The blueprint for improving the health of Americans, Healthy People 2010, contains eight measurable leading health indicators for adolescents and young adults, with six targets directed at morbidity and mortality. These are reduction of (1) deaths caused by motor vehicle crashes, (2) homicides, (3) proportion of youth engaging in binge drinking of alcoholic beverages, (4) past-month use of illicit substances, (5) tobacco use, and (6) proportion of youth who are overweight or obese. In addition, there are two targets directed at wellness, increasing the proportion of youth who (1) abstain from sexual intercourse or use condoms if currently sexually active and (2) engage in vigorous physical activity.1 Although each of these targets is related to potentially modifiable adolescent behaviors, traditional medical approaches have largely failed to reach them. Even public health approaches have predominantly been deficit-based, insofar as they tend to measure the reduction in morbidity or mortality, rather than improvements in health (including 75% of health indicators mentioned above). Moreover, an Institute of Medicine report recently expressed concern about the crumbling infrastructure of public health in America and noted the need to determine the best strategies to ensure the health of the public in the 21st century.2 Thus, specialists in public health and in adolescent healthcare have begun to recognize the promise of a more positive, asset-based approach to improve the health of our youth by focusing on healthy youth development (YD). The details of the YD approach are explored by several articles in this supplement of the Journal of Public Health Management and Practice and offer innovative alternatives to approaches that have failed largely because they did not include the target population in their design or implementation in meaningful ways.

Although not intentionally designed as a public health strategy, attention to positive YD nonetheless has demonstrated effectiveness in addressing public health goals. Youth with more developmental assets have reduced morbidity and better health outcomes.3 In recognition of emerging data regarding the protective value of YD approaches with respect to improving the health of youth, Dr Karen Pittman, one of the authors of another commentary in this supplement, was invited to be the keynote speaker at the Society for Adolescent Medicine annual meeting in 2000. Instead of focusing on the prevention of illness, the YD approach that she and others have espoused takes a positive and affirming ecological perspective, emphasizing young people's potential (not as problems) and the reciprocal interactions (positive or negative) that they have with their environment. As she and colleagues point out, a YD approach nurtures adolescents' internal assets, including their emerging capacities for empathy and engagement, meaningful relationships, critical thinking, and leadership, with a "downstream" effect of improving health-related behaviors. Adolescent health is not framed as the absence of health problems or risky behaviors but as the cultivation of internal and external strengths resulting in the attainment of an individual's full human potential, which is associated with better health. A feature of YD that makes it equally attractive to adolescent healthcare providers and to public health practitioners is its applicability across all levels of intervention, from the individual youth to entire populations of young people.

At the individual level, providers of adolescent healthcare, including private practitioners and school health professionals, need to be involved in YD at the individual and family levels. For example, Bright Futures4 is a set of guidelines for health supervision that very clearly focuses on the development of youth assets. Health maintenance visits in the YD framework include asking the adolescent about family, friends, academics, and leisure activities. Likewise, health counseling addresses not only high-risk behaviors but also issues such as community service and features related to character, confidence, competence, connectedness, and caring. Parents are similarly included in a YD framework, with appraisal of parenting style and practices and expectations and supervision of adolescent activities. Regardless of the purpose of the visit, recommendations to enhance an adolescent's developmental assets can be made at the individual and/or family level. For example, during a "sports physical," the practitioner can determine the role that sports plays in the adolescent's life, as well as how sports is balanced against other creative activities and academics. Nonparental adults, such as coaches, can function as important role models and external assets.

Two asset-based, autonomy-supportive YD techniques in providing healthcare to individual adolescents that can be used to address public health problems listed in Healthy People 2010 include the use of guided decision making and motivational interviewing. For example, youth who smoke can be engaged as active participants-with assistance from the healthcare professional using guided decision making-in determining the strategies most likely to help them quit using tobacco. This dynamic closely parallels youth involvement in YD at the population level, in which youth are fully engaged, not just as recipients of services but as active participants. As discussed elsewhere in this supplement, Assets Coming Together (ACT) for Youth is a public health initiative funded by the New York State Department of Health to infuse YD throughout all youth services state-wide. Youth participants in ACT for Youth have developed the motto "no decisions about us, without us." Similarly, motivational interviewing, grounded in the readiness-to-change model, is known to facilitate change in behavior by not only acknowledging, respecting, and nurturing the emerging autonomy in adolescents but also providing them with direct feedback.5 At the individual level, this can be focused on increasing the likelihood that a sexually active adolescent will decide to use condoms consistently by exploring the various pros and cons of use and nonuse. At the community level, this can be focused on increasing the likelihood that a group of adolescents will be motivated to engage in healthy leisure activities made available in their neighborhood because they were involved in the design and implementation of programming.

The public health implications of the YD approach span from the county to the national level. As an example, Monroe County (Rochester), New York, established an initiative called HEALTH ACTION in which the community would be considered "healthy" if it achieved optimal levels of objective measures of health status and sustained a commitment to health to all age groups. In this context, the two youth-oriented priorities for community action in 2001 were to reduce tobacco use and to build youth competencies to promote healthy lives. These continue to frame public health efforts in the community, with encouraging results. The rate of smoking among youth has been reduced by 50 percent and a Community Asset Partner Network has been established6 to enhance ongoing YD activities in the region, including a Youth Summit attended by more than 700 individuals. Overseen by the County Department of Health, HEALTH ACTION is a public health intervention that not only measures youth assets but also makes enhancing youth assets a community priority across all youth-serving agencies.

The National Initiative to Improve Adolescent Health by the Year 2010 (NIIAH) is a broad-based effort to improve the health, safety, and well-being of adolescents and young adults. Led by a federal partnership between the Centers for Disease Control and Prevention's Division of Adolescent and School Health (CDC/DASH) and the Health Resources and Services Administration's Maternal and Child Health Bureau/Office of Adolescent Health (HRSA/MCHB/OAH) working in collaboration, the goals of the NIIAH are to (1) elevate national, state, and community focus and commitment to the health, safety, and well-being of adolescents, young adults, and their families; (2) increase access to quality healthcare, including comprehensive general health, oral health, mental health, and substance abuse prevention and treatment services; (3) improve health and safety outcomes in areas defined by the "21 Critical Health Objectives" of Healthy People 2010; and (4) eliminate health disparities among adolescents and young adults. The NIIAH provides a unique opportunity for policy makers, health professionals, community members, adolescents, young adults, and their families to collectively address the issues that affect the health of our nation's youth.

With a focus on enhancing YD as a strategy to achieve its lofty goals, the NIIAH takes a positive and affirming ecological perspective. As a public health effort, it also recognizes that an adolescent's environment strongly shapes his or her choices and that families, schools, communities, and public policies influence behaviors. Although young people are responsible for their choices, adults bear some responsibility for the choices available to youth. This requires a commitment at the local, regional, state, and national levels, and a different way in which we measure success in efforts to improve adolescent health. In the YD framework, success is measured by an adolescent's personal growth and achievements, not merely by problems averted. To create healthy environments, all members of society-adults and youth-have a role to play in improving adolescent health. Adolescents and their families need support from schools, faith-based organizations, businesses, policy makers, medical and health professionals, and public health professionals.

The NIIAH encourages all adults to empower adolescents to take greater leadership in creating healthy environments and provides Web-based resources to support community, state, regional, and national efforts to do so with a wide array of materials and information.7 Especially important in this regard is a core document titled Improving the Health of Adolescents & Young Adults: A Guide for States and Communities.8 This is designed to help guide state and local agencies and organizations, and local adolescent health leaders, through public health processes and resources, facilitating initiatives related to the 21 critical health objectives. This guide is available online both as a 257-page complete monograph and as a 12-page executive summary.

Addressing the public health needs of youth in America is a complex enterprise. The states, through their public health agencies, ensure the infrastructure, support scientific and technical capabilities, and facilitate program capacity and services. NIIAH will support states by providing a range of practical resources focused on strategic action to improve the health of youth at state and community levels. Organizations such as the National Network of State Adolescent Health Coordinators9 and the Society for Adolescent Medicine¹⁰ working in partnership with other like-minded groups can bring efforts such as the NIIAH to fruition by utilizing the tremendous resources that have been-and will continue to be-developed and made available.

Regardless of the level at which individuals with an interest in public health choose to be involved in YD, whether at the individual, community, state, region, or national level, they can play an important role in improving the health of youth by becoming active and engaged participants in the process. My personal experience demonstrates that this has benefits for not only the young people whom we serve but also for ourselves as we develop connections and demonstrate caring for the next generation.

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