluate whether or not an adolescent did or did not access information or services based on participation in an adolescent health promotion program

Involvement in Policy Changes. Health educators working with adolescents have the unique opportunity to engage youth in policy and program decision making. Adolescents provide health educators with first hand observations and perspectives on the health challenges facing youth that can guide current and future decisions regarding effective health promotion interventions for youth. Developing mechanisms such as youth advisory committees or councils that can advocate for program and policy changes that benefit adolescents is critical to health promotion programs addressing adolescent health (Fine & Large, 2002). Evaluation methods for assessing adolescent involvement in policy changes may include techniques such as the number of youth advisory committees or councils form, the number of youth participating in such groups, or a survey to determine youth satisfaction with participation in policy making groups.

CONCLUSION

In recent years the concept of resiliency has received an increased amount of attention in the adolescent health behavior literature. Whereas much of the former research on adolescent health behavior has focused on identifying risk factors that increase the likelihood of adolescent engaging in negative health behaviors, the risk factor approach to problem identification only provides a partial understanding of adolescent health behavior. Closer examination of protective factors at the individual, family, school and community level is gaining momentum within the health education discipline. Health education specialists need to have sound knowledge and understanding of the resiliency research and the concept of protective factors to work with adolescents, families, schools and communities in order to plan, implement and evaluate effective adolescent health promotion programs.

CHES AREAS

Responsibility II--Planning Effective Health Education Programs

Responsibility III--Implementing Effective Health Education Programs

Responsibility IV--Evaluating Effectiveness of Health Education Programms

REFERENCES

Benson, P., Blyth, D., Deville, C., & Wachs, J. (1997). Developmental assets among Seattle youth. Minneapolis, MN: Search Institute.

Benard, B. (1991). Fostering resiliency in kids: protective factors in the family, school, and community. San Francisco: Far West Laboratory for Educational Research and Development.

Blinn-Pike, L. (1999). Why abstinent adolescents report they have not had sex: Understanding sexually resilient youth. Family Relations, 48, 64-74.

Bronfenbrenner, U. (1979). The ecology of human development: Experiments by nature and design. Cambridge, MA: Harvard University Press.

DuRant, R., Kahn, J., Beckford, P., & Woods, E. (1997). The association of weapon carrying and fighting on school property and other health risk and problem behaviors among high school students.Archives of Pediatrics and Adolescent Medicine, 15(4), 360-366.

Fine, A., & Large, R. (2002). A conceptual framework for adolescent health. Washington, DC: Association of Maternal and Child Health Programs.

Fors, S., Crepaz, N., & Hayes, D. (1999). Key factors that protect against health risks in youth: Further evidence. American Journal of Health Behavior, 23(5), 368-380.

Garmezy, N. (1985). Stress-resistant children: the search for protective factors. In J. E. Stevenson (ed.), Recent research in developmental psychopathology. Journal of Child Psychology and Psychiatry Book Supplement No. 4, 213-233. Oxford, UK: Pergamon Press.

Hawkins, D., & Catalano, R. (1992). Communities that care: Action for drug abuse prevention. San Francisco: Josey-Bass.

Hawkins, J., Catalano, R., Kosterman, R., Abbott, R., & Hill, K. (1999). Preventing adolescent health-risk behaviors by strengthening protection during childhood. Pediatric and Adolescent Medicine, 153, 226-234.

Hawkins, D., Catalano, R., & Miller, J. (1992). Risk and protective factors for alcohol and other drug problems in adolescence and early adulthood: Implications for substance abuse prevention. Psychological Bulletin, 112, 64-105.

Hawkins, J., Herronkohl, D., Farrington, D., Brewer, D., Catalano, R., Harachi, T., et al. (2000). Predictors of youth violence.Juvenile Justice Bulletin. Washington, DC: US Department of Justice, Office of Juvenile Justice and Delinquency Prevention.

Jessor, R., Van Den Bos, J., Vanderryn, J., Costa, F., & Turbin, M. (1995). Protective factors in adolescent problem behavior: Moderator effects and developmental change. Developmental Psychology, 31, 923-933.

Murry, V. (1996). An ecological analysis of coital timing among middle-class African American adolescent females. Journal of Adolescent Research, 11, 261-280.

Perkins, D., Luster, T., Villarruel, F., & Small, S. (1998). An ecological, risk factor examination of adolescents' sexual activity in three ethnic groups. Journal of Marriage and Family, 60, 660-673.

Resnick, M. (2000). Resilience and protective factors in the lives of adolescents. Journal of Adolescent Health, 27, 1-2.

Resnick, M., Bearman, P., Blum, R., Bauman, K., Harris, K., Jones, J., et al. (1997). Protecting adolescents from harm: Findings from the national longitudinal study of adolescent health. JAMA, 278, 823-831.

Rink, E., & Tricker, R. (2003). Resiliency based research and adolescent health behaviors. Prevention Researcher, 10, 1-4.

Santelli, J., Lowry, R., Brener, N., & Robin, L. (2000). The association of sexual behaviors with socioeconomic status, family structure, and race/ethnicity among US adolescents. American Journal of Public Health, 90, 1582-1589.

Scales, P., & Leffert, N. (1999). Developmental assets: A synthesis of the scientific research on adolescent development. Minneapolis, MN: Search Institute.

Small, S., & Kerns, D. (1993). Unwanted sexual activity among peers during early and middle adolescent: incidence and risk factors. Journal of Marriage and Family, 55, 941-953.

Stronski, S., Ireland, M., Michaud, P., Narring, F., & Resnick, M. (1999). Protective correlates of stages in adolescent substance use: A Swiss national study. Journal of Adolescent Health, 26, 420-427.

USDHHS (2000). Healthy People 2010. Washington DC: US Government Printing Office.

Werner, E. (1993). Risk, resilience, and recovery: Perspectives from the Kauai longitudinal study. Development and Psychopathology, 5, 503-515.

Elizabeth Rink, LCSW, CHES is the Health Promotion/Disease Prevention Program Manager for the Benton County Health Department. Ray Ticker, PhD, CHES is an Associate Professor of Public Health at Oregon State University. Address all correspondence to Elizabeth Rink, L.C.S.W., CHES, Benton County Health Department, PO Box 579, Elizabeth Rink, 530 NW 27th Street, Corvallis, OR 97339-0579; PHONE: [phone]; FAX: [phone]; E-MAIL: [e-mail].

Table 1. Different Conceptual Models of Protective Factors.

Researcher(s)        Protective Factors Framework

Garmezy (1985)       Three Categories of Protective Factors
                     Individual Differences
                       * High Self Efficacy
                     Family Attributes
                       * Family Support and Affection
                     Extrafamilial Situations
                       * Support From Other Adults
                       * Strong Community Integration

Hawkins & Catalano   Four Domains of Protective Factors
(1992)
                     Community Domain
                       * Community Laws and Norms Related
                         to Health Behavior
                     School Domain
                       * Bonding to School
                     Family Domain
                       * Supportive Family Environment
                       * Bonding to Parents and Siblings
                     Peer Domain
                       * Positive Peer Influence
                     Individual Domain
                       * Positive Individual Characteristics

Jessor et al.,       Three Psychosocial Systems of Protective Factors
(1995)
                     Personality System
                       * Positive Orientation Towards Health
                       * Intolerant Attitudes Towards Deviance
                     Perceived Environmental System
                       * Positive relations with Adults
                       * Awareness of Friends Who Model
                         Conventional Behavior
                       * Strong Social Controls
                     Behavior System
                       * Prosocial Behaviors

Benson (1997)        40 Developmental Asset Model
                     Internal Assets (Three Categories)
                       * Commitment to Learning
                       * Positive Values
                       * Social Competencies
                     External Assets (Four Categories)
                       * Support
                       * Empowerment
                       * Boundaries and Expectations
                       * Constructive Use of Time

Resnick et al.,      Concept of Connectedness
(1997)
                     School Connectedness
                       * Feels Treated Fairly by Teachers
                       * Close to People at School
                       * Feels Part of School
                     Family Connectedness
                       * Closeness of Mother/Father
                       * Perceived Caring by Mother/Father
                       * Satisfaction with Mother/Father
                         Relationship
                       * Feeling Loved and Wanted by Family
                         Members
                     Individual Characteristics
                       * Good Personal Qualities
                       * Has A lot To Be Proud Of
                       * Likes Self
                       * Feels Loved and Wanted