Determinants of adolescent health can be classified as factors that either increase or decrease the probability of a particular outcome or behavior occurring. Risk factors refer to behaviors or characteristics of individuals that increase the probability of a future negative health outcome or disease in one group relative to a comparable group without or with different levels of the behavior or characteristic (Rothstein, 2003). Risk factors may be either directly or indirectly related to a particular health outcome or disease (Rothstein, 2003). For example, smoking cigarettes is a behavioral risk factor that increases the likelihood of experiencing negative health outcomes (e.g., emphysema, increased blood pressure) and disease (e.g., cancer). Additional examples of risk factors on an individual level include sexual risk behavior, substance use, engaging in violent behavior, and suicidal ideation (Wang, Hsu, Lin, Cheng, & Lee, 2010).

In contrast, protective factors increase the likelihood of health-promoting behaviors and positive health outcomes (Jessor, Turbin, & Costa, 1998; Keeler & Kaiser, 2010). As such, protective factors are associated with decreased engagement in health risk behaviors and fewer negative health consequences (Keeler & Kaiser, 2010; Resnick et al., 1997). Further, protective factors may also buffer the negative influence of risk exposure (Jessor et al., 1998). For instance, parental monitoring of adolescents’ activities may serve as a protective factor decreasing adolescents’ engagement in health risk behaviors including use of alcohol or drugs (Barnes, Welte, Hoffman, & Dintcheff, 2005; Martins, Storr, Alexandre, & Chilcoat, 2008; Rai et al., 2003; Tobler & Komro, 2010). Other examples of individual-level protective factors include self-esteem, self-efficacy to engage in health-promoting behaviors, and effective emotion regulation (Wang et al., 2010). On a relational level, examples of protective factors include family connectedness, support or perceived caring from family members, and high perceived safety at school (Saewyc et al., 2009). Thus, determinants of adolescent health may be classified as either risk or protective factors for engaging in a particular health behavior and subsequently experiencing a given health outcome or disease.

While, for heuristic purposes, we have linked specific risk behaviors with specific adverse health outcomes, for instance, our example of smoking (risk behavior) and emphysema (adverse health outcome), a particular risk behavior may be related to a host of adverse outcomes. For illustrative purposes, non-condom-protected sexual behavior (risk behavior) may be related to HIV infection, infection with other sexually transmitted infections (e.g., chlamydia, gonorrhea, trichomoniasis, herpes simplex virus type 2), and, for women, unintended pregnancy. Each of these adverse outcomes, in turn, may be associated with further adverse conditions. For example, chlamydial infections may result in ectopic pregnancy or pelvic inflammatory disease; HIV infection may lead to a host of other opportunistic infections. Thus, while there is some specificity between risk behaviors and adverse health outcomes, it is worth bearing in mind that some risk behaviors, while certainly associated with specific adverse outcomes, may also be related to a host of other adverse health outcomes. Perhaps the best example is that of cigarette smoking. While we often think immediately of the association between cigarette smoking and cancer, particularly lung cancer, it is important to note that cigarette smoking is related to diverse cancers, including oral pharyngeal as well as heart disease, and other lung diseases (i.e., emphysema). Thus, preventing or reducing the likelihood of adolescents’ engagement in risk behaviors actually affects the probability of developing a wide array of health adverse outcomes. Of course, the number of preventable adverse outcomes will vary by the type of risk behavior.

Individual-level determinants of adolescent health include a multitude of risk factors. Unfortunately, the developmental period of adolescence is associated with greater engagement in some health risk behaviors including delinquency and crime. Indeed, Mash and Barkley suggested girls’ problems with delinquency increase from mid-adolescence to adulthood (2003). Delinquency is at its height during adolescence, marked by alcohol, tobacco, and other drug use. Teenaged adolescents and young adults also commit most crimes, with a peak during ages 15–17 years. The age-crime curve holds true for many countries, including the United States. Crime decreases with age; however there are not clear evidence-based explanations for this decline as adolescents age (Smith, 1995). Additionally, school engagement diminishes as adolescents lose interest or experience disciplinary problems with authority figures (Robins, 1995). Collectively, an individual’s age (i.e., the developmental period during adolescence) may serve as an important predisposing determinant for health risk practices and subsequent negative health outcomes.

Adolescents’ engagement in health risk behaviors tends to cluster such that individuals engaging in one risk behavior may be more likely to engage in other health risk practices. For instance, participating in physical fights, carrying weapons, and non-seat belt use are individual risk behaviors significantly associated with the leading causes of death among young people, namely, motor vehicle crashes, homicide, and suicide (CDC, 2010b). Research has also established that aggression and violent crime are strongly associated with drug use and a range of other criminal and delinquent behaviors (Farhat, Simons-Morton, & Luk, 2011; Smith, 1995). Substance use has also been identified as a risk factor for risky sexual behavior. In one study, African American adolescent girls with biologically confirmed marijuana use were more than three times more likely to test positive for an STD, two times more likely to report non-condom use in the recent past, and more than three times more likely to report a history of inconsistent condom use (Liau et al., 2002). Additionally, reporting a sex partner who was high or drunk during sex has been associated with STD transmission (Crosby et al., 2008; Doherty, Adimora, Schoenbach, & Aral, 2007).

Adolescents experiencing elevated psychological distress or mental illness may also be more prone to risky health behaviors and experience associated negative health outcomes. In a study examining the relationship between psychological functioning and sexual behaviors, young women with high psychological distress were significantly more likely to have a diagnosed STD, report inconsistent condom use, have sex while high or drunk, and report perceived partner concurrency (Seth, Raiji, DiClemente, Wingood, & Rose, 2009). Psychological distress has also been related to psychosocial mediators of condom use, including lower partner sexual communication, lower condom use self-efficacy, lower refusal self-efficacy, and higher fear of communicating with partners (Seth et al., 2009). High levels of depressive symptoms among adolescent girls have been associated with increased number of lifetime partners and having an external locus of control (Rubin, Gold, & Primack, 2009). These examples, among others from the adolescent health literature, point to the deleterious impact of psychological distress on adaptive health behavior engagement.

There are individual characteristics among adolescents that are protective against risky and unhealthy behaviors. When examining factors facilitating nonsmoking, adolescents cited self-confidence and concerns about their personal appearance as two of the most important reasons for not smoking (Kulbok et al., 2008). Prospective research has also shown optimistic thinking style as protective against depressive symptoms among adolescents (Patton et al., 2011). In one study, adolescents with high levels of optimism were half as likely to have depressive symptoms, compared to adolescents with low levels of optimism. Optimistic thinking was protective against substance use among girls, but not boys (Patton et al., 2011). Overall, life satisfaction among adolescents may also serve as a protective factor reducing risk practices. For instance, adolescents with high levels of life satisfaction were less likely to report current marijuana use or former marijuana experimentation (Farhat et al., 2011).

Cognitive risk appraisals allow adolescents to examine the advantages and disadvantages of engaging in a particular behavior. As such, adolescents are more likely to engage in healthy behaviors if perceived benefits exist. When examining tobacco use patterns, nonsmoking adolescents cited reasons of wanting to live longer, less worry about being addicted, better breathing, and easier participation in athletic activities as protective against their tobacco use (Kulbok et al., 2008). Additionally, likelihood of engaging in healthy behaviors increases when few perceived disadvantages exist. In one study, most nonsmoking adolescents agreed there was not anything bad about being a nonsmoker (Kulbok et al., 2008). Collectively, these studies point to adaptive psychological health and well-being as protective factors associated with reductions in health risk behaviors.

Unfortunately, adolescence is a period typically associated with greater engagement in some health risk practices relative to later in adulthood. Furthermore, individual health risk behaviors are likely to co-occur with other risk practices. While a review of all individual-level determinants of adolescent health is beyond the scope of this chapter, psychological functioning can serve as an important risk or protective factor for subsequent health outcomes. Additionally, cognitive strategies to appraise risk and evaluate the advantages and disadvantages of a particular behavior may serve to either increase or decrease engagement in these practices.

The roles of parents and family are critical in keeping adolescents safe (DiClemente et al., 2005). Perceived family support, parent-family connectedness, family structure, family cohesiveness, parental monitoring, and parent-adolescent communication may help prevent adolescents from engaging in many health risk behaviors as well as improve management of chronic illness or disease (DiClemente et al., 2005). For adolescents with chronic diseases, such as asthma, familial characteristics and interactions play an important role in the effective management of asthma symptoms and adherence to medication and other medical protocols (Fiese, Wamboldt, & Anbar, 2005; Fiese, 2008; Fiese, Winter, Anbar, Howell, & Poltrock, 2008; Fiese, Winter, & Botti, 2011). Indeed, established family medication management routines have been associated with greater asthma treatment adherence and effective health care utilization by adolescents and their caregivers (Fiese et al., 2005).

Monitoring of adolescents’ activities by parents or caregivers typically serves as a protective factor against adverse health outcomes. Indeed, greater parental monitoring has been associated with lower substance use among adolescents (Barnes et al., 2005; Farhat et al., 2011; Martins et al., 2008; Rai et al., 2003; Tobler & Komro, 2010). Parental monitoring may also mitigate the consequences associated with witnessing violent acts including externalizing behaviors and mental health difficulties (e.g., depressive symptoms; Bacchini, Miranda, & Affuso, 2011; Copeland-Linder, Lambert, & Ialongo, 2010; Sullivan, Kung, & Farrell, 2004). Additional evidence suggests that adolescents who report their parents know where they are and who they are with are substantially less likely to engage in sexual risk behaviors or have an STI (Crosby et al., 2006; DiClemente, Crosby, & Wingood, 2002; DiClemente et al., 2005; Voisin, DiClemente, Salazar, Crosby, & Yarber, 2006). Collectively, these studies point to parental monitoring as a protective factor against engaging in health risk behaviors and may buffer against negative consequences associated with experiencing adverse events.

Adolescents’ parental relationships are commonly in transition along with usually experiencing at least one transition into middle or junior high school (Alsaker, 1995; Rice & Dolgin, 2002). The influence of the parent-adolescent relationship is based on the frequency of their interaction. Parents’ communication with their adolescent children affords the possibility to impart health knowledge and promote health behavior engagement. Unfortunately, parents and caregivers may not discuss important health information before risk behavior occurs (Beckett et al., 2010). However, better communication between adolescents and their parents or caregivers may serve as a protective factor against engaging in risk behaviors. For example, adolescents who discuss sexual health topics with their parents have demonstrated greater confidence negotiating safer sexual practices with their partners including more consistent condom use (Buzi, Smith, & Weinman, 2009; DiClemente et al., 2001; Hadley et al., 2009; Shoop & Davidson, 1994; Whitaker, Miller, May, & Levin, 1999).

Family structure characteristics are often associated with adolescents’ health outcomes and behaviors. For example, family structure has been related to an adolescents’ STD status (Sionean et al., 2001). In one study, having unemployed parents more than doubled the likelihood of having a history of gonorrhea, relative to adolescents living with employed parents (Sionean et al., 2001). Additionally, the absence of a parent may adversely impact an adolescent’s moral development (Rice & Dolgin, 2002). Some research also suggests the association between family structure and adolescent risk behaviors occurs due to an interaction between protective and risk factors (Wang et al., 2010). Adolescents’ perception regarding their mother’s risk behavior has been a statistically significant factor explaining adolescent risk behavior (Wang et al., 2010). Family networks can also serve as a protective factor. African American adolescent girls living with their mothers who report a supportive family have endorsed fewer sexual risk behaviors, including being more likely to use condoms during sex, less likely to report emotional abuse from sex partners, reporting fewer partner barriers to engaging in safe sex, having less fear of condom negotiation, and having higher self-efficacy to negotiate condoms with partners (Crosby, DiClemente, Wingood, & Harrington, 2002). Thus, a supportive, cohesive family may be a protective factor while family structures characterized by greater distress may be a risk factor for health risk behaviors and negative health outcomes.

Another developmental aspect of adolescence is the increasing importance of peer influences (DiClemente et al., 2005). Perceived norms regarding peers’ engagement in health risk behaviors exert a strong influence on use of alcohol, tobacco, drugs, initiation of sexual intercourse, and sexual risk practices among adolescents (Andrews, Hampson, & Peterson, 2010; DiClemente et al., 2005; Kumar, O’Malley, Johnston, Schulenberg, & Bachman, 2002; Pandina, Johnson, & White, 2010; Schinke, Fang, & Cole, 2008; Sieving, Eisenberg, Pettingell, & Skay, 2006; Verkooijen, de Vries, & Nielsen, 2007). Consequently, adolescents may adopt the perceived high-risk practices of their peers. For instance, if adolescents believe that their peers are not using condoms and engaging in other sexual risk behaviors, they may be more likely to engage in these behaviors themselves (Bachanas et al., 2002; Boyer, Tschann, & Shafer, 1999; Doljanac & Zimmerman, 1998; Millstein & Moscicki, 1995; Salazar et al., 2011). In contrast, perceived peer norms may also serve as a protective factor when adolescents perceive that risk behaviors are not normative among their peers (DiClemente, 1991; Maxwell, 2002). For example, in a nationally representative sample of 8th, 10th, and 12th grade students, greater school-wide disapproval of substance use was associated with lower rates of tobacco, alcohol, and drug use by adolescents (Kumar et al., 2002). In an incarcerated sample, adolescents who perceived peer norms supportive of condom use were more likely to report consistent condom use (DiClemente, 1991). Research has also indicated that peer norms combined with self-efficacy to engage in safer sexual behaviors mediate the relationship between media exposure to sexual content and adolescents’ initiation of sexual behaviors (Martino, Collins, Kanouse, Elliott, & Berry, 2005).

Adolescents’ risk practices may be more directly influenced by the behaviors of their friends and peers (Pandina et al., 2010; Schinke et al., 2008). Peer pressure to engage in risk behavior increases during adolescence. There is greater pressure by peers to smoke, drink alcohol, and engage in sexual intercourse during this developmental period (Eicher, Clasen, & Brown, 1986). Indeed, one study found that alcohol and drug use by an adolescent girl’s best friend was predictive of her own substance use (Schinke et al., 2008). Among African American adolescent girls an association between reporting that less than half of their girlfriends used condoms consistently predicted youth’s own risky sexual behavior across six measures of condom use (Crosby et al., 2003). Adolescents have a propensity to select peer groups similar to them and seek out peer groups to assist with identity formation and consolidation (Eccles & Barber, 1999; Eccles & Gootman, 2002). Thus, associating with a peer group engaging in health risk practices may increase adolescents’ own health behaviors.

The structure of the peer network may also impact health outcomes among adolescents. Haynie assessed whether characteristics of the peer network were related to an adolescent’s delinquent behavior (2001). Results indicated an association between friends’ delinquency and an adolescent’s delinquent behavior (Haynie, 2001). Second, the delinquency-peer association was moderated by the structure of the peer networks (Haynie, 2001). The association was stronger when the peer network had high density, the adolescent was more popular, and the adolescent was more central in the friendship network. Thus, the level of network cohesion places more controls on network members to align with the network’s behavioral disposition (Haynie, 2001).

Relationship characteristics play an important role in influencing adolescents’ engagement in risk behaviors and likelihood of experiencing negative health outcomes. Characteristics of adolescents’ relationships are particularly prominent determinants of sexual health and influence adolescents’ risky behavior and their likelihood of acquiring an STI. There are also important gender differences in relationship features associated with STI transmission. Among adolescent females, lack of relationship control (Crosby et al., 2000), longer length of relationship (Catania et al., 1989; Crosby et al., 2000; Fortenberry, Tu, Harezlak, Katz, & Orr, 2002), fear of condom use negotiation (Sionean et al., 2002), less frequent partner communication about sexually related topics (Begley, Crosby, DiClemente, Wingood, & Rose, 2003; Catania et al., 1989; Sieving et al., 1997), and having older sexual partners (Begley et al., 2003; DiClemente, Crosby, et al., 2002; Miller, Clark, & Moore, 1997) have all been associated with greater likelihood of engaging in STI risk behaviors or STI transmission. Other relational risk factors associated with increased STI transmission risk include perceptions of partner control over STI acquisition (Rosenthal et al., 1999), perception of low partner support of condoms (Weisman et al., 1991), being a date rape victim (Valois et al., 1999), and being a victim of dating violence or abuse (Silverman, Raj, Mucci, & Hathaway, 2001; Valois et al., 1999; Wingood & DiClemente, 1997; Wingood, DiClemente, McCree, Harrington, & Davies, 2001). Similar associations have been found for having a new partner and having a risky sexual partner (Bunnell et al., 1999; Katz, Fortenberry, Tu, Harezlak, & Orr, 2001). Having greater partner-dependence has also been associated with less condom use (Senn, Carey, Vanable, & Coury-Doniger, 2010). Economic dependence on a sexual partner impacts the relationship’s power dynamics and subsequently prevents the dependent partner from engaging in risk reduction or protection strategies (Gorbach & Holmes, 2003).

The progression of adolescents’ romantic relationships also influences behavior practices and related health outcomes. Kaestle and Halpern examined the nature of adolescents’ relationships prior to engaging in romantic partnerships (Kaestle & Halpern, 2005). A majority of adolescent women, 51.8 %, reported being acquaintances with their partner before getting into a relationship, 42.6 % reported being friends, while 5.7 % reported not knowing their partner before getting into a relationship (Kaestle & Halpern, 2005). Adolescent women in this study who were friends before engaging in a romantic relationship were significantly less likely to have sex (Kaestle & Halpern, 2005). In contrast, adolescent women who had not met their partner before getting into a romantic relationship were more likely to have sex (Kaestle & Halpern, 2005). According to Andrinopoulos, Kerrigan, and Ellen (2006), young women may seek out romantic partnerships to fulfill a desire for emotional support, security, and intimacy in sexual partnerships. Furthermore, romantic relationships help young women cope with other problems and may subsequently affect their sexual behaviors (Andrinopoulos et al., 2006). For instance, one young woman discussed the process of “catching feelings” or developing emotional ties after having sex with a romantic partner (Andrinopoulos et al., 2006). Collectively, these studies highlight the important role that adolescents’ relationships play in shaping their behaviors which may in turn impact their short- and long-term health.

Community characteristics and involvement with community organizations can also influence adolescents’ adoption of protective health behaviors. Adolescents’ affiliations with social organizations, adolescents who perceive that they have higher levels of social support, and positive school environments may serve as protective factors (St. Lawrence, Brasfield, Jefferson, & Allyene, 1994). For example, among a nationally representative sample of adolescents, a sense of belonging to a school was associated with delaying sexual intercourse (Resnick et al., 1997). School connectedness and environment impact health outcomes for adolescents as well. In one study, having a positive academic climate was associated with lower risk for marijuana experimentation among girls (Farhat et al., 2011). In contrast, experiences of being bullied increased the risk for marijuana experimentation and other substance use among girls (Carlyle & Steinman, 2007; Farhat et al., 2011). Being bullied was also associated with depressive affect and substance use among adolescents (Carlyle & Steinman, 2007).

An emerging line of inquiry suggests that social capital, another community characteristic, may influence adolescents’ risk behaviors. Social capital is an index comprised of trust, reciprocity, and cooperation among members of a social network (Putnam, 2000). A recent study demonstrated that social capital was inversely correlated with AIDS cases and STI incidence including chlamydia, gonorrhea, and syphilis among adults (Holtgrave & Crosby, 2003). More recent research has shown that adolescents residing in states with greater levels of social capital were less likely to engage in certain sexual risk behaviors (Crosby, Holtgrave, DiClemente, Wingood, & Gayle, 2003). Greater levels of social capital, however, may not be protective for adolescents if the social network involved is antisocial in nature, such as a gang. It has been suggested that gangs are a community problem with underlying neighborhood factors such as the need for protection from crime and/or abusive families, peer pressures, and lack of money-making opportunities serving as major risk factors for gang involvement (Curry & Thomas, 1992; Walker-Barnes & Mason, 2001). When adolescents choose to join a gang, they put themselves at greater risk for engaging in a diverse array of health-compromising behaviors such as violence, risky sexual behaviors, antisocial behaviors, and alcohol/drug use (Deschenes & Esbensen, 1999; Esbensen, Peterson, Taylor, & Freng, 2009; Hunt, Joe-Laidler, & MacKenzie, 2000). One study of high-risk African American adolescent females found gang involvement to be related to school expulsion, binge drinking, using marijuana, engaging in physical fights, and positive diagnoses of Trichomonas vaginalis and Neisseria gonorrhoeae (Wingood et al., 2002).

Sociological constructs of race and gender influence adolescents’ health (DiClemente et al., 2005). Despite efforts to reduce health disparities, ethnic minority adolescents continue to experience poorer health outcomes. For example, epidemiological data indicate African American female adolescents experience disproportionate rates of sexually transmitted infections (STI) and HIV relative to other racial/ethnic groups and males (CDC, 2010a). The apparent influences of race/ethnicity may be confounded by a host of environmental factors (DiClemente et al., 2005). Indeed, disparities existing in the availability of preventative services and access to necessary medical care (Elster, Jarosik, VanGeest, & Fleming, 2003; Flores & Tomany-Korman, 2008). Poverty may be a risk factor where its direct association with race/ethnicity exerts an indirect influence on health outcomes (DiClemente et al., 2005). With regard to sexual health, it has been suggested that higher STI/HIV rates among African American adolescents may be linked to living in geographic clusters characterized by lower socioeconomic status, low educational attainment, compromised family structures, and poverty (DiClemente et al., 2005; Fullilove, 1998).

Sociological constructs of race and gender may also interact with adolescents’ peer network to heighten risk for adverse health outcomes. For example, high-risk sexual networks among Black women are a primary concern in STI transmission. Population patterns of exposure are fundamental determinants of health at the population level (Adimora & Schoenbach, 2005). Considering that the individual risk behaviors (i.e., number of sex partners, condom use) of young Black women are not significantly different than young White women, other larger societal factors are associated with increased risk for negative sexual health outcomes (Hallfors, Iritani, Miller, & Bauer, 2007). The pool of available sexual partners within which Black young women have sex is a higher risk network of partners. Black young women’s sexual networks have been negatively impacted by racial segregation, low sex ratios in the Black population, drugs, incarceration, as well as economic adversity operating alongside the low sex ratio (Adimora & Schoenbach, 2005). As an example, research indicates a strong correlation between incarceration and chlamydia and gonorrhea rates (Thomas & Sampson, 2005). Thus, the interaction between societal features and other levels within the socio-ecological model serves as an important determinant of adolescent health outcomes.

With widespread availability of media from a growing number of sources, adolescents are exposed to increasing amounts of media that can influence their health behavior choices (Strasburger & Hogan, 2009). For example, in a recent large cross-sectional survey of adolescents, youth reported being exposed to tobacco-promoting messages from a number of media outlets including television, movies, ads in magazines, and from numerous sources on the Internet (Duke et al., 2009). Unfortunately, positive media portrayals of risk behavior practices may increase engagement in these behaviors by adolescents (Media power-for good and for ill, 2010). For instance, studies point to an association between increased exposure to tobacco-promoting media and use of tobacco among adolescents (Primack, Land, & Fine, 2008; Villanti, Boulay, & Juon, 2011; Weiss et al., 2006). More broadly, a recent review of the impact of media exposure found a consistent association between increased media consumption and use of tobacco, alcohol, and other substances (Nunez-Smith et al., 2010). Therefore, frequent exposure to media messaging that normalizes risk behaviors may in turn promote adolescents engagement in those behaviors.

Implementation of policies and regulations to promote health behavior engagement at the societal level can serve as a protective factor for adolescents’ health. Legislation can modify health behavior via a variety of channels. For example, states with stricter tobacco control laws (e.g., clean air laws) have lower rates of adolescent tobacco use (Botello-Harbaum et al., 2009). Additionally, policies that increase the price associated with tobacco have been linked to decreased tobacco purchases and use by adolescents (Liang & Chaloupka, 2002; Tworek et al., 2010). Professional medical organizations also have the potential to promote adolescent health through their organization’s policy statements. For instance, the American Academy of Pediatrics now recommends banning all tobacco advertisements in the media given the role media can play to promote health risk behaviors (Strasburger, 2010). Thus, policy has great potential to improve the health of adolescents by enacting legislation or altering societal structures to prevent disease or adverse health consequences and decrease risk behavior engagement among adolescents.

Multiple individual-level interventions exist targeting a wide range of health behaviors among adolescents, including preventing pregnancy (Blank, Baxter, Payne, Guillaume, & Pilgrim, 2010), increasing STD screening (Tebb, Wibbelsman, Neuhaus, & Shafer, 2009), improving birth outcomes for adolescent mothers (Koniak-Griffin, Anderson, Verzemnieks, & Brecht, 2000), improving medication adherence (Dean, Walters, & Hall, 2010), reducing tobacco and substance use (Tait & Hulse, 2003), promoting weight loss for overweight adolescents (Stuart, Broome, Smith, & Weaver, 2005), reducing risky driving (Farrow, 1989), and treating depression (David-Ferdon & Kaslow, 2008) and anger (Eyberg, Nelson, & Boggs, 2008). These interventions use strategies such as increasing knowledge via education (Savage, Farrell, McManus, & Grey, 2010), self-efficacy to engage in behaviors, skills building (Savage et al., 2010), emotion regulation, role-plays, case management (Savage et al., 2010), and cognitive behavioral therapy (Forman & Barakat, 2011).

As an example, individual-level weight-loss interventions for overweight adolescents often focus on diet and exercise programs. Many of these programs target the individual (Krzystek-Korpacka et al., 2011), while some also tailor intervention messages to the adolescent’s specific needs or individual behaviors (Elloumi et al., 2009). Some weight-loss interventions are implemented face-to-face with a counselor or trainer (Elloumi et al., 2009; Krzystek-Korpacka et al., 2011). However, one study used an Internet-based approach to target individual-level weight loss strategies in conjunction with access to an online case manager. Intervention activities included setting nutrition and physical activity goals, self-monitoring, problem solving, creating a behavioral contract, and relapse prevention (White et al., 2004). Thus, individual-level interventions seek to improve individuals’ health knowledge while building skill and promoting self-efficacy to engage in behavior change. Such interventions offer the potential to address an individual’s unique needs and tailor intervention content.

Relational-level interventions target relationship factors (e.g., communication skills) within adolescents’ relationships to promote behavior change. Relational-level interventions are particularly important to consider when designing sexual health interventions. Such relational-level interventions directly address salient influences associated with STI risk and protective behaviors while also transferring the burden to initiate STI-protective behaviors from one person to the dyad. This is particularly important for adolescent females who are in power-imbalanced relationships with their male partners (Begley et al., 2003; DiClemente, Wingood, et al., 2002; Ellen, Aral, & Madger, 1998; Gollub & Stein, 1993). Additionally, this type of intervention holds great promise for enhancing not only the adoption of STI-preventive behaviors by the dyad but also, in the event of dissolution, the generalization of recently adopted STI-preventive behaviors to new relationships. In the same vein, existing strategies often fail to recognize the unique dilemmas that adolescents confront when disclosing positive STI diagnoses to sexual partners. Thus, “adolescent-friendly” partner services represent an approach that may promote disclosure and care-seeking behavior of partners. Specifically, “adolescent friendly” signifies an approach that is developmentally appropriate and incorporates activities designed to teach adolescents how to effectively communicate positive diagnoses to sexual partners and promote care-seeking among those partners (Fortenberry, Brizendine, Katz, & Orr, 2002). The use of partner-delivered medication for treating STIs could also be used as an adjunct to the adolescent-friendly services, thereby preventing subsequent reinfection and transmission (Kissinger et al., 1998).

Family-level interventions have been effective intervention approaches to improve adolescents’ mental health, reduce risk behavior engagement, and manage chronic illness. Family therapy approaches have demonstrated improvement among adolescents with mental health conditions including depressive disorders (Diamond & Siqueland, 1995; Diamond et al., 2010; Kolko, Brent, Baugher, Bridge, & Birmaher, 2000), anxiety disorders (Bögels & Siqueland, 2006; Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008; Storch et al., 2010), eating disorders (Doyle, Le Grange, Loeb, Doyle, & Crosby, 2010; Eisler, Simic, Russell, & Dare, 2007; le Grange, Crosby, Rathouz, & Leventhal, 2007; Lock et al., 2010; Schmidt et al., 2007), and substance use disorders (Liddle, Rowe, Dakof, Henderson, & Greenbaum, 2009; Rowe, 2010). Family-based interventions have also been developed to improve the management of chronic illnesses such as diabetes among adolescents (Anderson, Brackett, Ho, & Laffel, 1999; Keogh et al., 2007; Nansel et al., 2009; Satin, La Greca, Zigo, & Skyler, 1989; The TODAY Study Group, 2010). In one such trial of an intervention to manage type I diabetes, the family intervention was conducted during routine medical visits and provided youth and their parents with information regarding glucose management and sought to improve parental involvement with insulin injections and glucose monitoring (Anderson et al., 1999). This intervention also provided participants with skills to manage conflict and improve communication skills (Anderson et al., 1999). Results indicated that adolescents who received the family-based intervention had improved glucose levels and more consistent parental involvement with insulin injections, and decreased conflict (Anderson et al., 1999). Findings from this study and other family-level interventions highlight the important role families can play in working collaboratively to manage illness and also prevent negative health outcomes. In particular, such interventions typically seek to improve familial communication and to promote strategies to effectively manage conflict and manage disease.

Family-level interventions have also been effective in reducing risk behavior engagement. A recent meta-analysis of family interventions found that such interventions were efficacious in delaying initiation of alcohol use and frequency of drinking among adolescents (Smit, Verdurmen, Monshouwer, & Smit, 2008). Additionally, family interventions have resulted in decreased substance use and externalizing behaviors (e.g., aggression) among at-risk adolescents (Connell, Dishion, Yasui, & Kavanagh, 2007; Spoth, Redmond, Shin, & Azevedo, 2004; Stormshak et al., 2011). For example, one family intervention conducted ecological assessments in the home and schools and utilized motivational interviewing to promote parenting skills and provide caregivers and youth with feedback (Stormshak et al., 2011). Findings from this study suggest that adolescents receiving the family intervention, relative to the control condition, had decreased engagement in antisocial behaviors, alcohol use, marijuana use, and tobacco use (Stormshak et al., 2011). This study illustrates that intervening with caregivers and their children can be efficacious in reducing risk behaviors during adolescence.

Community-level health promotion interventions target entire communities or specific community structures (e.g., schools, community organizations) to improve health outcomes within an adolescent population. In such studies whole communities may be randomized to receive the treatment or to be a comparison community. As such, cities with similar characteristics (e.g., population density, prevalence of a given health outcome) are selected to ensure comparability of results across communities. Thus, the goal of this study design is to evaluate the efficacy of public health interventions to improve health outcomes community-wide. For example, to curb adolescents’ use of tobacco, several community-level interventions have been implemented and evaluated (Altman, Wheelis, McFarlane, Lee, & Fortmann, 1999; Biglan, Ary, Smolkowski, Duncan, & Black, 2000; Johnson et al., 1990; Pentz et al., 1989; Perry, Kelder, Murray, & Klepp, 1992). In one such study, eight Kansas City communities were randomized either to a comprehensive tobacco prevention intervention involving schools, parents, mass media, and community organizations or a control condition consisting of only media and community organization approaches (Johnson et al., 1990). Over a 3-year period there were significant reductions in adolescent tobacco use among those receiving the more comprehensive community-level intervention (Johnson et al., 1990). This study highlights the impact that interventions targeting multiple community structures can have on adolescent health promotion.

Alternatively, community-level interventions may target specific community structures or organizations to improve health behavior outcomes. To reduce adolescent tobacco use, a number of studies have sought to enforce stricter penalties for merchants selling to adolescents or alter adolescents’ access to tobacco products (Bowen, Orlandi, Lichtenstein, Cummings, & Hyland, 2002, 2003; Chen & Forster, 2006; Feighery, Altman, & Shaffer, 1991; Forster et al., 1998; Rigotti et al., 1997). One intervention sought to reduce merchants’ sales of tobacco-related products to minors (Rigotti et al., 1997). Across the communities that received the intervention there was significant improvement in business compliance with tobacco sales to adolescents (Rigotti et al., 1997). Thus, addressing specific community structures that contribute to negative health outcomes may be an efficacious approach to promote positive health behavior change. Such interventions also offer the potential to reach a larger number of adolescents.

Delivering behavior change interventions within school settings has also been an effective community-level approach. For examples, schools can play a role in reducing sexual risk-taking by making condoms available. Adolescents who have better accessibility and availability of condoms tend to have higher rates of condom use without an increase in overall rates of sexual activity (Bunnell et al., 1999; Wingood & DiClemente, 1997; Wingood et al., 2001). The link between better accessibility and availability and increased condom use may be explained by related research which showed that those who carry condoms are more likely to use condoms than those who do not always carry condoms (Katz et al., 2001). The Coordinated School Health Programs (CSHP) are another key strategy to increase opportunities to engage in physical activity and offer greater access to nutritious options for adolescents in school (CDC, 2008). The Centers for Disease Control and Prevention (CDC) also suggests strengthening schools’ physical activity and nutrition policies for students and programs for staff (CDC, 2008). This is an example of using coordinated efforts on multiple levels to impact the individual.

Societal level interventions have great potential to reach a large audience. Mass media campaigns can be an effective tool for reaching adolescents who may not otherwise be exposed to interventions (DiClemente et al., 2005). Mass media campaigns have been utilized to improve adolescents’ sexual health with messages to decrease behaviors that put youth at risk for negative health outcomes including STI and HIV and promote increased condom use (de Vroome et al., 1990; Hausser & Michaud, 1994; Kennedy, Mizuno, Seals, Myllyluoma, & Weeks-Norton, 2000; Romer et al., 2009; Zimmerman et al., 2007). A recent media campaign utilizing culturally sensitive HIV prevention messages targeted to African American adolescents found that the media intervention resulted in behavior change (e.g., increased condom use) and also positive changes in related psychosocial constructs (e.g., sex refusal self-efficacy; Romer et al., 2009). Another media campaign among sexually active 14–18-year-old adolescents study used radio ads, promotional materials, a telephone information line, and peer outreach and found that such an approach increased adolescents’ condom use (Kennedy et al., 2000).