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Theory and methods
Engaging youth in communities: a framework for promoting adolescent and community health
  1. Parissa J Ballard1,
  2. S Leonard Syme2
  1. 1University of California, Berkeley and University of California, San Francisco, California, USA
  2. 2University of California, Berkeley, California, USA
  1. Correspondence to Dr Parissa J Ballard, University of California, Berkeley and University of California, >#50 University Hall, MC #7360, San Francisco, CA 94720-7360, USA; ballardpj{at}berkeley.edu

Abstract

Health researchers and practitioners increasingly recognise the important role communities play in shaping individual health. Health researchers recognise the role of community factors as causes or determinants of health problems; use community-based methods for understanding complex health issues; and design community-level health solutions. In this commentary, we propose a fourth way to think about the role of communities in individual health by arguing that the community engagement process itself has implications for individual health and strong communities. This topic is especially important during adolescence, a developmental window of opportunity during which individuals need meaningful opportunities to contribute to the world around them.

  • SOCIAL CAPITAL
  • PSYCHOLOGY
  • POLICY

https://doi.org/10.1136/jech-2015-206110

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    The idea that communities play an important role in individual health is now well accepted in the fields of public health and social epidemiology. Health researchers focus on three roles of community for health: they recognise the role of community factors as causes or determinants of health problems; use community-based methods for understanding complex health issues; and design community-level health solutions. At the same time, it should be noted that individuals and groups contribute to building and maintaining strong communities. Indeed, current thinking on the topic extends beyond a unidimensional ‘context matters for health’ conceptualisation in favour of a more dynamic and bidirectional understanding of links between people and communities.1 In this commentary, we propose a fourth way to think about the role of communities for health: By examining implications of the community engagement process itself for individual and community health. From the perspective of developmental psychology, we argue that understanding the bidirectional links between adolescents and communities (which we consider to be groups defined by geographical and social boundaries) holds special promise for promoting individual health and strong communities.

    Communities in health research

    The first area where health research is affording a prominent role to communities is in understanding the social causes or determinants of good and poor health. A relatively recent movement in health fields advocates for emphasising the multiple social causes of health and health disparities rather framing health exclusively in individual terms. In social epidemiology, this can be seen through increasing attention to the social determinants of health. In this framework, there is specific interest in the role of place in health1 based on the understanding that communities ‘possess both physical and social attributes which could plausibly affect physical health.’2 Accordingly, evidence is mounting that features of the built environment (eg, walkability, community greenspace, and access to healthy food options)3 and the social environment (eg, social networks, trust, cohesion, bonds4) each contribute to individual health trajectories. Community-level factors might be especially important to health and well-being during adolescence; communities become increasingly salient developmental settings as youth spend more time outside their homes. Neighbourhood structural factors, such as socioeconomic conditions, are linked with a variety of adolescent academic and behavioural outcomes5 and recent prospective research points to neighbourhood factors, such as physical disorder, as a risk factor for physical health (obesity) among early adolescent girls.6 Importantly research shows that social environmental factors such as collective efficacy may play a protective role for youth development7 pointing to community level social conditions as modifiable social causes in adolescent health.

    Second, there has been a simultaneous movement in health research towards community-based methods for understanding health. Community-based methods are common in public health8 and are present, although less common, in social epidemiology (referred to as popular or participatory epidemiology).9 Most frequently, proponents suggest that health interventions will be most effective and sustainable when local communities are treated as partners, stakeholders and informants, as well as recipients, of health interventions.10 Community-based methods range from working with community partners to locate relevant health problems, to engaging communities in the research process as an empowering health intervention.8 One subset of community-based methods used with youth is especially relevant for the present article. Youth participatory action research is a community-based approach specifically designed to empower youth in their developmental settings, such as school and after-school programmes, to combat the ‘developmental mismatch’ between their increasing capacity and desire for agency and their often constrained opportunities for meaningful community contribution.11 ,12

    A third example of communities being afforded prominence in health research is seen through community-based solutions to health problems. If health researchers are increasingly recognising the role of community as causes of health problems and are employing methods for understanding complex health issues, it follows that health solutions should be community-based. A community solution focus is seen in funding initiatives, for example, focused on promoting a ‘Culture of Health’,13 in academic programmes with a specific ‘Community Health’ focus, and in more specific initiatives for multilevel and community-based interventions.14 These programmes share the common goal of improving the health of groups by recognising that health happens in communities rather than in isolation. Multilevel health interventions may be especially effective for youth as they capitalise on individual and group processes, which are developmentally salient for adolescents. In sum, then, many researchers and practitioners in the health fields are shifting towards supporting health and decreasing health disparities by understanding community causes of health, using methods that partner with communities, and crafting solutions that work for communities.

    A fourth role of communities in health

    Attention to the benefits that individuals receive from being embedded in cohesive and resourced communities is well documented in scholarly research. However, a long tradition of research from psychology and public health reveals that there may be something special about the flip side of being embedded in communities: contributing. What people contribute to their communities, through collaborating with others to address social issues, may be just as—or even more—beneficial to health than receiving support.15–17 Community psychologists have long argued that there are benefits of community participation for individual and communities;18 ,19 we add a developmental argument for focusing on adolescents and suggest psychological mechanisms that might link civic engagement with health. We propose an initiative in health research to focus on youth civic engagement (YCE) as a promising approach to synergise efforts to promote adolescent and community health (figure 1).

    Figure 1
    Figure 1

    Schematic representation of the role of communities in research on adolescent health.

    Youth civic engagement

    Adolescencei is a critical window of development characterised by changes at multiple levels, from biology to social role transitions,20 during which opportunities for participation in meaningful activities, feeling that one matters, and forming warm and supportive relationships with adults are crucial to positive youth development.11 ,12 ,21 ,22 Furthermore, adolescence is a formative window for life-long health23 and civic trajectories.24 Although civic development and adolescent health are traditionally examined as separate processes, we believe that there is a compelling reason for considering them together. A large body of work documents health effects of certain forms of civic engagement, such as volunteerism, among older adults.25 However, adolescents have a different set of developmental goals and needs that make it a relevant stage to understand how community participation affects healthy development. For example, a major developmental task of adolescence is identity formation, which includes defining one's role in relation to society26 and multiple developmental frameworks, such as positive youth development and sociopolitical development, suggest that youth engagement within their communities is an important part of development.27 ,28

    Civic engagement can be defined as ‘individual and collective actions designed to identify and address issues of public concern.’29 Diverse youth have access to different types of civic opportunities and may participate in a variety of such collective actions aimed at community contribution: formal volunteerism, political activities such as campaigning and voting (for older adolescents), and activism such as protesting.30 We believe that high-quality civic engagement, by offering youth meaningful and empowering opportunities to engage with their communities, can provide positive experiences for adolescents at a crucial developmental period while at the same time channelling the considerable skills and energy of youth to improve communities.31 ,32

    YCE can promote adolescent health

    We propose that high quality YCE can promote adolescent health by providing adolescents opportunities for care-giving and change-making. YCE could affect three aspects of adolescent health: health and risk behaviours, mental health, and indicators of disease vulnerability or physiological stress markers (eg, inflammation). The most direct evidence that YCE can promote adolescent health comes from research on care-giving through formal volunteering programmes. In a randomised control trial study, Schreier et al33 assigned high school students to volunteer weekly for 2 months in the Fall (intervention group) or Spring (control group) in after-school programmes with elementary school children. The authors found that intervention group participants had lowered cardiovascular risk as measured through inflammatory markers, cholesterol and body mass index33 compared to the control group, suggesting that volunteering can improve adolescent health. Extensive research with adults points to a link between volunteerism and better health34 and one suggested mechanism explaining the link between volunteerism and health is the promotive function of caring for others and giving support. Although caregiving for close others can increase health risk it might be protective or promotive for health when not overly burdensome and when appraised as meaningful and fulfilling.17 ,35 Indeed, psychological evidence suggests that providing care and support to close others (family, friends, neighbours) can predict positive affect,15 reduce mortality and morbidity15 ,36 and activate neural reward systems.37 While care-taking may provide health benefits across ages, adolescents might specifically benefit from the opportunity to contribute to their communities in meaningful ways.

    Volunteerism is one care-based category of civic activities; YCE can also take explicitly political forms. Political forms of civic engagement might affect health though a similar pathway giving adolescents a chance to contribute, provide care, and find meaning; or, it might operate through altogether different pathways, such as through psychological empowerment. Community and developmental psychologists give special attention to the positive role of empowerment in adolescent development, especially among marginalised young people.38 High quality civic programmes can help adolescents come to see themselves as civic actors with real opportunities to engage with communities. Such opportunities for civic empowerment among marginalised youth are positively associated with academic success, political engagement and general well-being.39 Further, civic empowerment mediates the links between supportive family and school contexts on well-being40 and political participation.41 Taken together, correlational and experimental evidence suggest that high quality YCE might have a positive developmental function for many domains of youth development, though more direct evidence is needed linking YCE and adolescent health. Given that adolescents self-select into civic activities based on internal motivations and structural opportunities and constraints21 ,42 it will be important to understand the interplay of selection effects and the civic experiences themselves on health outcomes.34 ,43 Other critical questions to address are about mechanisms linking various forms of YCE and health and understanding which youth may especially benefit from such experiences (see box 1 for a suggested research questions and hypotheses). Importantly, high quality YCE should operate at multiple levels to empower individuals and communities.19 ,39

    Box 1

    Specific Proposals for a Research Agenda Linking Youth Civic Engagement, Adolescent, and Community Health

    • 1. Community-engaged health intervention projects present an opportunity for understanding whether the engagement process has implications for health. Researchers engaging community members in projects to improve the health of their communities can add a dimension to studies by measuring the civic experience of community members and individual health during community engagement to gain insight about how community-engagement processes covary with individual health trajectories.

    • 2. Large national studies of adolescent development can add measures of civic experiences (eg, participation in different types of civic activities, feelings of empowerment, and feelings of contribution and meaning) to see how naturally occurring civic development affects, and is affected by, other domains of youth development.

    • 3. To overcome methodological challenges in civic development research, innovations in study methods for understanding civic development are needed. For example, randomised control trial studies will best enable researchers to establish causal links between civic engagement and health. There are challenges in designing random assignment studies in the context of activities that are typically voluntary, but these challenges can be overcome with creative methods such as simulation studies. Qualitative studies will be needed to contextualise particular civic experiences especially as they vary for adolescents from demographic groups.

    • 4. Researchers should examine complex links between civic engagement and health, informed by theory. For example, it is likely that links between civic engagement and health will:

      • A. Be non-linear over time (perhaps with negative initial health effects if civic engagement is stressful and positive effects over the longer-term if it is empowering)

      • B. Be moderated by things like social status and quality of civic experience

      • C. Be developmentally differentiated (with links stronger during developmental transitions)

      • D. Vary by type of civic engagement (volunteerism vs activism)

      • E. Vary by type of health outcome (health behaviours, mental health, physical health

    YCE can improve structural aspects of communities

    Ideally, high quality civic programmes offer youth a chance to collectively engage with their communities to solve what they see as pressing social problems. Although such change will be slow and setbacks inevitable, from the perspective of positive youth development, youth should be considered assets to communities31 with developing skills and ideas that can contribute to community life with appropriate mentorship from adults.22 As an example, youth from the San Francisco Youth Commission engaged in a multiphase process to identify teen transportation needs and to lobby for policy changes. After 3 years, the youth commission succeeded in convincing the San Francisco Municipal Transportation Agency (MUNI) board to approve a ‘Free MUNI for Youth’ programme with an expansion to include 18-year-olds from low to moderate income families in those eligible for free MUNI passes (SF Youth Commission). In this example, engaged youth formed horizontal partnerships with other youth across districts as well as vertical partnerships with local political leaders. Together, they successfully changed policy that directly improved the well-being of San Francisco teen residents and families by providing transportation access to some of the city's most vulnerable young people. Ultimately, incremental improvements in communities and policies affecting youth should feedback to support adolescent health and the broader health of communities.

    YCE can improve the social aspects of communities

    YCE can help build community social capital, increase social trust between community members, contribute to a sense of community social cohesion, and promote collective empowerment.19 ,39 From the perspective of social capital theory, individual civic engagement is indeed part of what defines communities high in social capital. A critical social aspect of communities is a sense of collective efficacy, or the perceived ability that communities can band together to solve social problems that arise. According to extensive work of Sampson et al,44 collective efficacy is a characteristic that varies dramatically by neighbourhood and predicts neighbourhood safety and the health and development of residents. High quality YCE, should directly increase participants’ sense of collective efficacy, and, especially when visible to other community members, could lead to broader a sense of community collective efficacy.45 Although this is a complex process with nuance regarding the conditions under which civic engagement indeed increases community capacity and health, ideally, engagement should affect the perceived and actual capacity of communities to meet their needs.19

    Conclusion

    Elaborating on Cummins et al's1 argument for a broader recognition of the ‘mutually reinforcing and reciprocal relationship between people and place,’ we argue that the process by which people and place are reciprocally related also has implications for individual and community health, especially during the developmental window of opportunity known as adolescence. Ideally, YCE operates at the individual level by offering youth a meaningful chance to care for others and to become empowered to create change, while also operating at the community level to increase local capacity through social action processes. It is very important to note that YCE also has the potential to undermine adolescent health and well-being; for example, if such engagement is stressful, burdensome or futile. The focus of the present paper is on the positive potentials of YCE; the negative possibilities are explored in depth elsewhere (eg, P J Ballard and E J Ozer. The implications of youth activism for health and well-Being. In: Conner J, Rosen S. Contemporary Youth Activism: advancing Social Justice in the United States (under review)). The promise of the approach outlined here is twofold: it offers a dual focus on promoting adolescent and community health and it relies on a transdisciplinary approach to health. Psychologists, epidemiologists and population health scientists each understand pieces of the conceptual puzzle about how people become engaged with places, how places support this process, and how this process can promote individual and community health. By offering a framework linking civic engagement, adolescent health, and healthy communities, we challenge psychologists to focus on promoting adolescent development in a way that also builds communities and we challenge population health scientists to consider how community engagement processes can affect adolescent health and well-being. YCE can be a lens for simultaneously considering individual and community health and the processes by which community participation might improve the health and well-being of our youth and our communities.

    What is already known on this subject

    • Adolescent health is affected by the communities adolescents live in. At the same time, adolescents affect their own communities through civic engagement (ie, taking collective action to address issues of public concern).

    What this study adds

    • We believe that the community engagement process has implications for adolescent health and strong communities. We propose an initiative in health research to focus on youth civic engagement as a promising approach to synergise efforts for promoting adolescent and community health.

    Acknowledgments

    The authors thank the Robert Wood Johnson Foundation Health and Society Scholars program for its financial support. The authors thank Keely Muscatell and Lindsay Till Hoyt for comments on an early draft and our many colleagues at UCSF and UC Berkeley for ongoing discussion of these ideas. We also thank Allen Lu from the San Francisco Youth Commission for feedback about the youth MUNI program.

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    Footnotes

    • Contributors PJB conceptualised and wrote this article. SLS discussed conceptualisation and helped with framing the idea and editing the article.

    • Competing interests None declared.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • ↵i We consider adolescence to be roughly from age 12 to 21 and refer to interchangeably with ‘youth’ in this paper.