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Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary (2013)

Chapter: 4 Safety- and Health-Related Behaviors

« Previous: Part II: Health and Safety of Young Adults
Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
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4

Safety- and Health-Related Behaviors

Important Points Made by the Speakers

  • Interventions during the treatment of injuries caused by intentional violence can interrupt a cycle of violence that causes many young adults to end up in prison or dead. (Corbin)
  • Research on the factors contributing to unintended pregnancy, HIV infection, and other sexually transmitted infections can better bring science to bear on the threats facing young adults. (Jaccard)
  • Interventions need to be available to all young adults to prevent problem drinking and drug use. (White)

Many of the safety- and health-related behaviors of greatest consequence for young adults are also behaviors seen during adolescence, including intentional and unintentional injuries, violence, suicides, substance use and abuse, risky sexual behaviors, and motor vehicle accidents. Three speakers at the workshop looked in detail at three of these behaviors: intentional injuries, risky sexual behaviors, and substance use.

VIOLENCE AND VICTIMIZATION

Violent injury (excluding suicide) is the number one cause of death among African Americans ages 15-34, the second leading cause of

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

death among Hispanics this age, and the number five cause of death among young non-Hispanic whites (CDC, 2011a). More than 150,000 incidents of violence against African American males ages 15-34 were treated in hospitals in 2011, representing about 1 of every 41 men in this demographic group. The numbers are “staggering,” said Theodore Corbin, an emergency room physician and associate professor in the Department of Emergency Medicine at the Drexel University College of Medicine.

Emergency departments have become extremely skilled at addressing the corporeal consequences of violence, said Corbin, but not the psychological consequences, even though they result from the same event. In urban community settings, 15 to 23 percent of victims of assaultive violence have a lifetime history of posttraumatic stress disorder (PTSD) (Corbin, 2013). In urban hospital settings, 27 percent of victims had PTSD 3 months after the violent injury and 18 percent were similarly affected a year later. Forty-one percent had acute stress disorder within a month of the violent injury (Corbin, 2013).

These traumas can compound prior traumas, abuse, and neglect. “There is a very high rate of exposure to adverse childhood experiences in the general population,” said Corbin. Moreover, the number of such experiences was strongly correlated with the development of smoking, chronic obstructive pulmonary disease, heart disease, diabetes, obesity, hepatitis, alcoholism, depression, attempted suicide, teen pregnancy, promiscuity, sexually transmitted infections, and other bad health outcomes.

Many trauma sufferers do not seek mental health services because of associated stigma and a lack of trust in mental health services and providers. Many are uninsured and unaware of the services that are available. They can become caught up in a cycle of violence that leads in the end to death or jail (see Figure 4-1).

Corbin and his colleagues have tried to take advantage of a particular point in this cycle to break the chain—the point where the victims of violence are treated in the hospital. The program with which Corbin is involved, known as Healing Hurt People, began in 2008 at Hahnemann University Hospital in Philadelphia. It currently reaches about 90 clients annually, and the children’s hospital sees about 70 clients, though both programs could do more if they had more capacity. The program is based on the twin concepts of teachable moments and trauma theory. During teachable moments, individuals are particularly receptive to interventions that promote positive behavior change, and many victims of violence are in this receptive state. Trauma theory, in turn, shifts thinking from the supposition that people who have experienced psychological trauma are sick, are deficient in moral character, or need to be punished to a perspective that they are injured and need healing.

Healing Hurt People provides assessment, case management and navi-

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

images

FIGURE 4-1 The Healing Hurt People program seeks to break the cycle of violence at the point where the victims of violence are treated in the hospital.
NOTE: PTSD = posttraumatic stress disorder.
SOURCE: Corbin, 2013.

gation, and mentoring to clients who are enrolled in the program. It uses psychoeducational groups to help young people learn how to feel safe, manage their emotions, deal with loss, and envision a positive future. It identifies PTSD and connects clients to mental health services, health services, and whatever other services they are assessed to need.

The program is comparing people who participate in Healing Hurt People with a control group at another hospital to determine whether participation decreases such indicators as PTSD, depression, and sleep quantity and quality that lead to poor health outcomes when not addressed. Corbin also suggested that additional research is needed to study the impact of trauma on boys and men of color over the lifespan and to support the movement from practice-based evidence to evidence-based practice.

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

UNINTENDED PREGNANCY, HIV INFECTION, AND OTHER SEXUALLY TRANSMITTED INFECTIONS

The rates of unintended pregnancy, HIV infection, and other sexually transmitted infections (STIs) among young adults are “far too high,” said James Jaccard, professor of social work in the New York University Silver School of Social Work. The 1 million unplanned pregnancies among unmarried women in their 20s represent a rate of more than 2,700 pregnancies per day, with unmarried women between ages 20 and 24 accounting for about two-thirds of these (Jaccard, 2013). About half of all abortions are to women in their 20s—a rate of about 1,600 abortions per day. Rates of unplanned pregnancy among teenagers have been declining in recent years, but the declines for women in their 20s have been much more modest, said Jaccard.

About 50,000 new HIV infections are diagnosed each year in the United States, with the rates of new infections highest in the 20- to 29-year-old age group (Jaccard, 2013). The risk is greatest for white and black men who have sex with men, followed by different heterosexual groups and injection drug users (Jaccard, 2013). About 20 million STIs occur each year in the United States, with 15- to 24-year-olds accounting for about half, representing about 27,000 infections per day divided more or less evenly between men and women—“staggering,” said Jaccard (see Figure 4-2). About 10 percent of young adults in their 20s have genital herpes infections, a rate that increases to 30 percent for black, non-Hispanic youth. Several major types of infection can go undetected because they have no immediate symptoms, even though they can be treated with antibiotics. Left untreated, they can have major health complications. “We have our work cut out for us in all of these areas,” said Jaccard.

Jaccard described four broad research areas that cut across these risk categories where we can focus increased efforts to “bring science to bear” on the threats facing young adults. The first is building a science of tailored and targeted intervention strategies. Most interventions involve communication of some form; there are seven facets of communication that can be tailored to individuals and groups:

  1. Who delivers the message (the source of communication)
  2. What is said (the content of communication)
  3. How it is said (the style of communication)
  4. When it is said (communication timing)
  5. Where it is said (communication context)
  6. How often it is said (communication frequency)
  7. Over what channel it is said (communication channel)
Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

images

FIGURE 4-2 About 20 million new sexually transmitted infections occur in the United States per year, with about half among 15- to 24-year-olds.
NOTE: HPV = human papilloma virus; HSV = herpes simplex virus.
SOURCE: Jaccard, 2013, adapted from CDC, 2013.

Research is needed on how to make choices in each of these seven categories when designing tailored interventions, Jaccard said. If such research results were available, computer and digital media could be used to deliver tailored messages to millions of people in cost-efficient ways. People could provide background information in interactive sessions with computers, including their demographics, personalities, lifestyles, beliefs, norms, sexual orientations, and so on. Communications then could be individualized based on that background information.

The second area where Jaccard recommended that research be pursued involves the integration and elaboration of design principles for behavior-specific intervention strategies with common-cause intervention strategies. At present, interventions tend to focus either on behavior-specific outcomes paying particular attention to, for example, sex and alcohol. Other interventions focus on more broadly based outcomes that are not behavior specific and that are thought to be common causes of multiple problem behaviors, such as positive youth development or emotion regulation interventions. Research to integrate these two different approaches could show how common-cause intervention strategies interact with behavior-specific intervention strategies and, together, form a more impactful package for fostering youth development. Although it is true that problem behaviors are correlated to some extent, each behavior also has large amounts of unique

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

variance, underscoring the need to take into account unique determinants, not just common causes. At present, common-cause interventionists tend to work independently of behavior-specific interventionists; greater collaboration between them is needed, said Jaccard.

The third area of needed research involves advancing a science of split-second decision making. Usually people do what they say they are going to do. But in some cases people intend to do something and then do not do it. Various theories have been developed to explain this disconnect between intended behavior and actual behavior. A major source of the disconnect is that people change their minds at the last second, a phenomenon known as decision instability. These last-moment, split-second decisions to act in ways other than originally planned need to be better understood, said Jaccard. In any given situation, people make cognitive and affective appraisals of the operative dynamics and these appraisals affect what enters their working memory and short-term memory as they contemplate how to behave. How and what information enters working and short-term memory in high-risk situations needs to be better understood. Current research tends not to appreciate such dynamic appraisal and memory processes. Such research has “many important implications for the way we develop our interventions,” said Jaccard.

The fourth and final area he highlighted involves LOVE—left out variable error. This is a modeling term from statistics that underscores the biased inferences that can result from leaving important variables out of the equations implied by a model. LOVE problems are particularly important in the sexual domain. For example, nearly all research in this area focuses on a given individual’s attitudes, orientations, cognitions, normative pressures, and emotions. But intercourse is a two-person enterprise and studying only one member of that couple potentially leaves out 50 percent of the important variables, that is, those of the partner. “It is so important that we do more research on couples, where both couple members are interviewed rather than just one of them” said Jaccard. The cognitions, norms, emotions, self-efficacy, and so on of each couple member are blended together to reach a joint decision to engage in protected or unprotected sex. Researchers need to develop models that respect such couple dynamics, Jaccard said.

SUBSTANCE USE

The transition to young adulthood is marked by large increases in substance use. Many reasons are behind these changes, including movement away from parents, initiation of new and varied friendships, new roles, more choices and opportunities, greater independence, identity exploration, reduced social control, and the use of substances for fun and for self-medication, noted Helene Raskin White, Professor II (Distinguished

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

Professor) in the Center of Alcohol Studies and Sociology Department at Rutgers University. Young adulthood also can be a period of heightened instability, and many young adults may turn to alcohol or drugs to deal with the stresses of this instability.

Binge drinking, defined as drinking five or more drinks on one occasion for men and four or more for women, peaks during young adulthood and declines over time (see Figure 4-3). The use of marijuana and other illicit drugs peaks slightly earlier, in the 18- to 20-year-old age group. White presented that a higher percentage of males than females ages 19-30 drink alcohol and use marijuana, and a higher percentage of whites ages 18-25 use alcohol and illicit drugs than blacks or Hispanics. However, White said, after age 26, African Americans are more likely to report illicit drug use than whites.

Psychosocial characteristics also place individuals at risk for substance use. Youth who are more impulsive and high risk takers are more likely to be involved in drug use and heavy drinking than their peers. Similarly, those who are depressed and anxious are more likely to be involved in drug use. Peer substance use is the best predictor of a young adult’s substance use, but parents continue to have an influence, even during young adulthood.

Eighteen-year-olds who are out of college are more likely to smoke, drink, and smoke marijuana than their peers who are still in high school (White et al., 2005). However, as these students are followed over time, different patterns emerge. Cigarette use is consistently higher among non-

images

FIGURE 4-3 Binge drinking during the past month peaks at ages 21-25.
SOURCE: White, 2013; adapted from SAMHSA, 2010.

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

student males and females. Marijuana use is consistently higher among nonstudent males. Alcohol use is not related to college status even during the college years. In addition, alcohol and marijuana problems are consistently highest among nonstudent males. However, this research was done predominantly with white middle- and working-class samples. Schensul and Burkholder (2005) argue that low-income and youth of color are an even more important target for prevention for substance abuse. Not only do they have the same risk factors that come with the transition from adolescence to young adulthood as their white middle- and upper-class counterparts, but they also experience many other risk factors, including lack of job opportunities, lack of good role models, and discrimination.

Not all youth are equally likely to use drugs or drink heavily. For example, young adults who are married are less likely to engage in these behaviors than their peers who are dating or single, said White. Those who live at home with their parents, especially college students, are protected from heavy drinking, but not necessarily from drug use. Those who work full-time in a satisfying job are less likely to drink heavily and use drugs than those who are unemployed or those working full-time in a menial job. Also, many young adults mature out of their substance use, even as others go on to develop alcohol and drug disorders.

Interventions need to be available for all youth, White said, but some youth are at higher risk of increased substance use in young adulthood. Heavy drinkers in college are an important target group for these interventions. Noncollege youth are also an important target group for alcohol use interventions and for cigarette and illicit drug use prevention programs.

One promising type of intervention involves personalized feedback, where information is tailored to the individual. For example, personalized feedback could include a student’s drinking compared with college averages, the negative consequences of use, and risk factors for later use, such as a family history of alcoholism or high levels of depression, blood alcohol concentrations and what those levels mean, the amount of money spent on alcohol, or the number of calories gained from drinking. By heightening an individual’s awareness of personal patterns of use in relation to that of peers, he or she can create greater awareness of risks, which can lead to changes in behavior. These types of interventions have proven very effective on college campuses, said White, especially when delivered in the context of a brief motivational interview. These approaches also are being adopted for marijuana use on college campuses, although research on this use is more limited. Also, the effects tend to dissipate over time, which may underscore the need for booster sessions.

New interventions for drug and alcohol use for both college and noncollege students are still needed. For example, accessing or recruiting

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

noncollege students has become a major issue. Also, delays in achieving traditional milestones of young adulthood may extend the period for problem behaviors to later ages than in the past. “If we can begin to move some of these interventions outside of the college campus, we will be able to reduce the problems associated with substance use for all young adults,” White concluded.

Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×

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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
Page 41
Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
Page 42
Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Suggested Citation:"4 Safety- and Health-Related Behaviors." Institute of Medicine and National Research Council. 2013. Improving the Health, Safety, and Well-Being of Young Adults: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/18340.
×
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Young adults are at a significant and pivotal time of life. They may seek higher education, launch their work lives, develop personal relationships and healthy habits, and pursue other endeavors that help set them on healthy and productive pathways. However, the transition to adulthood also can be a time of increased vulnerability and risk. Young adults may be unemployed and homeless, lack access to health care, suffer from mental health issues or other chronic health conditions, or engage in binge drinking, illicit drug use, or driving under the influence. Young adults are moving out of the services and systems that supported them as children and adolescents, but adult services and systems—for example, the adult health care system, the labor market, and the justice system—may not be well suited to supporting their needs.

Improving the Health, Safety, and Well-Being of Young Adults is the summary of a workshop hosted by the Board on Children, Youth, and Families of the Institute of Medicine (IOM) and the National Research Council (NRC) in May, 2013. More than 250 researchers, practitioners, policy makers, and young adults presented and discussed research on the development, health, safety, and well-being of young adults. This report focuses on the developmental characteristics and attributes of this age group and its placement in the life course; how well young adults function across relevant sectors, including, for example, health and mental health, education, labor, justice, military, and foster care; and how the various sectors that intersect with young adults influence their health and well-being. Improving the Health, Safety, and Well-Being of Young Adults provides an overview of existing research and identifies research gaps and issues that deserve more intensive study. It also is meant to start a conversation aimed at a larger IOM/NRC effort to guide research, practices, and policies affecting young adults.

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