Health promotion for adolescents: Specific characteristics of group programs

Promoção de saúde para adolescentes: Características específicas de programas em grupo

Promoción de la salud para adolescentes: características específicas de los programas grupales

Suzana Peron peron.suzana@gmail.com

University of São Paulo, Brasil

Carmem Beatriz Neufeld

University of São Paulo, Brasil

This study consists of an integrative literature review on group interventions focused on health promotion for adolescents, guided by the following guiding question:

• What are the group health promotion programs aimed at adolescents and the characteristics of the proposed interventions?

From this question, data collection was performed in the following bibliographic databases: Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS), Scientific Electronic Library Online (SciELO), PubMed, and PsycInfo, considering the period between 2008 and 2018. The following keywords were used to search for articles, considering their presence in the title or abstract and based on their combination using Boolean operators: ((“adolescente” OR “adolescent” OR “teenager”) AND (“health promotion” OR “promoção de saúde” OR “promoción de la salud”) AND (“mental health” OR “saúde mental” OR “salud mental”) AND (“grupo” OR “group”) AND (“programa” OR “program”)).

The searches in the databases were carried out in the languages that stood out in each database, thus using keywords in Portuguese, English, and Spanish, based on these specifications.

The search for articles was carried out through the Integrated Library System of the University of São Paulo (Sistema Integrado de Bibliotecas da Universidade de São Paulo - SIBiUSP), the part of the Rectory of the University of São Paulo that, which provides public access to bibliographic records of books, journals, theses and dissertations of the university, congress proceedings, catalogs, films, iconographies, newspapers, brochures, among others, allowing access to the full text whenever possible.

To refine the collection, the following filters were used when the organization of the database allowed: article format; published between 2008 and 2018; written in Portuguese, English, or Spanish. When these filters were not available in the database, the exclusion of articles that did not meet these criteria was performed manually. Furthermore, the following inclusion criteria were considered: 1. interventions aimed at adolescents, with the possibility of parallel or concomitant intervention by parents, guardians, and/or teachers; 2. written in English, Portuguese, or Spanish; 3. interventions aimed at health promotion; 4. interventions from the perspective of psychology; 5. article format; and 6. group interventions. The exclusion criteria were established: 1. interventions aimed at clinical populations (people with cancer, obesity, depressive disorder, eating disorders, HIV/AIDS, for example); and 2. exclusive interventions of other health areas. After performing the search, reading the abstracts and articles in full, and based on the aforementioned inclusion and exclusion criteria, the selected articles were retrieved, which constituted the search result, as shown in Figure 1. After reading these studies, there was a step of extracting the data of interest for the review, using an appropriate form containing the following fields: 1. article identification number; 2. title of the article; 3. authors; 4. country of origin; 5. year of publication; 6. journal; 7. database; 8. article language; 9. keywords; 10. study design; 11. participants; 12. instruments; 13. objective; 14. characteristics of the proposed intervention; 15. results; and 16. conclusion. We highlight that the peer review feature was not used in the selection of articles included in this review.

Figure 1
Flowchart of the selection procedure of the articles included in the literature review

Through the searches in the databases, a total of 381 articles were found. Initially, 91 articles were excluded due to the application of the filters: time interval (2008-2018), publication format (articles), and language (Portuguese, English, or Spanish). Then, the titles and abstracts of the remaining 280 articles were read, and, from this stage onwards, 39 articles were selected to be read in full. The next step consisted of the reading of the studies, application of the specific inclusion and exclusion criteria, and, finally, the removal of the studies that were repeated in the sample. Then, 17 articles were included in the review, which were used to fill in the coding forms with relevant information for this study. Figure 1 describes this procedure in detail.

Regarding the date of publication, there is a greater concentration in the years 2014 and 2016, with 23.5% of the articles being published in each of the years (n = 4). The selected articles ranged from 2009 to 2018, and no selected article had been published in the years 2008 and 2011 (Figure 2).

Figure 2
Distribution of years of publication of the articles selected for the review

As for the country of origin, the United States of America concentrated 29.4% (n = 5) of the articles, followed by Australia with 17.6% (n = 3), and the other countries (Brazil, Canada Spain, Finland, Nigeria, Norway, Portugal, Sweden, and Turkey) with 5.8% (n = 1) each. Still, in relation to the continent of origin, America was the continent with most studies, with 41.2% (n = 7); followed by Europe, with 35.3% (n = 6); Oceania, with 17.6% (n = 3); and Africa with 5.8% (n = 1).

The methodologies most used by the articles were quantitative, with the most common being the quasi-experimental methodology - 35.3% (n = 6) of the cases -, followed by randomized clinical trials (RCT) - 29.4% (n = 5) -, and pre-experimental and experimental - 5.8% (n = 1) each. As for qualitative methods, these were used by 11.7% (n = 2) of the studies. Mixed methods were used in 11.7% (n = 2) of the articles. In total, seven different types of methodologies used for the presentation and assessment of the programs, and their applicability and results were identified.

The objectives of the studies were different, depending on the variables considered in the intervention and the methodology used in the study. For this reason, they were grouped according to their assessment intent. As for the intention to assess the effectiveness of the intervention, 41.1% (n = 7) of the studies had this objective; 29.4% (n = 5) tried to assess the program’s efficacy; and 23.5% (n = 4), the efficiency. Still, the description of the intervention adaptation process was present in 5.8% (n = 1) of the studies, and the exploration of the participants’ experience, in 5.8% (n = 1).

Regarding the samples used, 5.8% (n = 1) of the studies considered only female adolescents, while all the other 94.2% (n = 16) selected individuals of both sexes. In addition, 17.6% (n = 3) of the studies presented interventions or instructions aimed at parents/relatives and/or teachers, which occurred at the same time that the adolescents underwent the intervention. As for the participants’ age, it ranged from ten to 18 years.

Table 1 summarizes the information of the selected studies, such as the authors, titles, results, and objectives.

Table 1
Description of articles included in the review and characteristics of the interventions

The characteristics of the proposed interventions are described in Table 1. The aspects considered by this literature review were the number of sessions, frequency, duration, place of intervention, theoretical framework, responsible professional, and topics covered. Also, the table describes the presence or absence of a complete description of the program, with the themes approached in the sessions of the programs and the activities carried out in each one of them.

As for the number of sessions, these ranged from one to 48, and programs that proposed more than 20 sessions occurred more than once a week or were inserted within school classes. Thus, 76.47% (n = 13) of the sample had weekly sessions. In relation to the duration of the sessions, there was an expressive variation. The duration of the sessions ranged from 30 minutes to 10 days - in this case, it was an immersion program.

Regarding the place of intervention, 72.2% (n = 13) were carried out in a school environment, 16.6% (n = 3) in a community environment, and 11.1% (n = 2) in other environments. It is important to emphasize that the activities in the community took place after school hours. Still, the option listed as “other” consists of an intervention with parents/relatives carried out in parallel with the intervention of the adolescents, which occurred in the homes of the participating families.

Interventions also did not show a pattern regarding the professional responsible for administering and conducting the groups (Table 1). In 33.3% (n = 6) of the cases, teachers were responsible for the application; in 22.2% (n = 4), health professionals did it; in 27.7% (n = 5) of the interventions, other professionals had this task; and in 16.6% (n = 3) of the studies, it was not reported.

As for the theoretical framework, it was observed that 64.70% (n = 11) of the articles did not explain the theoretical approach on which the intervention was based. Furthermore, 29.41% (n = 5) of selected interventions reported using cognitive-behavioral therapy (CBT), while 5.89% (n = 1) reported being mindfulness-based.

Regarding the content present in the interventions, these proved to be quite variable and involved several psychological and other aspects of health. The most frequent components involved stress management/reduction, effective communication, and regulation/emotional aspects, each present in seven interventions (10.4%), followed by problem-solving, which was used in 9% (n = 6) of the studies. The contents used for health promotion among the adolescents in the selected programs are described in Figure 3. And, finally, the structured program, or the specification of contents worked on in each session, was presented by 70.5% (n = 12) of the articles, while 29.5% (n = 4) did not bring this information.

Figure 3
Frequency of contents used by the programs

The aim of this review was to describe studies on programs to promote health for adolescents. In this way, the characteristics of the selected programs were presented, and their particularities and possibilities were described.

The method used to assess these programs is an essential factor to be analyzed, as it directly influences the assessment of the intervention. In this review, articles with different methodological approaches were selected. According to the literature, the methodology considered the “gold standard” for determining the therapeutic effect is RCT (Cook, 2009). These consist of prospective studies that seek to compare the effect and value of a controlled intervention in human beings, in which the analyzed factor is randomly distributed throughout the sample, through the randomization technique for the formation of experimental and control groups (Escosteguy, 1999). In the sample of this study, it was observed that 29.4% of the interventions were assessed through RCT, however, this was not the most applied method, since 35.3% of the articles described a quasi-experimental methodology.

Quasi-experimental studies are characterized by allowing greater methodological control than pre-experimental ones, but they cannot reach the rigor present in experimental studies and clinical trials. They are usually conducted in a natural environment (schools, hospitals, companies), in an attempt to improve people’s living and working conditions and/or assess the efficacy of interventions/treatments performed outside the laboratory environment and also in situations in which it is not practical or ethical to perform a neat experiment. This method lacks full experimental control, but it helps to investigate the practical importance and real significance of experiments, having a high external validity (Shaughnessy et al., 2012). In this sense, Shaughnessy et al. (2012) point out that it is more desirable to have some kind of knowledge about the efficacy of the treatment than no knowledge at all and that this is an advantage of quasi-experimental studies.

The pre-experimental design, which was used in one of the review articles, does not use a control group for comparison and has some limitations regarding history, maturation, test effect, instrument wear, and statistic regression, which results in low internal validity. The pure experimental design, also used in one of the studies, involves direct manipulation and control of variables, using the control group for comparison and experimental control with randomization, resulting in high internal validity (Campbell & Stanley, 1979).

As for focus groups, these are considered a qualitative data collection technique, which has been used to explore the conceptions and experiences of research participants (Backes et al., 2011). Hence, exploring the experiences of participants of a specific group seems to be an adequate method, as used in the study by Garmy et al. (2015). Finally, in two articles, mixed methods were used: data collection procedures, analysis, and a combination of quantitative and qualitative techniques in the same research design to achieve its assessment objectives (Paranhos et al., 2016).

A factor that influences the choice of methodology for a study is its objective. Thus, it is necessary to consider the differences between the efficacy, efficiency, and effectiveness of the proposed interventions. Efficacy refers to how well the treatment works under the conditions of the “ideal world”, which would be the assessment of the result of a treatment in a randomized clinical trial; efficiency refers to the cost-effectiveness of the treatment; and effectiveness refers to how the treatment works under “real world” conditions, that is, in situations in which patients/clients are heterogeneous regarding a certain characteristic (Rush, 2009). Thus, concerning the objectives of the selected studies, it was evident that 41.1% (n = 7) sought to assess the effectiveness of the program, while 29.5% (n = 5) assessed its efficacy. These objectives seemed to be in line with the methods used and described above, showing that the methodological choices of the studies were relevant to their objectives and practical possibilities.

The interventions were applied in three different environments, with the participants’ school being the most frequent among the selected studies, 72.2% (n = 13) of the cases. Pelicioni and Torres (1999) point out that interventions in the school context, aimed at promoting health, adopt an integral view of the human being, considering them as part of a family, community, and social sphere, in order to improve their quality of life. According to Herzig-Anderson et al. (2012), schools are promising environments for the implementation of mental health services for children and adolescents, as they can normalize mental health care and increase the chances of the population getting access to aid. Del Prette and Del Prette (2009) justify the inclusion of mental health promotion programs in schools through three fundamental functions: the social function of the school itself; the relationship between academic performance and social skills; and inclusion policies. However, this environment also has limitations, as it has scarce resources, and mental health programs in schools often depend on the training of professionals from the institution itself, in order to be implemented (Paternostro et al., 2015).

In this sense, the data from this review are in line with the literature. The results showed that, in 33.3% (n = 6) of the studies, the intervention was applied by trained teachers, which seems to be in accordance with the reality of the school environment and the possibilities of applying health promotion programs for this population. Paternostro et al. (2015) point out that developing the skills of the school team in providing mental health services is essential for the sustainability of these programs. Still, other health professionals were responsible for the application in 22.2% (n = 4) of the selected studies. As for the application of specific programs of the cognitive-behavioral approach, considering groups in a school environment, studies show that professionals from other areas (including teachers), when trained, can conduct the programs efficiently and successfully (Barrett et al., 2000; Maria-Warner et al., 2013).

Still regarding the individuals involved in the programs, adolescence is shown as a challenging phase not only for young people, but also for their parents, family members, teachers, and friends (Macedo et al., 2017). Thus, it is necessary for parents to assume new roles, especially considering parenting styles and their influences on their children’s behavior (Silva, 2009). In this sense, Luz et al. (2015) point out that promoting health for young people and adolescents also involves encouraging responsibility for health in other environments, such as the family, organizations, or communities. Considering these points, it is important to highlight the fact that only two programs among those selected by this review had interventions that also involved parents and family members in the health promotion process. In one of them, after the intervention, it was described that the paternal hostility behaviors increased after the program, as well as the problem-solving skills decreased, indicating problems in its application.

Considering the contents used in the interventions carried out by the programs, several components capable of achieving this objective are described in the literature. Zins et al. (2004) report that these programs typically focus on a variety of emotional and social skills, such as self-awareness, self-management, empathy, and problem-solving. In this review, the most used by the selected programs were stress management/reduction, regulation/emotional aspects, effective communication, and problem-solving, totaling 40.3% (n = 27) of the contents. Considering the abovementioned, these four intervention themes are LSs.

According to the WHO (1997), LSs refer to social, cognitive, and affective skills that are useful for coping with everyday demands. They are self-knowledge, critical thinking, creative thinking, decision-making, problem-solving, interpersonal relationships, effective communication, empathy, managing emotions, and coping with stress. Dealing with stress involves recognizing the sources of stress and developing coping strategies to resolve and reduce its effects. Dealing with emotions is about recognizing one’s own emotions and assertively express oneself, without harming their own health. Effective communication is the ability to express opinions, desires, needs, and feelings in a direct and socially appropriate way, seeking to reconcile the rights of both parties. And problem-solving is a skill that involves facing problems constructively, using one’s own resources and the environment, without harming others (Murta et al., 2010).

Social skills and assertiveness, in particular, are presented as contents in these studies. They add up to 6% of the topics covered. These skills are social behaviors that contribute to social competence and facilitate healthy relationships, namely: civility, interpersonal problem-solving, making friends, assertiveness, and empathy (Murta et al., 2010). Assertiveness consists of the ability to assert and defend one’s rights, through the expression of thoughts, feelings, and beliefs, directly and honestly, without disrespecting the rights of others (Lange & Jakubowski, 1976, as cited in Bandeira, 2003). The WHO proposes life and social skills education programs with the aim of developing adaptive and socially appropriate behaviors so that young people can effectively deal with the demands and challenges of everyday life (WHO, 1997). Currently, these skills have been heavily used in programs to promote well-being and quality of life (Murta & Barletta, 2015), as evidenced by this review.

Murta and Barletta (2015) also point out that the knowledge arising from CBT studies can be important an factor in the development of programs to promote mental health and prevent mental disorders. In this review, 10.5% (n = 7) of the contents studied had CBT elements, namely: the use of the cognitive model and the setting of goals. The cognitive model proposes that the individual’s thoughts influence their emotions and behavior, and goal setting is one of the basic assumptions of this form of therapy (Beck, 1997). Still, it is evidenced in the literature that CBT has been widely used in the contexts of prevention and health promotion.

Also considering CBT elements, in this study, 29.41% (n = 5) of the interventions reported having CBT as the theoretical approach on which the program was based. It was observed that most programs did not report their theoretical basis, which, according to Zeidner et al. (2009), is a common movement considering this specific literature, since the theoretical and empirical bases of most training programs are unclear, and their effects are often not rigorously assessed.

The results presented by the studies point to promising interventions, even if slight in some cases. Only one of the studies highlighted increase in symptoms of hostility and difficulty in problem-solving in the case of the intervention aimed at parents and family members. However, it is important to apply the proposed interventions to larger and more diversified samples, as suggested by the studies. One of the programs presented, COPE, was assessed in three of the selected articles. In fact, one of them made cultural adaptations to the population of Turkish teenagers, and all studies point to positive results to some extent at the end of the assessment. This fact emphasizes the importance of adapting health promotion strategies and programs to the local needs and resources of countries to take into account different social, cultural, and economic systems (Carta de Ottawa, 1986).

There is a difficulty in choosing the articles due to the fact that the concepts of prevention and health promotion are often used in a complementary way (Weisz et al., 2005). The elements of these strategies are usually present in the same programs, since they have the improvement of individuals’ mental health as a common objective, although they have different approaches (WHO, 2004).

Considering the abovementioned, it can be said that health promotion programs aimed at adolescents have been increasingly developed, as their importance and need have been highlighted through research. The strategies used are diverse and proved to be effective in most of the studies found, although LSs and social skills stood out in terms of indication and application, even if they were worked on in different ways and combinations in each of the interventions presented.

In this sense, this study seeks to contribute to the research area through a mapping and description of health promotion programs for adolescents and their specific characteristics. In this way, it allows for greater knowledge about how health promotion recommendations for this population are being applied in practice and through what specific content and interventions this has been done.

As a limitation of the research, we point out the selection of the studies, chosen from the inclusion and exclusion criteria, which limits access to the totality of research related to the topic. There may be specific studies that were not included in the sample and that may approach interventions different from those presented in this review. Thus, the need for further studies on the subject is evident to contribute to the increase in knowledge and evidence about health promotion among adolescents.

The specificities of each type of methodology and different contents make it difficult or even impracticable to compare them in terms of assessment and know which one is more effective in promoting health, since they are very different. Thus, it is important that further revisions be made, considering the methodologies used by the programs and their content, with a more restricted selection, so that comparable items are considered, enabling the assessment of the most appropriate program for the development of specific skills for promotion among adolescents.

This study also showed that there is no standard in the literature that proves to be hegemonic for this purpose, which can also translate the diversity and multiple aspects that can be used when working with health promotion and adolescents since they are complex themes that point to the possibility and need for broad and different perspectives.