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Search and eligibility criteria, study selection and compilation, comprehensive screening, sexual activity, mood and si, substance use, abuse and violence, conclusions, acknowledgment, adolescent risk behavior screening and interventions in hospital settings: a scoping review.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

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Nora Pfaff , Audrey DaSilva , Elizabeth Ozer , Sunitha Kaiser; Adolescent Risk Behavior Screening and Interventions in Hospital Settings: A Scoping Review. Pediatrics April 2021; 147 (4): e2020020610. 10.1542/peds.2020-020610

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Risky behaviors are the main threats to adolescents’ health; consequently, evidence-based guidelines recommend annual comprehensive risk behavior screening.

To review studies of adolescent risk behavior screening and interventions in urgent care, emergency department (ED), and hospital settings.

Our data sources included PubMed (1965–2019) and Embase (1947–2019).

Studies were included on the basis of population (adolescents aged 10–25 years), topic (risk behavior screening or intervention), and setting (urgent care, ED, or hospital). Studies were excluded if they involved younger children or adults or only included previously identified high-risk adolescents.

Data extracted were risk behavior screening rates, screening and intervention tools, and attitudes toward screening and intervention.

Forty-six studies were included; most (38 of 46) took place in the ED, and a single risk behavior domain was examined (sexual health [19 of 46], mood and suicidal ideation [12 of 46], substance use [7 of 46], and violence [2 of 46]). In 6 studies, authors examined comprehensive risk behavior screening, demonstrating low rates at baseline (∼10%) but significant increases with clinician reminder implementation. Adolescents and clinicians were highly accepting of risk behavior screening in all settings and preferred electronic screening over a face-to-face interview. Reported barriers were time constraints and limited resources.

Only 1 included study was a randomized controlled trial, and there was large heterogeneity of included studies, potentially limiting generalizability.

Rates of adolescent risk behavior screening are low in urgent care, ED, and hospital settings. Our findings outline promising tools for improving screening and intervention, highlighting the critical need for continued development and testing of interventions in these settings to improve adolescent care.

Risky behaviors present a great threat to adolescent health and safety and are associated with morbidity into adulthood. 1 , 2   Unintended pregnancy, sexually transmitted infections (STIs), substance use, suicide, and injury are the primary causes of morbidity and mortality in those aged 10 to 24 years. 3   Risky behaviors are prevalent among US high school students, with 35% reporting alcohol use, 23% reporting marijuana use, and 47% reporting sexual activity (but only 59% reporting using a condom during their last sexual encounter). 1   Consequently, the American Academy of Pediatrics recommends comprehensive risk behavior screening at annual preventive care visits during adolescence, 4   with the goal of identifying risk behaviors and providing risk behavior–related interventions (eg, STI testing). 5  

Adolescents have suboptimal rates of preventive visits, so emergency department (ED) and hospital visits represent an important avenue for achieving recommended comprehensive risk behavior screening annually. In the United States, young adults are the age group least likely to receive preventive care services, despite improvements in access to care through the Affordable Care Act. 1 , 6   Studies indicate that a majority (62%–70%) of adolescents do not have annual preventive care visits, and of those who do, only 40% report spending time alone with a clinician during the visit to address risk behaviors. 7 , 8   Screening for risk behaviors confidentially is crucial to disclosure of engagement in risky behavior and also increases future likelihood of patients seeking preventive care and treatment. 9   An estimated 1.5 million adolescents in the United States use EDs as their main source of health care, 10   and these adolescents are more likely to come from vulnerable and at-risk populations. 11   Additionally, risky behaviors and mental health disorders are prevalent among teenagers with chronic illnesses, a group that accounts for a significant proportion of hospitalized adolescents. 12 – 14   These findings underscore the need to perform risk behavior screening and interventions, such as STI testing and treatment, motivational interviewing (MI), and contraception provision, in ED and hospital settings.

Previous studies indicate low rates of risk behavior screening and interventions in ED and hospital settings. Inconsistent or incomplete adolescent risk behavior screening in these settings may result in missed opportunities to intervene, mitigate risk, and improve health outcomes. In this scoping review, we aim to comprehensively describe the extent and nature of the current body of research on risk behavior screening and risk behavior interventions for adolescents in urgent care, ED, and hospital settings. We review studies in which rates of risk behavior screening, specific risk behavior screening and intervention tools, and attitudes toward screening and intervention were reported. Our findings can help guide efforts in these settings to advance screening and interventions for risk behaviors, thereby improving health outcomes for adolescents.

We conducted a scoping review given expected heterogeneity of the body of literature on this topic. Scoping reviews map out broad themes and identify knowledge gaps when the published works of focus use a wide variety of study designs. 15   We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines to inform our search and synthesis of the literature. 16  

We conducted a literature search in June 2019. Data sources included PubMed (1965–2019) and Embase (1947–2019). In the Supplemental Information , we outline the details of our search strategy. We pooled results from both queries together and removed duplicates. Inclusion criteria were study population age (adolescents aged 10–25 years), topic (risk behavior screening or risk behavior interventions), and setting (urgent care, ED, or hospital). Given that guidelines recommend universal risk screening of all adolescents, we excluded studies that were focused only on high-risk adolescents, such as patients admitted to adolescent medicine, trauma, or psychiatry services or patients admitted for toxic ingestions, suicide, or eating disorders. We also excluded any studies with interventions taking place outside the urgent care, ED, or hospital because we aimed to identify interventions that could be completed during acute care encounters. In this study, the terms “hospitalized” or “hospital setting” refer to patients admitted to pediatric units under either inpatient or observation status. We only included studies published in English.

Two independent reviewers screened, extracted, and summarized the studies (N.P. and A.D.). We first screened titles and abstracts using Rayyan software (Qatar Computing Research Institute, Doha, Qatar), 17   and we resolved conflicts regarding the title and abstract screen through discussion. Next, the 2 reviewers independently completed a full-text screen. We calculated Cohen’s κ to assess interrater reliability. The 2 reviewers made joint final decisions on inclusion of studies with conflicting initial determinations.

Data extracted from the full texts included the full citation, study type, risk of bias, risk behavior domain, intervention or screening tool, results of the study, and conclusions. We described and summarized major findings, organized by the following risk behavior categories: comprehensive, sexual activity, mood and suicidal ideation (SI), substance use, and abuse and violence. Within each category, we grouped studies by subcategory: screening rates, screening and intervention tools, and attitudes toward screening and intervention. We did not combine and quantitatively analyze study results because of heterogeneity in study design.

This study was determined exempt by the Institutional Review Board at the University of California, San Francisco.

Our initial search yielded 1336 studies in PubMed and 656 studies in Embase. After duplicates were removed, 1867 unique studies were identified. After a title and abstract screen, 75 studies remained. In the full-text screen, both reviewers included 43 studies and excluded 25 studies; 7 studies were in conflict. Cohen’s κ was calculated and determined to be 0.8, correlating with a 90.7% agreement. One study that met inclusion criteria was found post hoc and included in the final review for a total of 46 studies ( Fig 1 ). Included studies were published between 2004 and 2019, and the majority ( n = 38) of the studies took place in the ED setting, whereas 7 took place in the hospital setting, and only 1 took place in the urgent care setting. Study design and risk of bias are presented in Table 1 . Using methods from a study by Rea et al, 18   we analyzed risk of bias for each of the included studies and found that only 2of 46 studies had a low risk of bias, 33 of 46 had moderate risk of bias, and 11 of 46 had a high risk of bias.

FIGURE 1. Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines flowchart of study selection.

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines flowchart of study selection.

Risk of Bias

Overall risk of bias was as follows: low, 1 variable not present; moderate, 2–3 variables not present; and high, 4–5 variables not present. RCT, randomized controlled trial; −, not present; +, present.

Below we report results by risk behavior domain, with studies organized into subcategories of screening rates, screening tools and interventions, and adolescent, parent, and clinician attitudes toward screening and intervention.

Six of 46 studies that were included in our review were focused on comprehensive risk behavior screening and/or interventions (across all risk behavior domains), as summarized in Table 2 . Two of the studies took place in the hospital setting and 4 in the ED setting.

Comprehensive Adolescent Risk Behavior Screening Studies

ED-DRS, Emergency Department Distress Response Screener.

Screening Rates

Yeo et al 13   found that ∼10% of admitted patients at a tertiary children’s hospital had a comprehensive risk behavior assessment documented (defined as ≥5 of 7 domains: home, education, activities, tobacco use, drug and/or alcohol use, sexual activity, suicide and/or depression). An additional 28% had partial or incomplete screening, with less sensitive issues, such as home life, education, and employment, documented significantly more often than sexual activity, depression, or drug use ( P = .013). In 75% of cases in which risk behaviors were identified, interventions were provided. Similarly, in a hospital study of surgical adolescent patients by Wilson et al, 19   the authors found that only 16% of patients were offered screening, and of these, 30% required interventions.

Screening Tools and Interventions

Three ED studies described interventions to increase comprehensive risk behavior screening. Bernstein et al 20   used nonphysician providers, or health promotion advocates (HPAs), to perform risk behavior screening and were successful in standardizing comprehensive screening and intervention for adolescents in a busy ED setting by having a dedicated role for the task. However, lack of initial physician buy-in and administrative hurdles, such as funding for HPAs, training, and competition with other medical professionals (ie, social workers), made it difficult to transition this intervention into sustainable clinical practice. 20   In 2 studies, researchers evaluated physician reminders to screen, including a home, education, activities, drugs, sexual activity, suicide and/or mood (HEADSS) stamp on paper medical charts and a distress response survey in the electronic health record (EHR). The HEADSS stamp resulted in a significant increase in postintervention screening rates (from <1% to 9%; P = .003). 21   The EHR distress response survey by Nager et al 22   was found to be feasible to integrate into the busy ED physician workflow, but the study offered limited insight into effects on screening or utility of the tool (assessed by using only yes or no questions).

Adolescent, Parent, and Clinician Attitudes

In an ED survey study by Ranney et al, 23   for all risk behavior categories assessed, 73% to 94% of adolescent patients ( n = 234) were interested in interventions, even when screen results were negative.

There were no studies on parent or clinician attitudes toward comprehensive risk behavior screening.

Nineteen studies on sexual activity screening and/or intervention were included in our review: 5 in the hospital setting ( Table 3 ) and 14 in the ED ( Table 4 ).

Adolescent Risk Behavior Screening and Interventions in the Hospital Setting

H&P, history and physical; IUD, intrauterine device.

ED and Urgent Care Adolescent Risk Behavior Screening and Interventions

ACA, adaptive conjoint analysis; ACASI, audio-enhanced computer-assisted self-interview; ARA, adolescent relationship abuse; AUDIT-C, Alcohol Use Disorders Identification Test—Consumption; AUDIT-PC, Alcohol Use Disorders Identification Test-(Piccinelli) Consumption; AUDIT-3, 3-Item Alcohol Use Disorder Identification Test; AUDIT-10, 10-Item Alcohol Use Disorder Identification Test; BHS, Beck Hopelessness Scale; BIS-11, Barratt Impulsivity Scale; CAGE, Cut down, Annoyed, Guilty, Eye-opener; CDS, clinical decision support; CRAFFT, Car, Relax, Alone, Forget, Friends, Trouble; CSSRS, Columbia Suicide Severity Rating Scale; CT, Chlamydia trachomatis ; CTS, Conflict Tactics Survey; DSM5, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ; EC, emergency contraception; ED-DRS, Emergency Department Distress Response Screener; EPT, expedited partner therapy; ER, emergency department; FAST, Fast Alcohol Screening Test; GC, Neisseria gonorrhoeae ; HCP, health care provider; HEADS-ED, Home, Education, Activities and peers, Drugs and alcohol, Suicidality, Emotions and behaviors, Discharge resources; IPV, intimate partner violence; LARC, long-acting reversible contraception; LR+, positive likelihood ratio; NIAAA, National Institute of Alcohol Abuse and Alcoholism; NP, nurse practitioner; NPV, negative predictive value; POSIT, Problem Oriented Screening Instrument for Teenagers; PRI, pregnancy risk index; PTSD, posttraumatic stress disorder; RADS-2, Reynolds Adolescent Depression Screening, Second Edition; RAFFT, Relax, Alone, Friends, Family, Trouble; RAPS4-QF, Remorse, Amnesia/blackouts, Perform, Starter/eye-opener, Quantity, Frequency; RBQ, Reckless Behavior Questionnaire; RUFT-Cut, Riding with a drinking driver, Unable to stop, Family/Friends, Trouble, Cut down; SIQ, Suicidal Ideation Questionnaire; SIQ-JR, Suicidal Ideation Questionnaire Junior; STD, sexually transmitted disease; TWEAK, Tolerance, Worried, Eye-opener, Amnesia, Kut-down .

Documentation of sexual activity screening of adolescents was low in both ED and hospital settings. In retrospective cohort studies by Riese et al, 24   McFadden et al, 25   and Stowers and Teelin, 26   sexual activity screening rates in the hospital setting are described. The authors reported screening rates of 55% to 62%. 24 , 25   For patients who had documented sexual or reproductive history, screening for more specific risk behaviors (such as condom use, birth control use, and number of sexual partners) was often omitted. 24  

Similarly, in the ED, a retrospective study by Beckmann and Melzer-Lange 27   reported that even in charts of patients diagnosed with an STI, documentation of sexual activity was incomplete and inconsistent. The authors noted that although 94% of patients in the study were documented as sexually active, only 48% of charts documented condom use, only 38% of charts documented STI history, and only 19% of charts documented the number of partners. No charts contained documentation on other important risk-stratifying details, such as contraception use other than condoms, the sex of partners, partners’ risk of STIs, anal sex practice, or partners’ drug use. 27   None of these studies reported on whether privacy was ensured in sexual history taking, although they did mention the need for confidentiality as a possible barrier to higher rates of screening. 23 – 26  

McFadden et al 25   described sexual health services provided in the hospital setting and reported that STI testing was conducted in 12% of patients, that pregnancy testing was done in 60% of female patients, and that contraception was provided for 2% of patients. Forty-six percent of patients were due for the human papillomavirus (HPV) vaccine, and 19% of these received it during admission. 25  

In the ED, researchers of a single-blind randomized controlled trial tested a computerized self-administered screening tool to identify adolescent patients who were at risk for STIs. In the intervention arm, the results of the screen provided decision support for ED physicians. Adolescents in the intervention group were more likely to receive STI testing compared with those in the control arm (52.3% vs 42%; odds ratio [OR] 2.0 [95% confidence interval (CI) 1.1–3.8]). These findings were more pronounced in adolescents without symptoms of STI (28.6% vs 8.2%; OR 4.7 [95% CI 1.4–15.5]). 28   In a study by Miller et al 29   done in the ED setting, MI was found to be a feasible, timely, and effective technique in promoting sexual health in adolescents.

In several of the included studies in the sexual activity domain, researchers looked at attitudes of adolescent patients, parents, and clinicians toward adolescents being screened in acute care settings. Many adolescents felt the ED should universally provide education on sexual and reproductive health practices and provide contraceptive services, especially for patients who may not have access to a primary provider. 25 , 30 – 32   Chernick et al 33   found that one-fourth of the adolescent patients in their study were interested in receiving contraception in the ED. In several studies, researchers found that computerized self-disclosure tools were preferred by adolescent patients, regardless of the presenting chief complaint. 34 , 35   Regarding counseling and interventions, adolescent patients generally valued clinician-patient interactions. For example, Shamash et al 36   found that the majority of adolescents did not support provision of expedited partner therapy and partner notification if an STI was identified, citing reasons such as the importance of interaction between the partner and his or her own clinician. The value of such interaction was echoed in another study in which patients preferred in-person counseling. 37   However, in a cross-sectional hospital study, Guss et al 38   found that patients who were interested in more information preferred learning about contraceptive options from a brochure rather than from a clinician.

Parents were overall supportive of sexual activity screening and care provision in the ED and hospital setting. In fact, in a study by Miller et al, 39   parents were more accepting of sexual activity screening and STI testing than surveyed clinicians.

In the hospital setting, the top 3 barriers to sexual activity screening among clinicians included concerns about follow-up (63%), lack of knowledge regarding contraception (59%), and time constraints (53%). The majority of respondents reported they would be more likely to increase delivery of sexual health services if provided with further education. 40   Clinicians expressed concerns about the acute nature of illness and injury in the ED and the sensitive nature of sexual activity screening. In several ED studies, authors cited concerns from clinicians that the ED was not the appropriate setting to address sexual activity, particularly if it was not related to the patient’s presenting problem. 39 , 41   Clinicians in the ED setting had a preference for computerized screening tools as well. 42  

Twelve studies on mood and SI screening and intervention were included in our review; 11 took place in the ED setting, and 1 took place in the urgent care setting ( Table 4 ).

No studies were found.

In our review, we found several reports on various SI screening tools in acute care settings, including the Ask Suicide-Screening Questionnaire (ASQ), the Risk of Suicide Questionnaire (RSQ), and the Behavioral Health Screening–Emergency Department (BHS-ED); these studies indicate the potential promise of these tools and also reveal significant SI risk in adolescents presenting for nonpsychiatric issues. The ASQ has been widely referenced in literature as a brief and feasible tool to assess suicide risk in pediatric patients in the ED. 43   The ASQ 4-question screen has a sensitivity of 96.9%, a specificity of 87.6%, and a negative predictive value of 99.7%. 44   In their review, King et al 45   found that universal screening for mood and SI in the ED setting can identify a clinically significant number of patients who have active SI but are presenting for unrelated medical reasons. To help identify such patients, a cross-sectional study done to validate the RSQ in patients presenting to the ED revealed a clinically significant prevalence (5.7%) of SI in patients with nonpsychiatric chief complaints. 46   However, another validation study revealed that in a low-risk, nonsymptomatic patient population, the RSQ had high false-positive rates. The authors concluded that a more general psychosocial risk screen, such as the HEADSS, should be implemented instead. 47   Ambrose and Prager 48   described potential screening tools for SI (eg, ASQ and RSQ) and concluded that these tools need further prospective study and validation in a general population of adolescents without mental health complaints.

Fein et al 49   describe successful implementation of a more broad behavioral health screen: the BHS-ED, which is used to assess for mood and behavioral health issues as well as associated risks, such as substance use. Fein et al 49   found that with the BHS-ED, mental health problem identification increased from 2.5% to 4.2% (OR 1.70; 95% CI 1.38–2.10), with higher rates of social work or psychiatry evaluation in the ED (2.5% vs 1.7%; OR 1.47 [95% CI 1.13–1.90]).

A 2-question SI screen was piloted by Patel et al 50   in an urgent care setting to identify adolescents at risk for SI. Most adolescents who screened positive did not have mental health–related chief complaints, and positive screening results led to interventions in the form of referrals (82% of positive screen results) or urgent admission to an inpatient psychiatric facility (10% of positive screen results). Specifically, 5 of 10 patients who met criteria for inpatient psychiatric facility admission did not have an initial mental health–related chief complaint. 50  

In a cross-sectional survey, O’Mara et al 51   found that after a positive screen result, the majority of adolescent patients and their parents valued the chance for immediate intervention and resources in the ED. Similarly, in 2 qualitative studies by Ballard et al, 52 , 53   90% to 96% of interviewed adolescents responded positively to SI screening in the ED. Positive themes included detection of youth who may be at risk and have a lack of social support as well as possible prevention of suicide attempts. The biggest concerns from adolescent patients included worries about privacy issues. 51  

Parental reservations regarding screening were focused on the patient being in too much pain or distress for screening. 46   Other identified hesitations were fear of a lack of focus on nonpsychiatric chief complaints and possible iatrogenic harm secondary to screening. 53  

Clinicians felt that a computerized depression screen would overcome many of the identified barriers (lack of rapport, time constraints, high patient acuity, lack of training or comfort, privacy concerns, and uncertainty with next steps), but they endorsed a need for support to facilitate connecting patients with mental health resources and interventions. 54  

Seven studies on substance use screening and intervention were included in our review; all took place in the ED setting ( Table 4 ).

In a 2011 systematic review of substance use screening tools in the ED, the authors concluded that for alcohol screening of adolescent patients, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) 2-item scale was best, with a sensitivity of 88% and a specificity of 90% (likelihood ratio of 8.8). 55   For marijuana screening, they recommended using the Diagnostic Interview Schedule for Children (DISC) Cannabis Symptoms, which is reported to have a sensitivity of 96% and a specificity of 86% (likelihood ratio of 6.83) and is composed of 1 question. More recently, researchers evaluated a self-administered 3-item screening tool based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , the Newton Screen, concluding that it was a brief and effective tool for screening both alcohol (sensitivity of 78.3% and specificity of 93%) and cannabis use (sensitivity of 93.1% and specificity of 93.5%). 56  

In a study on the use of the Alcohol Use Disorder Identification Test (AUDIT) tool, researchers observed differences in sensitivity based on the age group of adolescents, noting lower utility in younger adolescents. 57   The National Institute of Alcohol Abuse and Alcoholism 2-question screen, a self-administered tool via tablet that features 2 different questions for middle school–aged versus high school–aged adolescents, was found to be a valid and brief way to screen for alcohol use in the ED. 58  

For positive screen results, MI and brief intervention tools, such as the FRAMES acronym (feedback, responsibility, advice, menu, empathy, self-efficacy) have been found to be effective in addressing high-risk behaviors, particularly in adolescent patients. MI avoids confrontation, and the authors note that both of these evidence-based tools work with a patient’s readiness to change and build awareness of the problem, resulting in increased self-efficacy for the adolescent. 59  

In a qualitative study, researchers assessed ED physician use of screening, brief intervention, and referral to treatment (SBIRT) and found that <50% of respondents used a validated tool when screening for alcohol use. 60   Common perceived barriers were time constraints, inadequate staffing, lack of knowledge of screens, and concerns about parents’ reactions to screening. Falcón et al 61   found that, during implementation of a standardized screening program, it was important to minimize workflow disruption and provide adequate education to achieve participant buy-in.

There were no studies on patient or parent attitudes toward substance use screening or interventions.

Two studies on abuse and violence screening and intervention were included in our review; both took place in the ED setting ( Table 4 ).

In their study, Erickson et al 62   described screening and intervention regarding abuse or violence, specifically focusing on evaluating risk of intimate partner violence with an 8-item screening tool (the Conflict Tactics Survey). They found that the risk of intimate partner violence in female adolescents who presented to the ED was high (37%) and that 4 screening questions had 99% sensitivity. 62  

In a narrative review by Jackson et al 63   on adolescent relationship abuse screening and interventions in the ED, the authors described successful outpatient interventions that could be easily adapted for the ED setting. They described targeted computer modules as interventions for adolescents who screen positive or, alternatively, use of a universal education intervention, such as a wallet-sized informational card.

The studies in our review reveal ubiquitously low rates of risk behavior screening in the ED and hospital setting across all risk behavior domains. Our study also highlights the general dearth of studies on the topic (only 7 studies in the hospital setting, only 2 studies with low risk of bias based on our analysis). We outline potential tools and approaches for improving adherence to guideline-recommended comprehensive screening and adolescent health outcomes.

Although comprehensive risk behavior screens (eg, the American Academy of Pediatrics Bright Futures 64   and HEADSS 3 , 65   ) remain the gold standard, they have not been validated in the ED or hospital setting. We report on a number of successful domain-specific screening tools validated in ED and hospital settings. The Sexual Health Screen reported on by Goyal et al 35   presents a feasible and valid way to screen for sexual and reproductive health. For mood and SI screening, validated tools include the ASQ and RSQ. 48 , 53   For substance use screening, potential tools include the Newton Screen, the National Institute of Alcohol Abuse and Alcoholism 2-question screen, and SBIRT. 56 , 58 , 66   For intimate partner violence screening, Erickson et al 62   validated the 8-item Conflict Tactics Survey. These brief validated tools within single risk behavior domains could potentially be combined into a single comprehensive screen (with consideration that these screening tools may have been validated for specific populations and plans to assess feasibility and time burdens).

When patients screen positive for risky behaviors, it is imperative to have strategies and resources in place to address these behaviors. MI has been demonstrated to be feasible, effective, and a preferred method to change risky behavior across all risk behavior domains in ED and hospital settings. 29 , 59 , 67   Specifically, the FRAMES acronym provides a promising framework for MI for adolescent substance use but can be applied to any high-risk behavior change. 59   However, some adolescents may instead prefer paper materials or brochures over face-to-face counseling, so this presents an alternative option. 38   As demonstrated in the McFadden et al 25   study, other interventions to consider implementing in the ED and hospital settings include STI testing and treatment, contraceptive provision, HPV vaccination, and referral to subspecialty resources (both inpatient and outpatient). For intimate partner violence and adolescent relationship abuse, Jackson et al 63   outline successful outpatient interventions (eg, universal wallet-sized educational cards and targeted computerized interventions) that could be feasible in the ED setting but would require further investigation.

We found that although clinicians and patients are receptive to risk behavior screening and interventions in these settings, they also report several barriers. 54   Clinicians are concerned that parents may object to screening; however, parents favor screening and intervention as long as their child is not in too much pain or distress. 46   Clinicians additionally identify obstacles such as time constraints, lack of education or knowledge on the topic, and concerns about adolescent patients’ reactions. 40 , 60 , 61   Additionally, adolescent patients report concerns around privacy and confidentiality of disclosed information. 51  

To overcome these collective barriers, future researchers should investigate (1) feasible, efficient risk behavior screening tools with guidance for clinicians on providing risk behavior interventions and (2) tools that increase privacy and comfort for patients (likely through the use of electronic formats). Promising methods to increase screening rates include self-disclosure electronic screening tools coupled with reminders for clinicians (paper or within the EHR). Self-disclosure screening tools have been shown to increase privacy and disclosure of sensitive information by adolescent patients when compared with face-to-face screening by a clinician. 68   The use of technology and creation of electronic self-disclosure screens may further provide means to maintain comfort and patient privacy while streamlining workflow and maximizing efficiency for clinicians, particularly when a reminder to screen is integrated. 21 , 22   Special consideration should be given to the interplay between documentation of sensitive information in the EHR and the privacy and confidentiality crucial in screening for adolescent risk behaviors. 69   One strategy to mitigate possible breaches of confidentiality with EHR documentation is to mark risk behavior screening notes as sensitive or confidential, thus preventing parents or guardians from access to the note (an option that is available on most EHR software). Another option is creating labeling functions within the EHR for children aged 13 to 18 so clinicians can label whether each problem, medication, or diagnostic test result can be accessed by the patient, parents, or both. 69   In a recently published scoping review, Wong et al 70   further explore possible systemic solutions in designing digital health technology that captures and delivers preventive services to adolescents while maximizing safety and privacy.

A limitation of this scoping review is heterogeneity in the design and quality of the included studies, with only 1 randomized controlled trial in our area of focus. Additionally, most studies of screens or interventions have thus far been limited to a single study done in 1 center, thus limiting generalizability. With the heterogeneity of studies included, we could only summarize findings but could not perform a meta-analysis. Also, most studies had limited durations of follow-up, so we cannot comment on long-term effects. We excluded studies that involved outpatient follow-up of patients to evaluate interventions that could be completed in the ED or hospital setting, but this may have limited our review of more longitudinal effects.

ED and hospital encounters present a missed opportunity for increasing risk behavior screening and care provision for adolescent patients; current rates of screening and intervention are low. Patients and clinicians are generally receptive to screening in these settings, with barriers including adolescents’ privacy concerns, clinicians’ time constraints, and clinicians’ comfort and knowledge with risk behavior screening and risk behavior interventions. Promising solutions include self-disclosure via electronic screening tools, educational sessions for clinicians, and clinician reminders to complete screening. More prospective controlled studies are needed to evaluate such interventions in ED and hospital settings.

We acknowledge Evans Whitaker, MD, MLIS, for his assistance with the literature search.

Dr Pfaff conceptualized and designed the study, conducted the literature search, screened literature for inclusion, extracted data from included studies, and drafted and edited the manuscript; Dr DaSilva helped in study design, conducted the literature search, screened literature for inclusion, extracted data, and helped with drafting the original manuscript; Dr Ozer helped in study design, editing and revising the manuscript, and critically appraising the manuscript content; Dr Kaiser supervised the conceptualization and design of the study, supervised the data extraction from the included literature, and helped in revising and editing the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: Dr Kaiser is supported by grants from the Agency for Healthcare Research and Quality (K08HS024592 and R03HS027041). Dr Ozer is supported by grants from the Health Resources and Services Administration of the US Department of Health and Human Services and the Maternal and Child Health Bureau under cooperative agreement UA6MC27378 and Maternal and Child Health Bureau Leadership Education in Adolescent Health Training grant T71MC00003. These funders played no role in the study design, analysis, or preparation of this article.

Ask Suicide-Screening Questionnaire

Alcohol Use Disorder Identification Test

Behavioral Health Screening–Emergency Department

confidence interval

Diagnostic Interview Schedule for Children

Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition

emergency department

electronic health record

feedback , responsibility, advice, menu, empathy, self-efficacy

home, education, activities, drugs, sexual activity, suicide and/or mood

health promotion advocate

human papillomavirus

motivational interviewing

Risk of Suicide Questionnaire

screening, brief intervention, and referral to treatment

suicidal ideation

sexually transmitted infection

Competing Interests

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REVIEW article

Adolescents’ own views on their risk behaviors, and the potential effects of being labeled as risk-takers: a commentary and review.

Ivy N. Defoe

  • 1 Forensic Child and Youth Care Sciences, University of Amsterdam, Amsterdam, Netherlands
  • 2 Annenberg Public Policy Center, The University of Pennsylvania, Philadelphia, PA, United States

Adolescents are stereotypically viewed as risk-takers (“stereotypical risk-takers”) in science, mainstream media, fictional literature and in everyday life. However, increasing research suggests that adolescents do not always engage in “heightened” risk-taking, and adolescents’ own perspectives (motives) on risk-taking are largely neglected in research. Hence, this paper is a commentary and review with two aims. First, taking a cross-national perspective, we discuss the definition of adolescence and risk behavior. We argue that much of the research on what drives adolescent risk behavior (e.g., substance use) focuses on the harms that this behavior promotes rather than on the need to explore and grow into adulthood. Thereafter we summarize the dominant approach to studying motives behind substance use, which has mostly considered young adults, and which has typically not focused on adolescents’ own self-generated motives. The few empirical studies (including one of our qualitative studies) on adolescents’ own motivations for engaging in risk behavior (i.e., cannabis use, alcohol use, and tobacco smoking) show that the most frequently mentioned motives by adolescents were being cool/tough, enjoyment, belonging, having fun and experimenting and coping. Interestingly, the “cool/tough identity” motive is virtually overlooked in research on adolescent risk-taking. The above-mentioned motives, however, generally support newer theories, such as the Developmental Neuro-Ecological Risk-taking Model (DNERM) and the Life-span Wisdom Model that suggest that adolescents’ motivations to engage in risk-taking include experimentation, identity development, explorative behavior, and sensation seeking, all of which run counter to the stereotype of adolescents engaging in risk-taking due to “storm and stress.” Hence, we also briefly consider additional recent attempts to study positive forms of risk taking. Second, extrapolating from sociological/criminological theories on labeling, we suggest that caution is warranted when (inaccurately) labeling adolescents as the “stereotypical risk-takers,” because this can instigate a risk-taking identity in adolescents and/or motivate them to associate with risk-taking peers, which could in turn lead to maladaptive forms of risk-taking. Empirical research testing these hypotheses is needed. To conclude we argue that research on adolescent risk-taking could further benefit from considering adolescent’s own motivations, which is also in line with the participatory approach advocated by international children’s rights standards.

Introduction

The ongoing question of what adolescence entails: a cross-national perspective.

Adolescence is traditionally considered as the “in between” developmental phase, with the childhood phase at one end, and the adulthood phase at the other end. Being in this in-between phase, in which humans develop rapidly, has in part contributed to adolescence being described as a period of “storm and stress,” or a period of “confusion” ( Hall, 1904 ). Adolescents have been thought of as being “stuck” in a tug of war between two distinct developmental phases—childhood and adulthood, struggling with their developing body and mind. At the same time, adolescence is clearly also an exciting period, filled with many opportunities, such as finding one’s identity and building a life of his/her own, less dependent on the guidance of their parents. What makes this period even more fascinating, is that there has never really been a consensus on which ages the adolescent phase encompasses. Nevertheless, many scholars, especially developmental scientists (e.g., Crone and Dahl, 2012 ; Steinberg et al., 2018 ; Defoe, 2021 ), posit that adolescence begins approximately at the start of puberty, around the ages 10–12, which is also the age when most youth in the Western-World transition from primary school to secondary school.

When exactly adolescence ends has been more subject to inconsistency and little consensus. According to some scholars becoming an adult can be viewed as a gradual process, this distinct phase in life has been referred to as “emerging adulthood” ( Arnett, 2000 ). The definitions of adulthood in society are influenced by the cultural and normative framework on which the society is built. For example, in the Western world, the age when adolescence ends often coincides with when the laws of a country consider an individual as an “adult,” thus when individuals are allowed to attain adult roles in society. This has typically been the age of 18 or 21 ( cf Shulman et al., 2016 ; see also article 1 UN Convention on the Rights of the Child (CRC)). Age 18 has additionally been the age when most have completed secondary school in the Western world, but also in the Caribbean and Latin America more generally, and it coincides with the age when people have the right to vote and when most countries try individuals as an adult in criminal court (i.e., the upper age limit of the youth justice system; see Cipriani, 2009 ). Interestingly, although age 18 corresponds with adult status in many Non-Western (e.g., the Caribbean) and Western (e.g., Western Europe) nations, individual cultures differ when it comes to whether this age is the appropriate age for sexual consent, marriage and child bearing (see for example Horii, 2021 ).

From a child development perspective, the age of 18 is rather arbitrarily chosen. Studies on human brain development indicate that the prefrontal cortex of the brain, which is involved in cognitive control, is not fully myelinated and pruned until the age of 24 ( Giedd, 2010 ). Accordingly, some scientists (e.g., Crone and Dahl, 2012 ) argue that based on this biological marker, the definition of adolescence should be extended at least to the mid-twenties. The above-mentioned neuro-scientific findings have already impacted legislation. For instance, as of 2014, in the Netherlands young adults until the age of 23 can be imposed a youth justice sentence in criminal court, based on the personality of the accused or the circumstances under which the offense was committed ( Matthews et al., 2018 ; Rap et al., 2020 ). In sum, when considering what adolescence entails, the culture(s) within a country is a decisive factor, and historically, culture impacts legislation ( Defoe, 2021 ), which again in turn impacts how the span of the adolescent period is defined. The concept of adolescence can therefore be seen as a social construct that is influenced by the historical, cultural and societal context.

The ongoing question of what risk-taking entails: A cross-national perspective

Closely related to the concept of adolescence is “risk-taking,” “risky decision making” or “risk behavior.” These terms focus either on the decision-making side (risky decision-making) or the behavioral side of risk-taking (risk behavior). For our purposes, we treat these interchangeably. Nevertheless, it is also noteworthy that risk-taking can be defined in different ways. From an economic perspective, typical for the decision-making sciences, the definition of “risk taking” is: choosing an option with the most uncertain outcome ( Figner and Weber, 2011 ; Defoe et al., 2015 ). Alternatively, in (developmental) psychology, risk taking is described as deciding to engage in behaviors that are associated with at least some probability of undesirable outcomes ( Boyer, 2006 ). Some psychological scientists have emphasized the cultural component of this definition. Namely, Defoe (2021) defined mal-adaptive risk behaviors (e.g., substance use and delinquency) as “ behaviors that are associated with some probability of a maladaptive outcome—that is an outcome that can impede the acquisition of culturally-accepted goals ” ( Defoe, 2021 ; p. 2).

Of note is that despite the appearance of objectivity in the economic definition of risk-taking, the way in which researchers have studied this phenomenon has focused almost entirely on outcomes that are seen as undesirable from the adult’s perspective. For example, there are many behaviors children show that adults would find acceptable that also involve risks, such as learning a new skill (e.g., skiing), accepting an academic challenge (e.g., taking a more difficult course), or protecting a friend (e.g., intervening to stop a bully). But hardly any of the research on adolescent risk-taking has examined these “conventional” risks, which presumably also increase during the adolescent period ( Romer et al., 2017 ; Defoe and Romer, 2022 ). Moreover, in recent years increased attention has been directed toward participatory forms of research and research that focusses on the views and perspectives of children and young people, in line with their right to be heard and to participate (article 12 CRC), in order to better understand their lifeworld from their point of view (for an overview see Sommer et al., 2021 ; Freire et al., 2022 ).

No matter the definition of risk-taking, behaviors such as substance use and delinquency are often the focus of (maladaptive) risk behaviors in adolescence ( Defoe and Romer, 2022 ). In this paper we focus on substance use because it is a widely studied risk behavior that rises rapidly during adolescence in many cultures ( Willoughby et al., 2021 ) and is among the most studied risk behaviors in the literature. These risk behaviors typically show accelerated increases during adolescence and/or emerging adulthood ( Steinberg, 2015 ). In fact, adolescents are stereotypically viewed as risk-takers (“stereotypical risk-takers”) in science, the mainstream media, fictional literature and in everyday life. This goes as far back as over 400 years ago when Shakespeare described the ages between 13 and 20 as a period of heightened levels of misbehavior (e.g., stealing, and substance misuse; Shakespeare, 1623). In science, this characterization of adolescence has contributed to the formulation of multiple impactful developmental theories that aim to explain why adolescents engage in higher levels of risks (i.e., “heightened adolescent risk-taking”) compared to children and adults. In society, this has contributed to negatively labeling adolescents (see more below).

New directions toward risk-taking

We start from the presumption that there are at least two issues with the current conceptualizations of adolescence, risk-taking and the associated communication about this developmental phase. First, in this article we argue that in order to achieve a more comprehensive understanding of risk-taking during adolescence, the perspectives and experiences of the adolescents themselves need to be identified. That is, which behaviors do adolescents define as risky, and which motivations do adolescents report for engaging in those behaviors? In a unique recent qualitative study ( N = 57; 77% female; >90% European American), adolescents were asked the following question “What behaviors come to mind when I say “risk behavior?” ( Skaar, 2021 ). The findings revealed that educational risk behaviors (e.g., taking challenging classes) were the most mentioned by youth as risk behaviors, followed by drug and alcohol use and “trying something new.” Behaviors that were mentioned less often were “standing up to bullying,” “out of comfort zone” and “alcohol use” ( Skaar, 2021 ). Although the fact that educational risk behaviors being the most mentioned, was perhaps an artifact of the convenience sample that was used (i.e., students who were enrolled in an Advanced Placement Psychology course; cf Skaar, 2021 ), it is still telling that this rarely studied “risk” was mentioned by far the most by youth, whereas alcohol and drug use were the second and third runner up ( Skaar, 2021 ). When it comes to cross-national differences, such studies are rare, but it has been reported that youth in Turkey report substantially different risk behaviors, such as wearing revealing clothes, engaging in political activism, and losing one’s virginity, compared to youth in countries such as the United States ( Kloep et al., 2009 ). The, adolescents’ perspectives on what risk-behaviors entail might be very different across countries, again influenced by the cultural norms in which they grow up. Hence, in this review, we focus primarily on adolescents’ motives for engaging in the most common substance use behaviors during adolescence, namely, alcohol use, cannabis use and tobacco use (smoking). Unfortunately, only few developmental theories on risk-taking consider adolescents’ perspectives.

In this review we will discuss two relevant theories, namely the Lifespan Wisdom Model ( Romer et al., 2017 ) and the Developmental Neuro-ecological Risk-taking Model (DNERM; Defoe, 2021 ). The gap in theoretical substantiation is in turn also reflected in the few empirical studies that have investigated this phenomenon. Most studies on this topic have focused on emerging adults (ages 18–25; often college students; for reviews see: Cooper et al., 2015 ; Votaw and Wikiewitz, 2021 ). However, motivations might differ across age, which makes it pertinent to investigate adolescent specific motivations ( cf Cooper et al., 2015 ). Also, the legality of using such substances as alcohol, cannabis and tobacco depends on the age of the user (i.e., the adult status of the user), and thus youth might have different motives to use substances than adults.

As far as we know, this paper is the first to review the few empirical studies on adolescents’ own motivations for engaging in substance use (cannabis use, alcohol use, and smoking). In doing so, we use the state-of-art review of Cooper et al. (2015) as a point of departure, and we also draw conclusions from a more recent review that focused specifically on ecological momentary assessments ( Votaw and Wikiewitz, 2021 ). Moreover, we will review findings from a qualitative study by one of the authors (see Defoe et al., 2016 ; Lochs, 2020 ; Tabor, 2020 ), which is one of few studies that examined self-generated motives by adolescents in the Netherlands for engaging in risk behavior.

Second, increasing research suggests that adolescents do not always engage in “heightened” risk-taking (for a meta-analysis of experiments, see: Defoe et al., 2015 ; and a review of real-world risk-taking behaviors, see: Willoughby et al., 2021 ). Yet adolescents are widely labeled as the stereotypical risk-takers, while investigation of possible consequences of such an ingrained (and inaccurate) label on adolescents’ actual risk-taking appears to be uncharted territory. Therefore, we explore the labeling theory ( Becker, 1963 ) as a framework to discuss why such often-used conceptualizations of the adolescent period can be counter-productive when not used thoughtfully. Finally, we consider implications for policy.

Two recent theories that consider adolescent’s motivations for engaging in risk behavior

Life span wisdom model.

Before focusing on adolescents’ own motives for engaging in risk behavior, it is of relevance to briefly highlight the two previously mentioned developmental theories that explain risk taking behavior in adolescence while considering adolescents’ perspective. The first theory is the Lifespan Wisdom Model (LSWM; Romer et al., 2017 ) that considers adolescent motivations for novelty seeking. This model focuses on the adaptive function of sensation seeking during adolescence as a process that encourages exposure to novel experiences that can further the development of wisdom. Wisdom has traditionally had many meanings ( Curnow, 2015 ), but consistent across those interpretations is the accumulation of experience that allows one to make prudent decisions. Trying a substance like alcohol could be one step in this direction as far as this widely used beverage is concerned. It is nevertheless unfortunate that some adolescents will over-use the substance leading to a disorder. In other cases, such as use while driving, it may also cause harm. Society recognizes these problems and tries to discourage their occurrence, by limiting the sale and distribution of alcohol to youth.

According to the LSWM, some adolescents with high sensation seeking tendencies also have high levels of impulsive behavior tendencies, which reflect weaker abilities to refrain from immediately rewarding experiences, such as drug use. There is evidence that this tendency increases during adolescence for those with higher levels of impulsivity, thereby predisposing to continued use of drugs and risk for addiction ( Khurana et al., 2018 ; Khurana and Romer, 2021 ; Khurana et al., 2022 ). Such youth also have difficulties in learning from experience because of their heavier attraction to immediate reward, which also increases the risks for addiction and other problem behaviors ( Khurana and Romer, 2021 ). Nevertheless, the LSWM does not attribute all adolescent risk taking to a deficit in cognitive control relative to sensation seeking, since the two processes tend to increase in tandem as adolescents age. In addition, it is primarily older adolescents and young adults who engage in what is regarded as maladaptive “real-world” risk behaviors, due to greater opportunities for such behavior ( Willoughby et al., 2021 ; see also Defoe, 2021 ). This is in contrast to what is predicted by brain imbalance models which predict greater risk taking during mid-adolescence when the imbalance should be greatest (see, e.g., Casey et al., 2008 ; Steinberg, 2008 ).

The developmental neuro-ecological risk-taking model

The second theory we highlight is the Developmental Neuro-Ecological Risk-taking Model (DNERM), which hypothesizes that developmental phase (age) and culture predict levels of risk exposure (i.e., exposure to risk conducive situations; Defoe, 2021 ). That is, multiple types of risk exposures increase with age (at least up until young adulthood), and hence the developmental increases in risk behaviors we observe in the real-world. Also, certain types of risk behaviors would be more common in cultures where they are accepted (e.g., alcohol has been typically culturally accepted in the Western World). In the event of (physical) risk exposure, DNERM hypothesizes that particularly younger youth (versus older youth) will be more likely to engage in heightened levels of risk-taking via cue reactivity mechanisms and their natural tendency to explore their surroundings ( Defoe, 2021 ). However, this link from risk exposure to risk behavior could further be moderated by youth’s cognitive and affective self-control (perhaps especially affective self-control; Defoe, 2021 ). In other words, in relation to motivation, DNERM suggests that physical risk exposure in itself predicts potentially maladaptive risk behavior (e.g., substance use and delinquency), due to the curiosity and desire that a risk conducive situation can elicit, especially for youth ( Defoe, 2021 ). That is, risk exposure in the context of youth is associated with their need for exploration, which explains why a novel risk exposure is attractive for the adolescent who is still exploring his/her identity, and experimenting to learn if one fits with his/her surroundings (see, e.g., Erikson, 1968 ).

Indeed, as will be seen below in our qualitative study, perhaps adolescents, quest for especially a “cool/tough identity” is important to understand their engagement in risk behavior, since in that study ( Lochs, 2020 ; Tabor, 2020 ; see also Lee et al., 2007 ), adolescents mentioned being cool/tough as the primary motive for engagement in alcohol, tobacco, and cannabis use. However, according to DNERM, whether this curiosity for experimenting and exploring one’s identity will result in substance use (and other potentially maladaptive risk behaviors) could further potentially depend on self-control—an interaction effect which remains to be investigated in research.

The above-described theories place more emphasis on the exploratory motives for such risk behaviors as substance use, an area of research that has received far less attention in the literature than a focus on motives for regular use of substances. However, recent work has begun to explore the factors that encourage what has become known as positive risk taking ( Duell and Steinberg, 2021 ). We examine this new direction after we review the much larger volume of research that has dominated the field.

As mentioned earlier, the most comprehensive model of motives for substance use is due to Cooper et al. (2015) . Their model divides these motives into two dimensions: internal vs. external and approach vs. avoidance. Internal avoidance motives entail the effort to cope with negative emotions while external avoidance involves conformity pressures to use drugs. Internal approach motives involve feelings of enhancement due to the drug, while external approach motives involve socializing and the use of substances to facilitate those interactions. In essence, this is thus a two-dimensional model of motivation for substance use ( Cooper et al., 2015 ). The motives are typically measured using ratings of outcome expectancies for the use of a drug in general or in a specific situation. It is also noteworthy that most of the research assessing these constructs involves either college undergraduates or adult community members. As a result, what is learned in this research is more applicable to established users of substances rather than adolescents who are just starting to experiment with substances.

Adolescents’ motivations for engaging in risk behavior

Variations in motives for substance use are important to consider as they have predicted the frequency, quantity and extent of problems associated with substance use (see Cooper et al., 2015 for an overview). In the current review, we first focus on the motivations behind youths’ alcohol, cannabis and tobacco use as they have been described in past research. Adolescents’ motivations for engaging in substance use have successfully been incorporated in treatments, for example to lower heavy cannabis use among adolescents ( Blevins et al., 2016 ). Some research has examined the motivation underlying the use of all three substances in adolescents. For example, Hansen et al. (2022) summarized 25 studies that assessed use of all three substances by adolescents. They found that across all three substances, peer use and injunctive norms for use were important predictors. The valence of attitudes and beliefs about the consequences of substance use were also important. However, parent perceptions were much less predictive. Despite this large compendium of studies, we learn very little about the motivation for use of these substances from this work other than that what peers are seen as doing is important in the lives of adolescents.

Another review summarized the findings from 64 studies using ecological momentary assessment, mostly with non-Hispanic White college students ( Votaw and Wikiewitz, 2021 ). This research found that conformity motives were seldom studied and when they were, participants rarely reported this motive. The most frequent motives fell under the internal enhancement category in Cooper et al.’s scheme. Socializing was also frequently mentioned along with coping. Thus, one primarily gets a picture of motives for established use of these substances from this work.

A widely known motivational model for substance use is the alcohol motivational model of Cox and Klinger (1988 , 1990 , 2004 ), which is also used as the theoretical framework in the above-mentioned review of Cooper et al. (2015) . It was initially developed for alcohol use, but paved the way for understanding motivations for the use of other substances as well, such as tobacco and cannabis ( Cooper et al., 2015 ). Additionally, an extensive review demonstrated that this motivational model is generally applicable to tobacco and cannabis use by (emerging) adults (see Cooper et al., 2015 ). Although the review by Cooper et al. (2015) did not specifically focus on youth, the authors noted that motivations may differ across developmental stages of a person. For example, some studies have found identity motives to be specific for youth ( Cooper et al., 2015 ), perhaps because adolescence is a period of significant identity formation which could ignite curiosity to experiment with substances ( Defoe, 2021 ). Along those lines, youth who have not tried substances as yet, might have substantially different motivations for substance use compared to adults. For example, considering that adults have more experience using any drug, they are expected to be less motivated by curiosity compared to adolescents. Hence, previous literature that has especially focused on adults might not provide the most accurate representation of motives for adolescents.

The aformentioned Cooper model can be contrasted with the motives that are mentioned most by youth themselves. In our above-mentioned qualitative study (see Defoe et al., 2016 ; Lochs, 2020 ; Tabor, 2020 ) among 582 ethnically and socio-economically diverse Dutch youth (45.40% female; ages 13–16), who participated in a second wave data-collection of a 3-wave longitudinal study (for details on the sample, see Defoe et al., 2016 ), adolescents’ own perspectives on reasons for engaging in risk behavior were assessed. In that study the adolescents were asked to think of reasons why they or other youth drink large quantities of alcohol, smoke tobacco (cigarettes), and/or use soft-drugs (cannabis). A subsample of the youth answered these questions for alcohol ( n  = 360), smoking ( n  = 361) and cannabis use ( n  = 389). Of the answers given to these open-ended survey questions, the “being or acting cool/tough” motive (“stoer doen”) was reported the most for alcohol, cannabis and tobacco use ( Lochs, 2020 ; Tabor, 2020 ). Interestingly, this “cool identity” motive did not emerge in the adult literature on motives, which was typically based on closed-ended survey questions, but it did emerge in literature on youth cannabis use when open-ended questions were used, although it was mentioned to a much lesser extent than other motives (see: Lee et al., 2007 ). Perhaps the first publication to systematically investigate the meaning of coolness consisted of a series of three studies which were conducted primarily among North American (United States and Canada) university students. In that study, the participants described “coolness” with socially desirable attributes (e.g., social, popular, talented). Additionally, factor analyses identified two factors for coolness. Namely the first factor “Cachet coolness” reflected active, status-promoting, socially desirable characteristics ( Dar-Nimrod et al., 2012 , 2018 ). The second factor “Contrarian coolness” reflected rebellious, rough, and emotionally-controlled characteristics. The authors concluded “ coolness is reducible to two conceptually coherent and distinct personality orientations: one outward focused and attuned to external valuations, the other more independent, rebellious, and countercultural ” ( Dar-Nimrod et al., 2012 ; p. 175). A follow-up study ( Dar-Nimrod et al., 2018 ) based on university students in Canada (17–36 years; M  = 19.91; SD  = 2.92) largely replicated these findings and additionally showed that the coolness concept is not captured in the Big Five personality characteristics. Of note, is that Contrarian coolness is what the Dutch youth appear to be referring to with the phrase “stoer doen” (“acting cool/tough”) in the above-mentioned qualitive study ( Lochs, 2020 ; Tabor, 2020 ). However, it is still questionable to what extent the abovementioned findings ( Dar-Nimrod et al., 2012 , 2018 ) that are primarily based on university students would fully generalize to adolescents, but they could provide a starting-point for such research on adolescents.

The second most reported motive among Dutch adolescents for alcohol, cannabis and tobacco use, was a self-focused motive, namely “enjoyment” [e.g., it is tasty (“lekker” in Dutch)]. Other motives that were frequently reported were all self-focused motives, namely experimenting, stress reduction, and having fun ( Lochs, 2020 ). Addiction was additionally frequently mentioned as a motive for tobacco use ( Tabor, 2020 ).

Three important conclusions can be drawn from the above-mentioned findings based on Dutch youth. First, youth mention both self-focused and social-focused motives for engaging in substance use, and hence although studies suggest that substance use in adolescents is primarily a social behavior (e.g., Roditis et al., 2016 ), the notion that the main factor why youth engage in substance use is due to peer influence (e.g., because their peers are doing it, or because they feel pressured from their friends) is not entirely true. Also, even when the youth reported that they engage in substance use because their peers are doing it, negative forms of peer influence such a peer pressure was rarely mentioned, although especially such negative conceptualizations of peer influence are most common in the literature ( cf Defoe et al., 2018 ).

Secondly, the most frequently mentioned motive by youth “being cool/tough” is not a common factor that is investigated in adolescent risk-taking research. Of note is that “being cool” which has been conceptualized as “image enhancement” ( Lee et al., 2007 ) or as “impressing others” (conformity motive) in the motivation literature (see, e.g., Lee et al., 2009 ) may be a different form of social influence than social pressure which is a common theme in the adolescent risk-taking literature. It would be of added value for future research to look into what “being cool” essentially means from an adolescent’s perspective , as surprisingly, such research does not exist in the risk-taking literature, to our knowledge.

Thirdly, as the second motive for all substance use, youth mentioned the enjoyment that they experience while using substances, for example due to the feeling they receive from the substance or due to its taste. This sensory motive is virtually absent from both past and current theories on adolescent risk-taking.

Although being cool/tough was by far the most frequently mentioned motive for alcohol, smoking and cannabis use among Dutch adolescents, research on motives that were primarily based on adults and college students show that motives can differ across substance use type ( Cooper et al., 2015 ). Moreover, three other reasons for doing so can be mentioned as well. First, the three substances have different psychoactive effects, and thus different susceptibility for addiction as well. Nicotine is most addictive of the three ( Rigter, 2020 ). Secondly, whereas alcohol has been classified primarily as a depressant, cannabis has been primarily classified as a hallucinogen and nicotine as a stimulant, which may affect the motivations for using a certain substance ( Rigter, 2020 ). Thirdly, the availability of these substances can differ dramatically. For example, although in most Western and non-Western countries, both alcohol use and smoking is legal for persons ages 18–21 and over, recreational cannabis use is illegal for all ages in most countries, although cannabis (especially medical cannabis) is increasingly being legalized. Thus, since recreational cannabis is illegal for persons below 18 or 21, it would be expected to be most difficult to acquire, perhaps more so for youth below those ages. Relatedly, another reason for considering the motivations for the use of these substances separately, is the cultural acceptance of substances. An example is the Caribbean island of Sint Maarten, where alcohol and tobacco are available to a similar extent, but still culturally alcohol use is more accepted than tobacco use ( Defoe, 2021 ). The cultural acceptance can differ cross-nationally too. For example, generally speaking, in the Middle East, alcohol is less culturally accepted than in the Caribbean, and hence it is to be expected that alcohol use in the Caribbean would be more common. Hence, taking into account the possibility that motives can differ across substances, below we summarize the literature separately for youth’s motives for engaging in alcohol use, tobacco use and cannabis use.

Current descriptions of adolescents’ motivations for engaging in alcohol use

As with any risk behavior that emerges in adolescence, the focus has been on the maladaptive aspects of the behavior. In the case of alcohol, there has long been the concern that alcohol use in adolescence will lead to alcohol use disorder later in life ( Grant et al., 2001 ). There is also the concern that it will impair activities such as driving ( Hingson et al., 2009 ). Both concerns are valid, but it is also important to recognize that alcohol is the most used substance in many parts of the world, and that for example most adults in the United States have used it at some time as part of a social gathering or source of relaxation ( Cooper et al., 2015 ).

Alcohol is a sedative which means that it can reduce anxiety and make one feel relaxed ( Wenk et al., 2017 ). For some, it can also produce euphoric effects, all of which can be attractive to adolescents. As a result, there are many reasons why adolescents might become interested in trying alcohol. Of note is that adolescents who are prone to dependence on alcohol are also more likely to experience internalizing symptoms ( Deas-Nesmith et al., 1998 ). Those youth may well be using alcohol for its sedative effects. In our above-mentioned study among Dutch adolescents, primarily “being cool/tough” was mentioned by far the most, enjoyment (i.e., for the “taste,” for the feeling”) was 2nd runner up, followed by to be cozy (gezellig in Dutch), “for fun,” and “to belong,” which were all mentioned a similar number of times ( Tabor, 2020 ). Thus, social conformity and sensation seeking (“for fun”) motives that are common in the literature are often mentioned by youth, although youth mentioned “being cool/tough” and enjoyment (sensory) motives more often whereas these motives are not typically considered in adolescent risk-taking research. Hence, it would be for example interesting for research to investigate whether the motives coolness and enjoyment predict adolescent substance use to a similar extent as more often investigated factors such as peer influence and sensation seeking,

As mentioned above, the research literature over the years has focused on social influences, with strong evidence that both family ( Donovan, 2004 ) and peer use ( Leung et al., 2011 ) are associated with greater likelihood of trying alcohol as well as tobacco and cannabis ( Marziali et al., 2022 ). There is also strong evidence that advertising for alcohol on television and in magazines encourages adolescent trial ( Smith and Foxcroft, 2009 ).

Much research has also focused on personal characteristics that predispose to alcohol use in adolescence. This research tends to find the same predictors as for use of other substances, like tobacco and cannabis. Youth with higher levels of sensation seeking as mediated by expectancies for alcohol’s positive affective effects have been found to try using alcohol and other substances before others do ( Romer and Hennessy, 2007 ). It is less clear however that this characteristic is predictive of alcohol use disorder ( Khurana et al., 2018 ). In any case, it is informative to examine the role that sensation seeking plays in predisposing interest in substances such as alcohol. Sensation seekers are open to trying new experiences and this extends to the use of substances. However, sensation seeking increases during adolescence, suggesting that this drive is biologically based in the dopamine reward system, which is attuned to novel reinforcing experience ( Khurana et al., 2018 ). It would seem therefore that interest in trying a substance like alcohol would be expected, especially given its widespread use among adults.

In sum, alcohol use by adolescents is likely motivated by its widespread use by adults which makes it appear more acceptable as a substance and also more available in the home and elsewhere. Youth with greater exploratory drives, such as sensation seeking, are also more likely to try alcohol at an early age and if peers and family use the substance, this will make it all the more socially acceptable and “cool” to the adolescent.

Current descriptions of adolescents’ motivations for engaging in smoking

Another risk behavior among adolescents is smoking cigarettes and recently the use of e-cigarettes (also known as vaping). Smoking tobacco differs however crucially from drinking alcohol or using cannabis. It does not cause disabling states of intoxication, such as hallucination, it improves working memory and concentration and suppresses appetite, it is much more addictive and hence withdrawal symptoms set in quickly ( Cooper et al., 2015 ). These characteristics of smoking tobacco make it more likely that people are motivated to smoke more frequently, for a larger number of purposes and in a variety of daily situations ( Cooper et al., 2015 ).

Research has predominately focused on personal and demographic factors predicting smoking initiation. Several factors have been found to be associated with ever and current cigarette smoking among youth, such as having parents or friends who smoke, the likelihood of accepting a cigarette from a friend, academic success, other substance use, sensation seeking and friends’ attitudes ( Khuder et al., 2008 ; Guo et al., 2013 ; Sawdey et al., 2019 ; Creamer et al., 2021 ). One study showed that adolescents having one best friend who smoked increased the likelihood of initiating smoking by almost five times. Moreover, adolescents who had a higher percentage of friends who smoked were four times more likely to initiate smoking at a younger age than their peers ( Khuder et al., 2008 ). However, very early initiation of smoking may be driven more by family and personal attraction to smoking than by peer influence ( Loan et al., 2021 ). Cigarette and e-cigarette use are associated with similar factors, however, youth who use both types of products may have more risk factors compared to those who report to be single product users ( Sawdey et al., 2019 ).

Research among adults’ motives for tobacco show a stark contrast with motives for alcohol or cannabis use, since it is less strongly associated with coping with negative emotions and primarily seen as habitual and automatic behavior that is largely driven by withdrawal cues (which can be experienced as negative emotions as well), because of its highly addictive nature ( Cooper et al., 2015 ). Adolescents’ motives for smoking, however, can be centered around themes such as relaxation/pleasure, friends’ behavior and attitudes and the image of smoking (e.g., smokers are more popular, smoking is cool; Stanton et al., 1993 ). Additionally, in the aforementioned qualitive study among Dutch adolescents ( Tabor, 2020 ), self-focused avoidance motives such as addiction and stress-related motives were more often mentioned for smoking than for alcohol and cannabis use ( Tabor, 2020 ).

The most recent body of research on adolescents’ motivations for smoking mainly focusses on the use of e-cigarettes, because the novelty of this phenomenon. A survey among Mexican middle-school students showed that the most common reason for using e-cigarettes was curiosity in trying this substance ( Zavala-Arciniega et al., 2019 ). This is consistent with other studies that show that the availability of flavors and the belief that the taste is better compared to regular cigarettes were important reasons for adolescents to start vaping ( Sussan et al., 2017 ; Temple et al., 2017 ). Other reasons that were reported, were associated with the specific characteristics of vaping, such as that it was allowed in places where smoking is prohibited, that it helped in smoking fewer cigarettes or in quitting smoking altogether ( Temple et al., 2017 ; Zavala-Arciniega et al., 2019 ). Specific to vaping is also the perception among adolescents that it is less harmful compared to regular cigarettes and that it can serve as a healthier alternative to smoking ( Sussan et al., 2017 ). As is the case with alcohol, adolescents may also be more susceptible to the influence of advertisements and glamorization of vaping by celebrities ( Sussan et al., 2017 ). In addition, just as smoking of regular cigarettes in movies and on television was found to encourage initiation of smoking in adolescents ( Dal Cin et al., 2008 ), the role of the media in making smoking look cool is likely to have played a role in the rapid uptake of e-cigarettes in adolescents. Smoking tobacco among youth may be seen as one of the more acceptable forms of risk behaviors, because it does not have direct intoxicating effects and the health consequences are only visible at the long term. However, nicotine is highly addictive and smoking in public places has become less socially acceptable in Western societies. In conclusion, adolescents’ motives for smoking can be centered mostly around self-focused approach motives (e.g., experimenting) and social motives (e.g., smoking is seen as cool/tough).

Current descriptions of adolescents’ motivations for engaging in cannabis use

It is important to also consider motivations for youth cannabis use, since cannabis is illegal in most countries, yet it is the most used illicit drug among youth. Youth can also develop a cannabis use disorder ( Defoe et al., 2019 ). For example, in the Netherlands, cannabis outscores alcohol and tobacco, as the most diagnosed substance use disorder among youth ( Braet and Bögels, 2014 ), and in the United States, it is the most common drug for which youth seek treatment ( Johnston et al., 2015 ). However, unlike other substances such as alcohol and tobacco, cannabis has been used to treat medical conditions ( Cohen et al., 2019 ), and thus especially medical cannabis use (versus recreational cannabis us) is currently being legalized to a larger extent. All these unique attributes of cannabis can thus have a different impact on motivations for cannabis use versus alcohol and tobacco use.

The predictors of youth cannabis use appear to be similar to alcohol and tobacco youth use. Both old and more recent (meta-analytical) reviews on predictors of youth cannabis use have consistently shown that demographic (lower socioeconomic status, male sex), personality (sensation seeking) and social factors (peers’ cannabis use, parent–child relationships problems) predict youth cannabis use ( Guxens et al., 2007 ; Kirst et al., 2014 ). For example, in one longitudinal study, peer cannabis use predicted adolescent cannabis over three waves, and these cascading links predicted cannabis use disorder in emerging adulthood (ages 18–20; Defoe et al., 2019 ). As for media effects, unlike multiple studies on the effects of adolescents’ media exposure to alcohol and tobacco use (e.g., Sargent et al., 2005 ; Dal Cin et al., 2008 ; Curtis et al., 2018 ), similar studies on cannabis use are lacking and are primarily limited to a few studies on cannabis advertisements in the media. For example, Fa recent study showed that adolescents’ exposure to cannabis marketing in states in the United States with legalized cannabis laws was associated with recent cannabis use ( Whitehill et al., 2020 ).

Although there is a plethora of studies on the predictors of cannabis use, research on the motivations of cannabis use has lagged behind, especially compared to the relatively vast research on the motivations for alcohol use ( cf Cooper et al., 2015 ). Nevertheless, the assessment of cannabis use motivations has been inspired by the motivations for alcohol use (see, e.g., Simons et al., 1998 ). However, while there can be overlapping motivations for alcohol and cannabis use, there might also be some unique motivations per substance. For example, the Marijuana Motives Measure (MMM; Simons et al., 1998 ), was inspired by Cooper’s (1994) original four factor alcohol motivational model (i.e., Coping, Conformity, Enhancement, Social). However, the “expanded experiential awareness” (i.e., altered perceptions) motive needed to be additionally included in the Marijuana Motives Measure to capture the unique psychedelic effects produced by cannabis use ( Simons et al., 1998 ).

Of note is that after the development of the Marijuana Motives Measure Lee et al. (2007 , 2009) followed-up by developing the Comprehensive Marijuana Motives Questionnaire (CMMQ). The Comprehensive Marijuana Motives Questionnaire was created from self-generated reasons for cannabis use that were reported by emerging adults ( N  = 634; 57.9% female) who were in-coming college students (i.e., recent high-school graduates) in the United States. From a total of 19 motives that were mentioned from the open-ended questions, a total of 12 subscales (“motivations”) were identified via a factor analysis. The 12 subscales were: (1) Enjoyment, (2) Conformity, (3) Coping, (4) Experimentation, (5) Boredom, (6) Alcohol, (7) Celebration, (8) Altered Perception, (9) Social Anxiety, (10) Relative Low Risk, (11) Sleep/Rest, and (12) Availability ( Lee et al., 2007 , 2009 ). Follow-up analyses showed that experimentation and availability motives were uniquely associated with lower levels of cannabis use. However, the enjoyment, boredom, altered perception, relative low-risk, and sleep/rest motives were uniquely associated with higher levels of cannabis use ( Lee et al., 2009 ). After controlling for levels of use, the enjoyment motive was associated with fewer negative consequences while using cannabis or as a result of cannabis use (e.g., “Not able to do your homework or study for a test”), whereas coping and sleep/rest were associated with more negative consequences ( Lee et al., 2009 ). Of note, is that the sample consisted of college students (emerging adults).

The only adolescent (ages 13–16) study we are aware of that was based on normative (non-high risk or non-clinical) individuals, is our aforementioned qualitive study among Dutch adolescents ( Defoe et al., 2016 ; Lochs, 2020 ; Tabor, 2020 ). This study found that for cannabis use, most frequently mentioned motives were acting cool/tough, enjoyment (e.g., for “the feeling), “belonging” and “experimentation” ( Tabor, 2020 ). Interestingly, these motives overlap with the above-mentioned motives that were reported in Lee et al. (2007) , besides for the “acting cool/tough” motive. However, in our study, we did not investigate whether the reported motives were related to cannabis use and/or cannabis-use related problems. As for the literature on high-risk adolescents, of note is a recent study that used the CMMQ contained 252 adolescents attending high-school (9th–11th graders), albeit they were heavy cannabis-users who were enrolled in motivational enhancement/cognitive behavioral intervention ( Blevins et al., 2016 ). That study reported that particularly the coping motive (i.e., using cannabis to forget one’s problems, or due to feeling depressed, or to escape from one’s life) was associated with more cannabis-related problems, lower levels of self-efficacy for avoiding cannabis use, and higher levels of internalizing and externalizing symptoms ( Blevins et al., 2016 ).

In sum, when youth (1st year college students) in the United States are asked about their reasons to engage in cannabis use, the top 3 motives reported are enjoyment/fun, conformity, and experimentation, whereas for heavy-cannabis youth users, the top 3 motives that are most commonly endorsed are enjoyment, availability, and sleep ( Blevins et al., 2016 ). However, Dutch youth reported that their top 3 motives are to act tough or cool, for enjoyment, and belonging ( Tabor, 2020 ). Thus, interestingly, the primary motive for youth from the United States (enjoyment) is very different than youth from Netherlands (being cool or tough). Finally, based on at least one adolescent study with an at-risk sample (i.e., heavy cannabis-using youth) in the United States, we can tentatively conclude that particularly the coping motive is associated with more (cannabis use-related) problems in adolescence ( Blevins et al., 2016 ).

To conclude, it can be extrapolated from our review of the literature that adolescents’ quest for a “cool/tough identity” is important to understand their engagement in risk behavior, since in our study ( Lochs, 2020 ; Tabor, 2020 see also Lee et al., 2007 ), adolescents mentioned being cool/tough as the primary motive for engagement in alcohol, tobacco, and cannabis use. This quest for a cool/tough identity could be tied with experimentation, which is also among the most-mentioned motives by normative adolescents to explain their cannabis use ( Lee et al., 2007 ; Lochs, 2020 ; Tabor, 2020 ). Of note, although prior studies have shown that adolescents report experimentation among the most common motives for cannabis use in both the United States ( Lee et al., 2007 ) and the Netherlands ( Tabor, 2020 ), according to the above-described DNERM framework, it might be that youths with lower levels of self-control, are the ones who would find it more difficult to discontinue with substance use after the experimentation phase is over ( cf Defoe, 2021 ).

More recent positive risk-taking research

Recently there has been growing recognition that some risk-taking is adaptive for adolescents who are seeking to define their identities and learn about their place in the world. Adolescents are poised to gain this understanding through their increasing ability to learn from experience and gain control over their behavior ( cf Defoe and Romer, 2022 ). There is also a growing recognition that the dominant meaning of risk-taking in the developmental literature follows the lay usage of behavior that risks harmful outcomes, such as drug use, unprotected sex, and distracted driving. However, adolescents may not view risk behavior from the same perspective as adults ( Defoe and Romer, 2022 ). Namely, as noted above, Skaar (2021) found that educational risk behaviors (e.g., taking challenging classes) were the most mentioned by youth as risk behaviors, followed by “drug and alcohol use” and “trying something new.” Related to this, Duell and Steinberg, (2021) recently presented an approach that focuses on adaptive forms of risk taking, such as developing a new skill, that need to be encouraged despite the prospect of challenges that such learning may require.

Labeling theory and adolescent risk-taking

As mentioned above, adolescents are often labeled as the stereotypical risk taker, in society and in scientific research. This characterization of adolescents implies that it is normal or expected that adolescents engage in heightened risks compared to other age groups. This idea that adolescents are the stereotypical risk-takers, often carries a negative connotation. For example, it is often associated with the maladaptive types of risk taking (e.g., binge drinking or engaging in delinquency). However, adolescents engage in adaptive risks too, although this is far less investigated ( Duell and Steinberg, 2021 ; Defoe and Romer, 2022 ). Moreover, laboratory studies on age differences in risky decision-making show that adolescents do not always engage in heightened risk-taking ( Defoe et al., 2015 ). Recent theories (see below) and reviews ( Willoughby et al., 2021 ) suggest that adolescents might only be overrepresented in some types of risk behaviors (e.g., minor delinquency), whereas it is emerging adults who are over-represented in other types of risk behaviors (e.g., substance use). In sum, adolescents are not the only “stereotypical” risk-takers. But what consequences does labeling them as such have on their levels of engagement in risk-taking? This question appears to have not yet been addressed in research, and hence below we start the conversation about possible consequences of such labeling in the context of labeling theory ( Becker, 1963 ).

Labeling theory originated in the sociology discipline (e.g., Becker, 1963 ). In criminology, this theory is among the primary classical theories used to explain criminal behavior ( Murray and Farrington, 2014 ; Bernburg, 2019 ). Originally, one of the main questions labeling theory sought to answer was what are the effects of official labeling (e.g., arrest and conviction) on subsequent (criminal) behavior? ( Murray and Farrington, 2014 ). This is exactly the question we explore in this part of the review. Namely, what is the effect of the historically ingrained label “stereotypical risk-takers” that has been associated with the adolescent period on subsequent adolescent risk behavior? By exploring this question, we aim to start a conversation in the field of psychology, considering that labeling theory is not commonly used among psychologists who study criminal behavior or risk behavior more generally. Of note is that there has been some attention by sociologists ( Scheff, 1966 ) on labeling of mental illness which is an inherent topic of the fields of psychology and psychiatry. Namely, it has been argued whether when an individual is labeled as “mentally ill,” these individuals adapt their behaviors to fulfill the expectations of such a label ( Pasman, 2011 ; Scheff, 1966 ). Here we apply the same reasoning to the label of stereotypical “risk-taker.”

Extrapolating from labeling theory, it is particularly the “deviant self-concept” that is likely to mediate the link between deviant labeling (e.g., “juvenile delinquent”) and deviant behaviors ( Murray and Farrington, 2014 ). This is an important assertion when considering the impact labeling might have during the adolescent period, when individuals are still exploring their identity. Extrapolating from the symbolic interactionist theory ( Mead and Schubert, 1934 )—which was inspired by labeling theory—it is conceivable that “when adults label a youth a “troublemaker,” the youth may come to see himself as a troublemaker, eventually adopting the identity as a troublemaker” (p. 14–15, Matsueda, 2014 ). This association begs the question whether labeling adolescents as stereotypical risk-takers contributes to them identifying as such, which then leads to higher levels of risk behaviors in the future.

To the best of our knowledge, the above-described mediation question which has far-reaching implications has not been empirically investigated within the context of risk-taking. More specifically, the question as to whether labeling adolescents as stereotypical risk takers fosters a risk-taking identity in adolescents, which in turn leads to higher levels of adolescent risk-taking has been unexplored. In fact, although in criminology there is strong evidence that criminal labeling predicts more criminal behavior (see Murray and Farrington, 2014 ), empirical longitudinal tests of a similar mediation via “criminal identity” is also difficult to retrieve in the criminological literature (see Murray and Farrington, 2014 ; Bernburg, 2019 ). Nevertheless, a groundbreaking longitudinal study based on data on adolescent males from the National Youth Survey, showed that parental labeling of their sons as rule-breakers predicted subsequent adolescent delinquency via their sons’ own views of themselves (reflected appraisals of self) as rule-breakers ( Matsueda, 1992 ). Additionally, a more recent retrospective study corroborated these results by showing that adolescent’s own delinquent self-views (delinquent identity) mediated the link between “their reflected appraisals of delinquency by others” (parents and friends) and “future adult delinquency” ( Walters, 2016 ). In Walters (2016) , “reflected appraisals of delinquency by others” referred to retrospective accounts of the participant’s interpretation of the actual appraisals of their parents and peers. Alternatively, other scholars have suggested that deviant peer affiliation might also be an important factor that mediates the link between such deviant labeling and deviant behavior (for an overview, see: Bernburg, 2019 ). This is another relevant hypothesis, particularly for adolescence, as this period has been conceptualized as being associated with heightened susceptibility to deviant peer influence ( Brechwald and Prinstein, 2011 ).

Of course, similar to how multiple mediators might be at play in the link between such deviant labeling and future deviant behavior, multiple moderators might be at play as well. That is, labeling might not affect all youth to a similar extent. Or as eloquently put: “Of course, different youths respond to negative labeling in different ways—sometimes actively resisting with aggression, sometimes fleeing, and sometimes surrendering” (p. 20, Matsueda, 2014 ). For example, boys might be more susceptible to the “stereotypical risk taker” label, due to social or cultural norms that imply that certain deviant behaviors are more acceptable for males compared to females. Finally, of note is that we do not posit that labeling of adolescents as stereotypical risk-takers is the sole cause of risk behaviors during the youth period, but it warrants research attention to confirm whether it is a contributing factor.

Discussion and conclusion

Risk behaviors such as substance use typically show accelerated increases during adolescence. In fact, adolescents have virtually always been considered as the “stereotypical risk-takers” in science, but also in the mainstream media, fictional literature and in everyday life. However, adolescents’ own perspectives for engaging in risk-taking have been largely neglected in research on adolescent risk-taking, and increasing research suggests that adolescents do not always engage in “heightened” risk-taking. Hence in this paper, we argued that if it is the intention to achieve a comprehensive understanding of risk-taking during adolescence, then the perspectives and experiences of the adolescent need to be identified in research. This is also in line with the participatory approach advocated by international children’s rights standards. Hence, using a culturally sensitive approach, we summarized the few empirical studies on adolescents’ own motivations for engaging in substance use (cannabis use, alcohol use, and smoking). We found that being cool/tough, enjoyment (the taste of the substance or the feeling it gives), belonging (fitting in/impressing others), having fun, experimenting and coping (e.g., stress reduction) were frequently mentioned by youth as motives for substance use. Addiction was additionally mentioned for smoking. Interestingly, in our study among Dutch adolescents ( Lochs, 2020 ; Tabor, 2020 ), the motive that was mentioned the most “stoer doen” (acting cool or tough) is not a common theme in adolescent risk-taking research (but it was mentioned to a lesser extent in the study by Lee et al., 2007 ). It could be of added value to investigate whether “cool” or “tough” identity motive predicts risk-taking behavior in modern times among adolescents , in addition to more currently explored factors such as sensation seeking and peer influence. Identity formation is an important task for adolescents and thus it would be meaningful for research to investigate the implications that comes with the drive of adolescents to acquire a “cool/tough” identity. The above-described findings on youth motivations to engage in substance use generally support the Developmental Neuro-Ecological Risk-taking Model (DNERM; Defoe, 2021 ) and the Life-span Wisdom Model that suggest that adolescents’ motivations to engage in substance use, include experimentation, exploration, and sensation seeking. These conclusions all run counter to the stereotype of adolescents engaging in risk-taking especially due to “storm and stress.” We further conclude that although the quantity and types of risk behaviors might differ across countries (e.g., United States and Europe), the frequently mentioned motives (i.e., to be cool/tough, enjoyment, belonging, having fun, experimenting, coping; and additionally, addiction for smoking) to engage in substance-use appear to be similar across cultures. Still, of note is that unlike other youth, Dutch youth frequently mentioned “stoer doen” as a motive for engaging in substance use, which can be translated as “acting cool” or “acting tough” in English. Although the current literature suggests that “rebelliousness/roughness” is a component of the concept of “coolness” (see Dar-Nimrod et al., 2012 , 2018 ), we did not retrieve literature from other countries (besides the Netherlands) that referred to “acting tough” as a motive for substance use (but see Lee et al., 2007 , in which a minority of college students mentioned “to be cool/to feel cool” as a motive for cannabis use). But then again, the literature on self-generated motivations of youth for risk-taking is still in its infancy, and if more studies were to assess self-generated motives, then adolescents might more often mention some form of “coolness” as a motive. Self-generated motives can be assessed by applying straightforward qualitative methods (see, e.g., Skaar, 2021 ). All in all, this observation pertaining to the “being cool/tough” motive, perhaps suggests that although motives for risk behaviors such as substance use might generally be the same across countries, still unique motives might be encountered across countries (cultures), which could also be tied to differences in linguistics. Clearly, we still have a lot to learn about self-generated motives by adolescents, especially since adolescents have a greater chance of becoming dependent on substances ( Chambers et al., 2003 ).

Finally, we made a case for why nuance is warranted when labeling adolescents as stereotypical risk-takers. In doing so, we applied the labeling theory ( Becker, 1963 ) in the context of adolescent risk-taking research. Extrapolating from the sociological/criminological literature on labeling, we put forward that labeling adolescents as stereotypical risk takers may instigate a risk-taking identity in adolescents and/or motivate adolescents to associate with risk-taking peers, and both could in turn lead to adolescent risk-taking. Besides these individual and social mediators, moderators could also be at play as all adolescents might not be equally susceptible to labeling effects. Research on labeling within the context of adolescent risk-taking is needed to confirm these speculations, and that research could further benefit from taking the adolescent’s motivations for engaging in risk-taking into account.

It is of importance to further cross-nationally investigate the behaviors that adolescents and young adults themselves consider to be risky and their motivations for engaging in these behaviors. This could more thoroughly explore the idea that young adults may engage in more extensive risk behaviors such as substance use, because they have the legal age to do so. This may also give further clarification on the influence that peers may have, which is generally considered stronger in early adolescence compared to late adolescence and young adulthood, and on the relation between peer influence and motivations. In other words, is heightened peer influence related to the desire to act “cool” or “tough”? Such research could have both extensive policy and clinical implications. It may further shape the image that adults have of adolescents. For example, not automatically labeling adolescents as the typical risk-takers, and thereby directing the view to more acceptable forms of risk behavior, such as educational risks and activism, that may have positive outcomes for both adolescents and society. Adolescent’s perspective on all this ought to be acknowledged, as that respects the important right of young people to be heard in accordance with the international children’s right standards.

Author contributions

ID developed the study concept and outline, co-wrote the paper, and provided critical revisions thereafter. DR and SR co-wrote the paper and provided critical revisions. All authors contributed to the article and approved the submitted version.

Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

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Keywords: adolescence, risk-taking, substance use, motivations, labeling effects, children‘s right to participation

Citation: Defoe IN, Rap SE and Romer D (2022) Adolescents’ own views on their risk behaviors, and the potential effects of being labeled as risk-takers: A commentary and review. Front. Psychol . 13:945775. doi: 10.3389/fpsyg.2022.945775

Received: 16 May 2022; Accepted: 10 October 2022; Published: 17 November 2022.

Reviewed by:

Copyright © 2022 Defoe, Rap and Romer. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Ivy N. Defoe, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

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The Palgrave Handbook of Heterogeneity among Family Firms pp 431–460 Cite as

Risk Behavior of Family Firms: A Literature Review, Framework, and Research Agenda

  • Markus Kempers 3 ,
  • Max P. Leitterstorf 3 &
  • Nadine Kammerlander 3  
  • First Online: 06 September 2018

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21 Citations

This chapter reviews prior, so far inconclusive, research on the risk behavior of family firms. On the one hand, scholars assume risk-averse behavior of family firms based on agency theory and wealth concentration arguments. On the other hand, scholars predict that family firms are willing to take substantial financial risks to preserve their SEW. By integrating finance, management, and entrepreneurship literature, we show that different underlying definitions of “risk” are key for a better understanding of family firms’ risk behavior and subsequent strategic decisions. We provide a conceptual model, highlight gaps in the existing literature, and propose fruitful areas for further research.

  • Family firms
  • Vulnerability risk
  • Variability risk

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By doing so, articles published in the following journals were included in our literature review: “Academy of Entrepreneurship Journal,” “Academy of Management Journal,” “Administrative Science Quarterly,” “Entrepreneurship & Regional Development,” “Entrepreneurship: Theory & Practice,” “European Financial Management,” “Family Business Review,” “International Journal of Entrepreneurial Behavior & Research,” “International Review of Financial Analysis,” “International Small Business Journal,” “Journal of Banking & Finance,” “Journal of Business Research,” “Journal of Consumer Affairs,” “Journal of Corporate Finance,” “Journal of Family Business Strategy,” “Journal of International Business Studies,” “Journal of Management Studies,” “Journal of Product Innovation Management,” “Journal of Small Business Management,” “Small Business Economics,” and “Strategic Management Journal.” Other highly ranked journals, such as “Academy of Management Review,” are not included in this list, as we could not identify any published article on the topic of this manuscript.

“*” indicates a paper that was part of the systematic and unsystematic literature review.

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Kempers, M., Leitterstorf, M.P., Kammerlander, N. (2019). Risk Behavior of Family Firms: A Literature Review, Framework, and Research Agenda. In: Memili, E., Dibrell, C. (eds) The Palgrave Handbook of Heterogeneity among Family Firms. Palgrave Macmillan, Cham. https://doi.org/10.1007/978-3-319-77676-7_16

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Social Support and HIV-related Risk Behaviors: A Systematic Review of the Global Literature

Existing empirical evidence has well documented the role of social support in both physical and psychological well-being among various populations. In the context of HIV prevention, the rapid increase of studies on social support merits a systematic review to synthesize the current global literature on association between social support and HIV-related risk behaviors. The current review reveals a complex picture of this relationship across diverse populations. Existing studies indicate that higher levels of social support are related to fewer HIV-related risk behaviors among female sex workers and people living with HIV/AIDS and heterosexual adults in general. However, influences of social support on HIV-related risk behaviors are inconsistent within drug users, men who have sex with men and adolescents. These variations in findings may be attributed to different measurement of social support in different studies, specific context of social support for diverse population, or various characteristics of the social networks the study population obtained support from. Future studies are needed to explore the mechanism of how social support affects HIV-related risk behaviors. HIV prevention intervention efforts need to focus on the positive effect of social support for various vulnerable and at-risk populations. Future efforts also need to incorporate necessary structure change and utilize technical innovation in order to maximize the protective role of social support in HIV risk prevention or reduction.

Introduction

HIV has been significantly threatening the health of human beings since the early 1980s. Globally an estimated 34 million persons were living with HIV (PWHIV) at the end of 2010; an estimated 1.8 million people died from AIDS-related causes during 2010 [ 1 ]. As HIV transmits through risky behaviors, behavior change is regarded as an important component of HIV prevention strategies [ 2 ]. Recent studies of HIV prevention intervention have presented that HIV-related risk behaviors are influenced by both individual level factors and socio-cultural level factors [ 3 , 4 ]. Since the 1990s, the relationship between social support and HIV-related risk behaviors has been drawing increased attention in both research and practice fields [ 5 , 6 ]. To date, this relationship has been examined in diverse populations including drug users [ 7 ], men who have sex with men (MSM) [ 8 ], and female sexual workers (FSWs) [ 9 ].

Lakey and Cohen [ 10 ] presented three theoretical perspectives on the relationship between social support and health: the stress and coping perspective, the social constructionist perspective and the relationship perspective. The stress and coping perspective proposes that social support indirectly influences health by buffering negative impact of stressors [ 11 ]. The social constructionist perspective, drawing from social-cognitive theories of personality [ 10 ] and symbolic interactionism [ 12 ], proposes that social support directly affects health by promoting self-esteem and self-regulation [ 13 , 14 ]. The relationship perspective attributes social support to relationship qualities or processes [ 10 ]. According to the relationship perspective, relationship qualities including positive ties (e.g., companionship, intimacy) and negative ties (social conflict) among people can predict psychological and physical well-being [ 15 – 17 ].

Social network approach can be another theoretical perspective on social support study. Mitchell [ 18 ] has defined a social network as “a specific set of linkages among a defined set of persons, with the additional property that the characteristics of these linkages as a whole be used to interpret the social behavior of the person involved” (18:p2). Social networks describe social relationships, some of which may provide social support. Therefore, the functional characteristics of a defined social network, which refer to the functions provided by network members, often manifest in the form of social support [ 17 ].

The diversity of theoretical perspectives of social support results in various definitions of this concept. Some frequently cited definitions of social support focus on structure of social support, such as structure of support networks (size, density, characteristics of members, etc.). Some definitions focus on sources of social support, such as the types of interpersonal relationships [ 19 ]. Some focus on functions of social support including emotional support (affect, esteem, concern), appraisal support (feedback, affirmation), informational (suggestion, advice, information), and instrumental support (aid in labor, money, time) [ 20 – 22 ]. Some studies also focus on the quality of social support, such as the adequacy or satisfaction of the support [ 23 ]. The term of “social support” in the current review is used in its broader meaning to cover most aspects of this concept in both theoretical and empirical research.

Although social support has been recognized as an important socio-cultural level factor in HIV prevention intervention, limited literature has synthesized studies regarding relationships between social support and HIV-related risk behaviors. In a review mainly focusing on U.S. Caucasian homosexual men at a symptomatic stage of HIV infection, Green [ 23 ] highlighted the importance of exploring the association between functions of social support and health and how this association might change over time through different stages of the disease and by socio-cultural characteristics of the study population. However, the review did not include the studies among other vulnerable populations. The scope of the review was also limited by the small number of the studies at the time of the review. Hall [ 24 ] conducted a review of studies among homosexual men living with HIV by analyzing three specific areas: structure of social support (e.g., social network), relationship between coping and social support, and relationship between mental health and social support. The review indicated a positive role of social support in coping with HIV and improving psychological well-being among homosexual men with HIV [ 24 ]. In addition, the review suggested that for Caucasian homosexual men with HIV social support from friends or partners were more important than that from the family [ 24 ]. Two additional reviews addressed the issues of social support measurement. One discussed different measurements adopted by various theoretical perspectives [ 10 ], and the other examined social support measurement with a focus on measurements that were related to the role of families in prevention and adaptation to HIV/AIDS [ 25 ].

These existing reviews have shed light on the effects of social support in improving psychological well-being and quality of life of PWHIV. However, several knowledge gaps still remain. First, the studies covered in existing reviews lacked sufficient representation of diverse populations. Data were limited regarding ethnic minority PWHIV, or other vulnerable groups (e.g., drug users, FSWs, etc.) who are at high risk of HIV infection or transmission. Second, existing reviews lacked a focus on how social support might influence HIV-related risk behaviors. Third, these reviews did not systematically examine the measurements of social support and their potential effect on various findings of existing studies. The rapid increase of research and practice on social support and HIV prevention during the past two decades merits an updated review that will summarize and synthesize the current literature on social support and HIV-related risk behaviors.

The current review focuses on the association between social support and HIV-related risk behaviors with three primary objectives: first, to review measurement of social support used in empirical studies and the main findings of these studies regarding the association; second, to compare and interpret how this association may vary across different populations; third, to provide recommendations for further research and practice in this area. The term of “HIV-related risk behaviors” in the current review refers to drug-related risk behaviors (e.g., drug use, sharing needles) and sex-related risk behaviors (e.g., multiple sexual partners, unprotected sexual intercourse). It is necessary to clarify that behavioral outcomes in this review will not include psychological adaption to HIV/AIDS (e.g., coping with HIV infection or AIDS symptoms), or HIV-related “health seeking behaviors” (e.g., accessing health care providers, seeking HIV/STI consulting and testing), or adherence to medication. Although these behaviors are critical for the psychological or physical well-being of HIV-infected individuals, the scope and depth of these issues deserve a separate review.

Data Source

The literature search was conducted in May 2013 using electronic bibliographic databases: CINAHL, PsycINFO, PubMed/Medline, and Web of Science. We generated a master list of search terms and tailored search queries to each electronic database. The search terms included social support, social network, HIV and AIDS. We used the controlled vocabulary tool MeSH if available (e.g., controlled “social support” in PubMed/Medline) to more efficiently retrieve the target articles. All the citations were imported into EndNote X5.0 for data management. The search of these four databases yielded 5,699 citations in total. After deleting duplications and non-English journals, 2,681 citations remained in the EndNote data set for further screening.

Inclusion and Exclusion Criteria

Our literature review aimed to identify studies that were: (1) peer-reviewed and published in English-language journals prior to May 2013, (2) studies reporting the association between social support and at least one of the HIV-related risk behaviors (drug-related risk behaviors and sex-related risk behaviors), and (3) empirical studies using either qualitative or quantitative methodology. Articles were excluded if they met one the following criteria: (1) used language other than English, (2) were not empirical studies, (3) focused on health outcomes (physical or psychological well-being) rather than behaviors, (4) examined the relationship between social support and other behaviors (caregiving, coping with HIV, disclosing HIV status, medication adherence, etc.), (5) focused on the influence of spiritual or religious support.

The two authors conducted citation screenings by three steps: title review, abstract review, and article review. At the stage of title review, we independently reviewed the titles and resolved disagreements through discussions until we reached a consensus. We decided to apply only exclusion criteria at this stage in order to be cautious in excluding citations. Therefore, some citations might remain for the next step of screening even though their titles did not explicitly indicate they met all the inclusion criteria. We first excluded 239 extraneous articles which did not examine the relationship between social support and HIV prevention/ treatment. We then excluded 713 non-empirical studies and 77 studies with focuses on program implementation. Applying exclusion criteria 3–5, we further excluded 392 articles that did not examine HIV-related risk behaviors and 984 articles that did not focus on associations between social support and HIV-related risk behaviors. Using both inclusion and exclusion criteria, we reviewed abstracts from the remaining 277 articles, further excluding 196 additional articles. At the article review step, two authors reviewed the full text of the remaining 81 articles. We decided to exclude 45 articles, of which nine were descriptions on projects providing social support for high risk population or PWHIV, six focused on social network, three were studies conducted among special populations (rape survivors, released prisoners, and women with severely mental illness), six examined health-seeking outcomes rather than behavioral outcomes, and 21 articles did not explicitly explore associations between social support and HIV-related risk behaviors. The three-step screening then left 36 peer-reviewed articles. The references of these 36 eligible articles were also searched until no new references were identified. We also reviewed the citations from prior literature reviews on social support and/or HIV-related risk behaviors for possible references. An additional four articles identified from this hand search process survived the title-review, abstract-review and full-text-review screening, yielding a total of 40 articles for further analysis. Figure 1 summarized the screening results for each step and presented the reasons for excluding articles.

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Process of screening studies

We used a structured data abstraction form to extract key information from each of the 40 articles (e.g., study location, study population, study design, measurement for social support, main findings). We then created tables to display and categorize the information we extracted. The 40 articles were organized by types of HIV-related risk behaviors and study populations in the current review. Because of the focus on different types of HIV-related risk behaviors in this review, studies that addressed both drug-related and sex-related risk behaviors were counted as separate studies. This approach results in a total of 41 studies from the 40 publications (See Table 1 ).

Distribution of the reviewed studies by populations and HIV-related risk behaviors

Studies that addressed drug-related and sex-related risk behaviors were counted as separate studies. Thus, there are 41 studies from the 40 publications in the table

Characteristics of the Reviewed Studies

As shown in Table 1 , most of the studies (34/41) in this review focused on sex-related risk behaviors with the remainder focusing on drug-related risk behaviors. The studies explored the relationship between social support and HIV risk behaviors across diverse populations, including both most-at-risk populations such as drug users ( n = 14 studies), MSM ( n = 8 studies), FSWs ( n = 5 studies), PWHIV ( n = 4 studies), transgender women ( n = 1 study), and general populations such as adolescents ( n = 5 studies) and heterosexual adults ( n = 4 studies). The measurements of behavioral outcomes are presented in Table 2 ; and the measurement instruments for social support used in these studies are summarized in terms of type and dimension by Table 3 . The key characteristics of the reviewed studies are summarized in terms of authors, publication year, study location, sample size, study design, and main findings (See Table 4 ). All the studies employed quantitative methodology except one applied both quantitative and qualitative methodologies [ 26 , 27 ]. Of the 40 quantitative studies, 83 % (33/40) used a cross-sectional design, 8 % (3/40) used a pre-/post-test design, and 10 % (4/40) used a longitudinal design.

Summary of measurement instruments for HIV-related risk behaviors used in the reviewed studies

Summary of measurement instruments for social support used in the reviewed studies

Summary of the reviewed studies

Measures of HIV Risk Behaviors

The measures of behavioral outcomes were inconsistent across the existing studies. First, the measures varied with diverse populations. For example, the measures for drug users focused on whether or not using drugs, number of injections, and sharing of needles. The studies on FSWs assessed condom use with clients and the ones on MSM measured unprotected anal intercourse and number of sexual partners. Second, the measures applied different lengths of recall period. The respondents might be asked to recall their sexual behaviors during the past 30 days ( n = 4 studies), the past 2 months ( n = 3 studies), the past 3 months ( n = 8 studies), the past 6 months ( n = 6 studies) or the past 1 year ( n = 2 studies). Third, the scope of sex-related risk behaviors diverted according to specific study populations and research emphasis. In some studies on MSM, the unprotected sexual intercourse defined as unprotected anal intercourse, while in other studies among MSM it also included vaginal and oral sexual acts. Similarly, some studies on FSWs assessed condom use with clients, and other studies also measured condom use with their sexual partners. In addition, although most studies used single-item measure to assess HIV risk behaviors, some employed measures based on multiple items. For instance, two studies calculated an HIV risk behaviors index by combining multiple risky behaviors including drug-related risks, sex-related risks and alcohol abuse [ 28 , 29 ]. Some studies dichotomized sexual behavioral outcomes into “high risk” and “low risk” based on different items (e.g., numbers of sexual partners, having high risk partners, having sex for drugs or money) [ 30 , 31 ].

Measures of Social Support

The measures of social support were categorized into “established social support scales” and “self-developed measures” in the current review (See Table 3 ). About 45 % of the studies ( n = 19) adapted or directly used established scales and 55 % ( n = 23) created measures based on specific research questions. In total, 16 established social support scales were used in the reviewed studies. The most frequently used scales were the Social Provisions Scale [ 32 ] ( n = 4), followed by the Arizona Social Support Interview Schedule [ 33 ] ( n = 3), and the Multidimensional Scale of Perceived Social Support [ 34 ] ( n = 3).

We depicted and compared two types of social support measurements with respects to the aspects of social support they assessed, including type and content of support, size of support networks, as well as sources, functions and satisfaction of support. The established scales and self-developed measures were similar with respect to the types of social support they examined. Most of these measurement instruments assessed perceived support rather than actual support. Of the 16 established scales, 14 scales focused on perceived support and 2 scales focused on actual support [ 35 , 36 ]. Similarly, of the 23 self-developed measures, 19 examined perceived support and 4 examined actual support [ 27 , 37 – 39 ].

However, the established scales and self-developed measure were different with respect to the content of social support they focused on. Two of the established scales (i.e. Social Support Behavior Code and UCLA Social Support Inventory) were adapted to measure both general support and HIV-specific support, but the remaining 14 scales only measured general support. By contrast, the majority (61 %) of self-developed measures focused on HIV-specific support rather than general support. Of the 23 measures, nine assessed general support, 12 assessed HIV-specific support, and two assessed both general and HIV-specific support [ 40 , 41 ].

The characteristics of measurement instruments for social support were also summarized in terms of various dimensions (i.e. size of support networks, sources of support, functions of support, satisfaction of support). As shown in Table 2 , 5 of 16 established scales focused on size of support networks. The Arizona Social Support Interview Schedule [ 33 ], Social Network Inventory [ 42 ], and the Perceived Social Support Network Inventory [ 43 ] measured the size of networks, and characteristics of network members. The Norbeck Social Support Questionnaire [ 44 ] also assessed the size of networks and the social relationship between the subject and the network member. One self-developed measure examined the size of support networks and the drug use behaviors of the network members [ 41 ].

The majority of measures examined sources of social support. 11 of the 16 established scales and 19 of the 23 self-developed measures identified the sources of support (e.g., family, friends, and relatives). Of the 11 studies using established scales, nine examined support from almost all available interpersonal relationships, but two just focused on support from certain relationships such as friends, family [ 29 ], and primary caregivers [ 31 ]. Among the 19 studies using self-developed measures, eight assessed support from a single specific source such as sexual partners, gatekeepers in commercial sex venues; seven examined all available informal and formal sources of support [ 31 , 39 , 41 ]; two examined support from both friends and sexual partners [ 45 ]; and another two measured support from friends, relatives and sexual partners [ 27 , 46 ].

As for functions of social support, most of the established scales assessed different functions of general social support (e.g., emotional, tangible, information, feedback, etc.). Two scales were adapted to measure HIV-related support including HIV/STI information support and health seeking support [ 36 ], as well as support for people living with HIV/ AIDS [ 47 ]. By contrast, most of the self-developed measures focused on functions related to HIV-related protective behaviors (e.g., using condoms, dealing with clients, reducing drug use). Few measurements examined satisfactions of social support. Two self-developed measures assessed satisfaction of support [ 31 , 39 ]. Four established scales contained this dimension. They were the Social Support for Adolescents Scale [ 48 ], the Perceived Social Support Network Inventory [ 43 ], the Arizona Social Support Interview Schedule [ 33 ], and the UCLA Social Support Inventory [ 49 ].

Existing studies examined both drug-related risk behaviors and sex-related risk behaviors among drug users. Studies on social support and drug use behaviors mainly focused on drug use frequency and risky drug use behaviors such as needle-sharing among injection drug users and methadone clinic patients. It seems that more social support might be associated with less frequent drug use. One study among Puerto Rican injection drug users showed that emotional support was negatively associated to injection frequency in the sub-group of migrant drug users [ 50 ]. In an evaluation study on drug recovery program for female crack cocaine users, Nyamathi et al. [ 51 ] reported that the improvement in social support was significantly lower for women who continued using cocaine than the ones who did not maintain drug use. However, another study among methadone clinic patients indicated that perceived general social support, as measured by the Interpersonal Support Evaluation List [ 11 ], was not correlated with drug use during the previous 3 months [ 52 ].

A few studies examined how drug use behaviors were influenced by characteristics of social network and functions of social support. Suh et al. [ 53 ] suggested that the size of the drug user network providing support, as measured by the Arizona Social Support Interview Schedule [ 33 ], was positively associated with needle-sharing among injection drug users. Drug use behaviors might not be related to partner’s provision of drugs or other instrumental support, but were affected by emotional support [ 54 ]. However, the results are mixed about the relationship between emotional support and needle-sharing. Unger et al. [ 54 ] reported that male injection drug users were more likely to share needles with partners providing emotional support. A cross-sectional study among Puerto Rican injection drug users reported that emotional support was positively associated with sharing needles in the sub-group of non-migrant drug users [ 50 ]. A longitudinal study among injection drug users in the U.S. indicated that increasing number of network members who provided emotional support was negatively associated with needle-sharing [ 55 ].

The findings on associations between social support and sexual behaviors were mixed among drug users. A longitudinal study among male alcohol and drug abusers suggested that perceived social support, as measured by the Perceived Social Support Network Inventory [ 43 ], did not significantly predict unprotected sex during follow-up [ 56 ]. Several cross-sectional studies indicated that social support might be related to safer sexual behaviors. A study among female methadone clinic patients reported that perceived social support, as measured by Social Support Appraisal Index [ 20 ], was correlated with communicating about sex with sexual partners and asking partners’ HIV status [ 41 ]. Latkin et al. [ 57 ] reported that a large social network that can provide health advice and financial support, as measured by the Arizona Social Support Interview Schedule [ 33 ], might improve condom use among network members ever using heroin or cocaine in the United States. One study applied HIV risk index to assess a variety of drug-and sex-related risk behaviors including using drugs, sharing needles and injection paraphernalia, engaging in unprotected sex, and having sex for drugs or money. This study was conducted among HIV-positive IDUs, indicating that more social support, as measured by the Multidimensional Scale of Perceived Social Support [ 34 ], was significantly associated with fewer HIV risk behaviors [ 28 ]. In addition, the evaluation study on drug recovery program among female crack cocaine users suggested that improvement in social support was significantly associated with not maintaining multiple partners [ 51 ]. However, in a study among HIV seronegative non-injecting heroin users, Miller and Neaigus [ 58 ] reported that men with high perceived emotional or material support from sexual partners were more likely to have unprotected sex.

MSM and Transgender Women

The behavioral outcomes for most studies on MSM and transgender women focused on unprotected anal intercourses (UAI) and non-monogamous relationships. Empirical studies indicated that social support was negatively associated with risky sexual behaviors among this population. One study among 75 transgender women reported that higher levels of social support was related to fewer UAI [ 59 ]. Another study on young MSM suggested that a larger social support network size was associated with a lower likelihood of engaging in UAI among Hispanic/Latino MSM [ 60 ]. Lauby et al. [ 61 ] conducted a large-sample study among 1,286 MSM recruited from multiple cities in the U.S., reporting higher supportive relationship scores, as measured by the Medical Outcomes Study Social Support Survey [ 62 ], were associated with lower odds of UAI with a casual partner and lower odds of trading sex in the past 3 months [ 61 ].

The association between social support and sex-related risk behaviors among MSM might be shaped by their HIV-status, disclosure of their homosexual identities, and characteristics of social support they received. For instance, a study among young MSM recruited from 13 geographically diverse sites in the U.S. indicated that social support was positively associated with safer sexual behaviors among HIV-positive MSM ( n = 171), but this association was not significant among HIV-negative MSM ( n = 8,064) [ 63 ]. According to a study among 54 homosexual couples, the association between social support and safer sexual behaviors is more profound among those whose partners disclosed homosexual identities to people [ 64 ].

The influence of social support on sex-related risk behaviors among MSM might depend on the source and the functions of support. Having a sexual partner in a social support network was associated with increased odds of UAI among both Hispanic/Latino young MSM [ 60 ]. One study among homosexual men with HIV infection reported that actual HIV-risk behaviors were not significantly associated with any social support including perceived social support from friends or families, as measured by the Perceived Social Support-Friends and Perceived Social Support-Family [ 65 ], or available social support, as measured by the Arizona Social Support Interview Schedule [ 33 ], although higher perceived and actual family support were correlated with the intention to reduce risk behaviors [ 29 ]. Siegel et al. [ 66 ] reported that MSM having risky sexual behaviors had higher perceived emotional support. However, the safer sexual behaviors among MSM might be promoted by HIV-specific support from peers or partners. One cross-sectional study among African American and Latino MSM suggested that higher perceived support of condom use from peers was related to lower rates of UAI with both casual partners and main partners [ 67 ]. One longitudinal study examined both perceived general social support, as measured by the Social Provisions Scale [ 32 ], and perceived HIV-specific support from partner among homosexual couples over a period of 6 months [ 68 ]. Couples reporting high perceived partner support engaged in less HIV-related risk behavior longitudinally; while couples with high perceived social support from other people did so only at the follow-up survey [ 68 ].

All the existing studies on FSWs were conducted in Asia, with a focus on the effect of social support on consistent condom use with their clients or sexual partners. Studies suggested that HIV-related support from managers of entertainment and FSWs themselves (peer educators, support groups) played a positive role in promoting condom use with clients. Two cross-sectional studies in China indicated that FSWs’ perceived gatekeeper support for condom use was positively associated with their consistent condom use with clients and stable partners [ 9 , 69 ]. One longitudinal study in South Thailand reported that receiving HIV-specific support from managers of entertainment was related to increased condom use among FSWs [ 70 ]. Another evaluation study for an HIV intervention program in Bangladesh assessed type and amount of social support provided to FSWs by peer educators using the Social Support Behavior Code [ 36 ]. The FSWs receiving more informational support reported a higher rate of using condoms in previous workday [ 36 ]. In a study among FSWs in India, Dandona et al. [ 40 ] created a social support measure to assess tangible, informational support and support to deal with abusive and difficult clients. The study indicated significant association between consistent condom use with clients and participation in social support group among FSWs [ 40 ].

People Living with HIV/AIDS (PWHIV)

Four studies included in the current review were conducted among PWHIV, applying frequency of condom use during sexual intercourse as a main measure of behavioral outcome. In general, social support was positively associated with consistent condom use among PWHIV. One study in the U.S. indicated that PWHIV with high level of perceived HIV-specific support were more likely to consistently use condoms during sexual intercourse [ 39 ]. A study in South Africa suggested that general social support measured using the Medical Outcome Study Social Support Survey [ 62 ] was positively associated with condom use among HIV positive women [ 71 ]. Another study in Africa examined the relationship between peer support and consistent condom use among HIV positive couples in clinics in Uganda [ 72 ]. The peer support was significantly associated with consistent condom use in the past 6 months in bivariate analysis but not in multivariate analysis [ 72 ]. One exceptional finding was reported by Gore-Felton et al. [ 47 ], suggesting perceived partner support, as measured by an adapted version of the UCLA Social Support Inventory [ 49 ], was positively associated with the number of unprotected (vaginal, oral and/or anal) sex in the past 3 months.

Some studies were conducted among heterosexual adults who were impoverished but not defined in the current review as high-risk populations for HIV infection and transmission. The behavioral outcomes employed in these studies were mainly sex-related risk behaviors. The findings varied across gender and sources of support. One cross-sectional study among adults in Zimbabwe suggested that a higher level of HIV-specific support was related to fewer sexual partners, fewer prostitute visits and more frequent condom use among men and fewer sexual partners among women [ 45 ]. Another study among low-income urban African American heterosexual men in the U.S. indicated that high perceived social support, as measured by Multidimensional Scale of Perceived Social Support [ 34 ] might buffer negative impact of racial discrimination on sexual risk behaviors [ 73 ]. Among men perceiving high racial discrimination, those with higher social support reported less sexual risk behaviors [ 73 ].

As for women, the association between social support and sexual behavior varied across sources of social support and characteristics of their social network. For instance, among homeless women in the U.S., those who reported higher support from non-substance users were less likely to engage in substance use or have multiple sexual partners [ 46 ]. One study conducted among impoverished inner-city women in the U.S. suggested that women who received regular financial assistance and other resources or aid (e.g., materials, entertainment, housework) from family and friends might be more likely to use condoms compared to those that received limited or no support from their network [ 27 ]. Women who were dependent on sexual partners for emotional fulfillment and self-esteem were more likely to engage in unsafe sex [ 27 ]. The other study among Puerto Rican women used a measurement instrument that combined subscales from the Source-Specific Social Provisions Scale [ 74 ] and the Interpersonal Support Evaluation List [ 75 ]. This study suggested unprotected vaginal sex was associated with higher guidance and tangible support from partners but not with support from family or friends [ 76 ]. The effect of social support on sexual behaviors among vulnerable women might be reshaped by the characteristics of their social networks. Among urban African American women with a high prevalence of drug use, having multiple sexual partners in the past 3 months was significantly associated with larger personal networkers, more members who provided instrumental support and financial support [ 35 ].

Adolescents

The results of studies among adolescent population were mixed. Findings of two studies supported positive effect of social support on promoting safer sexual behaviors among adolescents. One study conducted among African American adolescents in the U.S. suggested that adolescents with higher perceived general social support, as measured by the Social Provisions Scale [ 32 ], were less likely to engage in casual sex, have more sexual partners, report more frequent coercions into unwanted sex, and show higher rates of STIs [ 77 ]. Another study conducted in Ghana indicated that male adolescents with a higher level of social support were more likely to have used a condom [ 78 ]. However, three studies indicated that perceived social support was not associated with or negatively associated with safer sexual behaviors among adolescents. According to a study among African American girls (aged 12–19), adolescents’ perceived social support, as measured by the Medical Outcomes Study Social Support Survey [ 62 ], was not significantly related to their engaging in risky sexual behaviors [ 79 ]. Another study among adolescents in rural Kenya reported higher perceived support from primary caregivers, as measured by the Parental Social Support for Adolescents Scale [ 48 ], was associated with higher sexual behaviors risk based on bivariate analysis, but this association was not significant in multivariate analysis [ 31 ]. Based on a study among undergraduate students in the U.S., Basen-Engquist [ 80 ] reported that perceived social support for condom use was positively associated with self-efficacy of condom use, but negatively associated with condom use.

Although there are considerable theoretical rationales for the association between social support and HIV-related risk behaviors, empirical studies present a complex picture of this relationship. Findings of existing studies have suggested that higher level of social support (either general or HIV-specific) might be generally related to fewer HIV-related risk behaviors among FSWs, PLWHIV and heterosexual adults. However, results about relationships between social support and HIV-related risk behaviors varied across populations and they were inconsistent within drug users, MSM, and adolescents.

The inconsistent findings may result from different potential confounders in the studies. Although the majority of existing studies controlled basic demographic characteristics, there might be considerable protective and risk factors for performing HIV-related behaviors that were not included in the final analysis models. For instance, individuals with different level of social support might report different levels of condom use self-efficacy, negotiation skills with sexual partners, and HIV prevention knowledge, etc. The associations between social support and behavioral outcomes then might be confounded by these uncontrolled factors. Therefore, findings of these studies might vary with different potential confounders.

The complicated and mixed findings may result from the complexity of social support as a concept with multiple dimensions. The empirical studies suggested that the effect of social support on HIV-related risk behaviors varied with functions and sources of social support the study populations received. For instance, MSM with higher perceived emotional support might be more likely to take unprotected sexual behaviors; while homosexual couples who reported high perceived HIV-specific support from a partner engaged in less HIV-related risk behaviors. The behaviors of diverse populations may be affected by various matrixes of social support composed of its functions and sources through different mechanisms. The influence of social support on HIV-related behaviors then varies with these mechanisms in terms of direction and magnitude.

Another possible reason for the mixed findings may be that the effect of social support is context dependent. Social support is generally viewed as a positive and important aspect of healthy behaviors or positive behavior change [ 81 ]. However, social support may be a resource to promote HIV-related risk behaviors under some circumstances [ 2 ]. Because social support is often embedded in a certain network, the association between social support and HIV-related risk behaviors may be influenced by characteristics or social norms of the support networks. Fisher [ 82 ] suggested that social norms being consistent with HIV prevention efforts will promote protective behaviors while social norms being inconsistent with HIV prevention will be barriers of positive behavior change. For example, the support from a drug-using network thus may reinforce HIV-related risk behaviors when its social norms encourage risky behaviors [ 83 ].

Some of the inconsistent findings may also attribute to different measurements of behavioral outcomes and social support in different studies. The measurements for HIV-related risk behaviors varied across diverse populations with different demographic and behavioral characteristics. In addition, the existing studies employed inconsistent recalling periods in the measures of self-reported behaviors. As for measures of social support, a few studies developed their own measures of social support due to specific research needs. Both established scales and self-developed scales varied from study to study in terms of dimensions or items. The difference in measurements may contribute to the variation of study findings. For example, most of the studies used self-developed measures that tended to be more HIV-specific. These studies indicated a positive role of social support in reducing HIV-related risk behaviors.

There are some limitations in the current literature review. First, non-English-language articles or unpublished studies (e.g., dissertations) were not included in this review because of concerns regarding the accessibility to these studies for a general audience. Second, we did not conduct meta-analysis to calculate and compare effective size of the studies in the review because of the large variation or inconsistency in measurements for both social support and HIV-related behaviors in the existing studies. Third, the current review was largely focusing on the issues of HIV-related risk behaviors but not on the HIV treatment and care, although social support may also play an important role in HIV treatment and care. Forth, a majority of the studies included in the current review were cross-sectional studies, which provided empirical evidence for associations rather than causality between social support and HIV-related risk behaviors. Fifth, data collections of the reviewed studies are subject to recall bias, social desirable bias due to self-reported social support and HIV-related risk behaviors. In addition, confounders (e.g., demographic characteristics, features of social networks) controlled in data analyses were inconsistent in different studies, which may inevitably introduce bias into the comparison and synthesis of the findings.

Despite these limitations, the findings of the current review have several important implications for future research and intervention. First, future research needs to pay attention to several issues related to research methodology. For example, future studies should be guided by theoretical models to examine the mechanism of how social support may affect HIV-related risk behaviors. Only three studies explicitly applied theoretical models to guide the research hypothesis [ 38 , 79 , 80 ]. Future studies should employ a longitudinal study design whenever possible to establish a meaningful causal relationship between social support and HIV-related risk behaviors and recruit an adequate number of respondents to ensure the power of analysis. The number of existing longitudinal studies was limited ( n = 4). About 43 % (17/40) of the existing quantitative studies had no more than 250 respondents.

Second, future studies need to pay attention to measurement issues related to social support. Measurement of social support varied across existing studies in terms of type, content and dimensions, which made it difficult to compare or generalize the findings across studies. Generally, established scales were widely used and well tested in terms of validity and reliability, but they might not measure HIV-related support. Self-developed measures assessed certain functions or sources of social support in a specific context (e.g., condom use support from gatekeepers in commercial sex venues), but they were often non-validated or non-standardized. Researchers should choose appropriate measurement instruments of social support based on their study population, as well as specific questions and hypothesis. In addition, as Lakey and Cohen [ 10 ] highlighted, researchers should also pay attention on the theoretical frameworks that different scales were derived from.

Third, carefully designed evaluation studies related to social support are urgently needed in order to inform effective and sustainable HIV prevention strategies. In the current review, only two studies focused on evaluating impacts of social support provision on reducing HIV-related risk behaviors [ 36 , 70 ]. Evaluation studies are needed to assess outcomes of the interventions aiming to foster social support [ 84 – 86 ]. Evaluation studies are also needed to examine the effect of social support, as an important social or contextual factor, in mediating the impacts of other types of intervention (rather than social support-based) on HIV-related risk behaviors.

Forth, future research and practice of HIV prevention intervention using approach of social support should consider specific needs of different populations in different stages of their lives. The needs for different functions of social support vary widely across diverse vulnerable populations. For some groups, tangible support such as clean needles and free condoms may be what they needed to perform and maintain safer behaviors; while for other groups, information support about accessing STI clinics and HIV-testing centers may be a key for seeking medical services. In addition, people may need support from a certain source to reduce HIV-related risk behaviors. Furthermore, individuals at a certain stage of their lifespan may need particular support with regard to HIV prevention. Some researchers have questioned the utility of general social support in exploring health behavior with an argument that general support may be more useful for predicting psychological outcomes but less useful for specific behavioral outcomes [ 87 ]. Therefore, future studies need to examine the functions of social support that are stronger predictors for a specific HIV-related risk behavior, and sources of social support that may have more influence on a certain population, and content of support that is more appropriate for individuals in a particular developmental stage.

Fifth, future research and practice regarding social support and HIV prevention should consider dynamics of relationships within the social networks of the target population. The practice of providing and receiving social support may be embedded in power dynamics within social relationships. Social support may also mask dependence and be intermingled with coercion within relationships with unbalanced power [ 58 ]. For instance, women with smaller external support networks may be more dependent on their partners for social and emotional support and thus would like to maintain the emotional closeness with their partners even through unsafe sex [ 27 , 88 , 89 ]. Similarly, female drug users who have sexual relationships with male drug users may have fewer negotiation abilities or options for risk reduction behaviors because of their dependence on men in accessing drugs or obtaining other support [ 90 , 91 ]. Therefore, not all types of social support can result in desirable behavior outcomes. HIV-prevention programs need to understand social norms and power dynamics of the target networks prior to design and implement interventions related to social support, and develop appropriate strategies to address challenges resulting from these specific characteristics of the networks. Organizing support group, empowering women with alternative resources may promote their HIV-preventive behaviors by reducing their dependence on negative resources and improving their self-efficacy to perform positive health behaviors [ 92 ].

Sixth, the future research and interventions also need to incorporate necessary structure change and utilize technical innovation. Structural interventions may provide social support to not only individuals but also facilitate a supportive environment. For example, micro-economic interventions may enable individuals to avoid vulnerable situations and thus protect them from engaging in HIV-related risk behaviors [ 93 ]. Community-based interventions for adolescents may also influence not only networks of target adolescents but also their teachers and family members [ 94 ]. In addition, new technical innovations such as internet and mobile technology may be incorporated into HIV prevention interventions to facilitate social support [ 95 ]. One study in China indicated that online HIV prevention programs may be a promising form of informational support for FSWs [ 96 ]. Using short message service may also help notifying support groups and other educational opportunities [ 97 ].

In summary, increasing empirical studies on social support and HIV-related risk behavior indicate the importance of social support in HIV prevention. However, the findings about associations between social support and HIV-related risk behaviors vary widely across diverse populations. Although previous theoretical and empirical studies suggest that social support can play a positive role in maintaining human well-beings, the current review indicates that increasing level of social support may not necessarily result in desirable HIV-related behaviors. Researchers and health professionals need to be cautious in the issue about the impact of social support on reducing HIV-related risk behaviors, considering context-dependent social support practice, different characteristics of individuals and their social networks, various needs for diverse populations, and complicated power dynamics within social relationships. There are numerous knowledge gaps regarding the mechanism of how social support affects HIV-related behaviors. Future studies need to be guided by solid theoretical frameworks, with appropriate study design and measurement, with efforts to examine how characteristics of social networks may affect the relationship between social support and specific behaviors. Social support is a two-edge sword. Future HIV prevention intervention efforts need to focus on the positive effect of social support for various vulnerable and at-risk populations. Future efforts also need to incorporate necessary structure change and utilize technical innovation in order to maximize the protective role of social support in HIV risk reduction.

Acknowledgments

The study was supported by National Institute of Child and Human Development Grant # R01HD074221-01. The authors also want to thank Joanne Zwemer for assistance with the manuscript preparation.

  • Research article
  • Open access
  • Published: 02 February 2024

Strategies for addressing the needs of children with or at risk of developmental disabilities in early childhood by 2030: a systematic umbrella review

  • Tracey Smythe   ORCID: orcid.org/0000-0003-3408-7362 1 , 2 ,
  • Nathaniel Scherer 1 ,
  • Carol Nanyunja 3 , 4 ,
  • Cally J. Tann 3 , 4 , 5 &
  • Bolajoko O. Olusanya 6  

BMC Medicine volume  22 , Article number:  51 ( 2024 ) Cite this article

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There are over 53million children worldwide under five with developmental disabilities who require effective interventions to support their health and well-being. However, challenges in delivering interventions persist due to various barriers, particularly in low-income and middle-income countries.

We conducted a global systematic umbrella review to assess the evidence on prevention, early detection and rehabilitation interventions for child functioning outcomes related to developmental disabilities in children under 5 years. We focused on prevalent disabilities worldwide and identified evidence-based interventions. We searched Medline, Embase, PsychINFO, and Cochrane Library for relevant literature from 1st January 2013 to 14th April 2023. A narrative synthesis approach was used to summarise the findings of the included meta-analyses. The results were presented descriptively, including study characteristics, interventions assessed, and outcomes reported. Further, as part of a secondary analysis, we presented the global prevalence of each disability in 2019 from the Global Burden of Disease study, identified the regions with the highest burden and the top ten affected countries. This study is registered with PROSPERO, number CRD42023420099.

We included 18 reviews from 883 citations, which included 1,273,444 children under five with or at risk of developmental disabilities from 251 studies across 30 countries. The conditions with adequate data were cerebral palsy, hearing loss, cognitive impairment, autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder. ASD was the most prevalent target disability ( n  = 8 reviews, 44%). Most reviews ( n  = 12, 67%) evaluated early interventions to support behavioural functioning and motor impairment. Only 33% ( n  = 10/30) of studies in the reviews were from middle-income countries, with no studies from low-income countries. Regarding quality, half of reviews were scored as high confidence ( n  = 9/18, 50%), seven as moderate (39%) and two (11%) as low.

Conclusions

We identified geographical and disability-related inequities. There is a lack of evidence from outside high-income settings. The study underscores gaps in evidence concerning prevention, identification and intervention, revealing a stark mismatch between the available evidence base and the regions experiencing the highest prevalence rates of developmental disabilities.

Peer Review reports

There are approximately 53 million children under 5 years of age with developmental disabilities worldwide [ 1 ]. Prevalence varies widely across regions and countries, with low- and middle-income countries (LMIC) experiencing a higher prevalence of developmental disabilities than high-income countries [ 2 ]. Developmental disabilities are a diverse group of conditions that affect a child’s physical, cognitive and social development [ 3 ]. These conditions encompass cerebral palsy, intellectual and learning impairments, epilepsy, hearing and vision impairment and autism spectrum disorder and attention deficit/hyperactivity disorder [ 4 ]. Typically, these conditions manifest during early childhood and can have a lifelong impact on children, their families and communities [ 5 ]. Children with developmental disabilities may experience delays in reaching developmental milestones, difficulty with social interactions and challenges in accessing and continuing education [ 6 ]. These challenges can have long-term consequences, such as decreased employment opportunities and increased dependence on caregivers [ 7 , 8 ]. Families of children with developmental disabilities may experience financial strain, social isolation and mental health issues [ 9 ]. Nevertheless, despite efforts to improve child health and well-being, children with developmental disabilities continue to experience health disparities, social exclusion and limited access to care, particularly in LMIC where the majority of affected children live [ 10 , 11 ].

In this context, the Sustainable Development Goals (SDGs) aim to achieve universal health coverage, reduce poverty and promote social inclusion, amongst other goals by 2030 [ 12 ]. SDG 4 is dedicated to early childhood development and care; specifically, Target 4.2 calls for actions to facilitate school readiness for children with disabilities towards inclusive education. These goals require the identification of children with or at risk of developmental disabilities in the first 5 years of age and the provision of services to address their needs before school entry [ 13 ]. However, despite the growing number of children with developmental disabilities, global funding schemes for early childhood development do not adequately address the challenges faced by these children and their families [ 14 ].

While services for children with and at risk of developmental disabilities (encompassing prevention, identification and rehabilitation interventions) are often perceived as highly specialised and costly, it is crucial to understand and provide evidence for comprehensive support that may not be so. For instance, evidence-based developmental screening tools integrated into regular early childhood check-ups can streamline identification of potential challenges early on, leveraging existing healthcare infrastructure [ 15 ]. This integration eliminates the need for extra appointments, ensuring timely support and contributing to intervention sustainability by utilising the existing network of healthcare professionals, making essential care accessible to a wider population and broadening their impact. Access to care and support should begin with ensuring that routine child health services and education are inclusive of children with disabilities [ 3 ]. By embedding inclusivity at this foundational level, we pave the way for a more equitable and supportive environment that can foster better developmental outcomes [ 16 ].

Consequently, amidst this drive for equitable access and comprehensive support, there is a growing interest in early identification of developmental disabilities, spurred by a global commitment to equity and inclusive education [ 17 ]. However, this poses practical and ethical challenges when suitable services are not available for identified children, particularly in LMIC. The goal of early identification is universal, and some methods and tools used in high-income countries can be beneficial without requiring significant adaptation, depending on the specific disabilities. For example, corrective glasses may not need adaptation to be prescribed in all populations. It is therefore essential to consider contextual differences and carefully assess how evidence-based interventions can be adapted and effectively implemented in various settings to ensure their relevance and effectiveness for the target population. Stigma, discrimination and exclusion further emphasise the need for a transformative approach to early care and support, because they perpetuate societal inequalities, hinder access to essential services and reinforce barriers that impede the holistic development and well-being of children with developmental disabilities [ 18 ].

In light of these considerations, this paper sets out to summarise available data on the prevalence of eight prominent developmental disabilities in children younger than 5 years, and the evidence-based interventions for prevention, early detection and rehabilitation. For the purpose of this review, we use the terms “early intervention” and “rehabilitation” for children under 5 with developmental disabilities to refer to timely and targeted strategies that address and mitigate challenges in physical, cognitive, communication and social development. These interventions may encompass a range of services, therapies and support systems designed to enhance their overall well-being, functional abilities and potential for successful integration into society as they grow.

This umbrella review was conducted following the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement for conducting umbrella reviews [ 19 ]. The protocol for this systematic umbrella review was registered in the International Prospective Register of Systematic Reviews (PROSPERO), reference number CRD42023420099. A comprehensive search of electronic databases was conducted on 14th April 2023, including Embase, Medline, Cochrane Library and PsycINFO, to identify relevant systematic reviews and meta-analyses published in English in the last 20 years (from January 2003 to May 2023). The search strategy included relevant keywords and MeSH terms related to developmental disabilities, prevention, early detection, rehabilitation and children under 5 years of age.

For example: ("PREVENTION" OR "EARLY DIAGNOSIS" OR "EARLY DETECTION" OR "REHABILITATION" OR "EARLY INTERVENTION) AND ("DISABILITY" OR "IMPAIRMENT" OR "DISORDER") AND ("CHILD*" OR CHILD* UNDER FIVE OR CHILD* UNDER 5").

Inclusion and exclusion criteria

Meta-analyses that met the following criteria were included in this umbrella review:

Population: Children under 5 years of age diagnosed with or at risk of developmental disabilities, including autism spectrum disorder, attention deficit/hyperactivity disorder, cerebral palsy, epilepsy, hearing loss, intellectual disability, learning disabilities and vision loss. No distinction was made between reviews that evaluated population-based primary studies and those based on a random sample of participants.

Interventions: Evidence-based interventions for prevention, early detection and rehabilitation of developmental disabilities, including but not limited to medical, behavioural, educational and psychosocial interventions.

Study design: Systematic reviews and umbrella reviews that included meta-analyses and assessed the effectiveness of interventions for developmental disabilities using rigorous systematic review methodology, including comprehensive literature search, inclusion and exclusion criteria, and quality assessment of included studies.

Outcome measures: Meta-analyses that report a pooled effect size for child functioning outcomes related to prevention, early detection, or rehabilitation of developmental disabilities, including measures of developmental outcomes, cognitive function, social skills and quality of life.

Systematic reviews that did not meet the above inclusion criteria, such as narrative reviews, opinion pieces, or reviews with low methodological quality, were excluded.

Additional exclusion criteria are meta-analyses that:

Do not include results for children under 5 years of age

Address secondary health issues in children with disabilities (e.g. oral health for children with cerebral palsy)

Focus only on parents and do not include outcomes for children with disabilities

Focus on a specific population group such as children exposed to HIV or malnutrition

We also excluded studies that reported surgical interventions and all invasive medical procedures requiring hospitalisation (such as intrathecal baclofen, scoliosis correction, selective dorsal rhizotomy and umbilical cord blood cell therapy).

Data extraction

Two independent reviewers screened the titles and abstracts of identified articles for eligibility based on the inclusion and exclusion criteria (TS and either NS or CN). Full-text articles of potentially eligible reviews were retrieved and assessed for inclusion. Disagreements between reviewers were resolved through discussion or consultation with a third reviewer if necessary.

Data from studies retrieved through the systematic search were extracted using Rayaan.ai using pre-defined and piloted forms and exported to Microsoft Excel for analysis. Where studies included data with both child and adult information, only the child information was extracted. Extracted data included the characteristics of included reviews (e.g. authors, publication year, country of origin), population characteristics (e.g. sample size, age range for the meta-analyses undertaken), interventions assessed and outcomes reported. Disaggregated data were managed as follows: where data allowed for disaggregation by children under five, only these specific data were extracted. In cases where data were not disaggregated by age but included children under five, these data were extracted to a separate Excel sheet, and the age range was noted. Extracted data that were not disaggregated were presented as an appendix.

Quality assessment

The risk of bias (quality) in the included reviews was assessed by the lead author. The Assessment of Multiple Systematic Reviews (AMSTAR2) [ 20 ] tool, which is specifically designed for evaluating health intervention research, was utilised to evaluate relevant sources of bias in the reviews. The AMSTAR2 tool takes into consideration the quality of the primary studies included in the meta-analysis, rather than being limited to assessing only the technical aspects of the meta-analysis itself. The AMSTAR2 questionnaire comprises 16 criteria, and reviewers were required to respond with "Yes," "Partial Yes," "No," or "No Meta-analysis" options. The overall quality of the reviews was classified into categories of "critically low," "low," "moderate," or "high."

Data synthesis

Meta-analyses were grouped by target disability, tabulated and narratively synthesised. Data on effectiveness measures were summarised. Further quantitative meta-analysis was not performed, as studies reported a range of different measures, often in non-representative populations. We present the disaggregated data, with children under 5 years old, with nonaggregate data reported in an appendix.

Global burden of disease and prevalence of developmental disability

In addition to findings from the included meta-analyses, data were presented on the prevalence of developmental disabilities, as extracted from the most recent prevalence estimates reported by the Global Burden of Disease (GBD) study [ 21 ]. This is presently the only source of data on specific developmental disabilities in children under 5 years covering over 200 countries from all world regions [ 2 , 4 ]. We identified the world regions with the highest prevalence according to the classification of developmental disability and the top ten affected countries. The findings of high-quality reviews were then mapped to the conditions and tabulated.

We identified 883 citations in our umbrella review. Of these, 37 met inclusion criteria and three studies were included after manual review (Fig.  1 ). Amongst the 40 studies, 18 included disaggregated data for children under 5 years, while 22 reviews contained data for children under 5 years, but these were not disaggregated by age.

figure 1

Study selection. *Full texts excluded with reasons provided in Additional File 1

Eighteen systematic and umbrella reviews explored evidence-based prevention, early detection and early intervention and rehabilitation for 1,273,444 children under five with or at risk of developmental disabilities from 251 studies in 30 countries. Amongst them, half of the reviews ( n  = 9) focused on interventions for children with behavioural disorders, including autism spectrum disorder (ASD) and attention deficit/hyperactivity disorder (ADHD) followed by six reviews (33%) that focussed on children with physical impairment, including cerebral palsy (CP) and neuromotor delay. One review looked at prevention and early intervention, while two focused solely on prevention, and three concentrated on early detection. The remaining 12 reviews (67%) were centred around early intervention (Table  1 ).

Out of the 30 countries represented in the studies included in the reviews, 20 (67%) were high-income countries, while 10 (33%) were middle-income countries. No low-income countries were represented in the reviews. The highest number of studies came from the USA with a total of 101 studies (40%), followed by the UK with 28 studies (11%) and China and Australia with 24 (10%) and 20 (8%), respectively. Four studies were undertaken in multiple countries. The middle-income countries represented included Bangladesh, China, Egypt, India, Iran, Pakistan, South Africa, Thailand, Tunisia and Turkey. The participant numbers varied across the included reviews, with sample sizes of the meta-analyses ranging from 58 participants with neuromotor delay [ 22 ] to 1,023,610 newborns evaluated for early screening for hearing loss [ 23 ].

Regarding quality review, this umbrella review includes a majority of reviews ( n  = 16, 89%) with high and moderate confidence (nine reviews and seven reviews respectively) and two reviews (11%) of low confidence (Additional File 2 show the results of the risk of bias assessment of each study with the AMSTAR tool, including the studies that were not disaggregated by age). The most common reasons for low confidence included a combination of the absence of an explicit statement regarding the establishment of review methods before conducting the review, the lack of a list detailing excluded studies and justifying these exclusions, and inadequate investigation of publication bias.

The outcomes and impacts varied across the studies, ranging from reduction in core symptoms for ASD, improved cognitive function and adaptive behaviour, to neuroprotection and improved sitting balance. Table 2 provides a summary of studies focusing on various disabilities and their corresponding evidence for children under 5 years [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 ].

Data that were not disaggregated are presented in Additional file 3  [ 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 ].

Cerebral palsy

Globally, approximately 8 million (95% uncertainty interval [UI] 7,113,334–9,231,577 children younger than 5 years had CP in 2019, with the highest burden being in the African Region (2.7million) and Southeast Asia (2.4million) [ 21 ]. Amongst the six (33%) reviews that examined prevention and early intervention for CP, only two [ 27 , 28 ] included data from a country ranking within the top ten highest prevalence countries, specifically China. Four reviews focussed on early intervention, one on prevention, and one on prevention and early intervention. Amongst preterm infants, antenatal corticosteroids, magnesium sulphate and prophylactic caffeine were all found to significantly reduce the risk of cerebral palsy when compared to placebo or standard care. Likewise, therapeutic hypothermia amongst term neonates with hypoxic-ischemic encephalopathy significantly reduced the risk of motor impairment at 18 months. Improved cognitive outcomes were seen during early childhood (age 2–3 years) following a variety of early developmental interventions, such as early rehabilitation (that included sensory stimulation, co-ordination training) and environmental enrichment. This effect continued to preschool age (4–5 years) (Table  3 ).

Cognitive impairment

Approximately 16 million (95% UI 11,515,194–20,980,652) children under 5 years had cognitive impairment worldwide, with the highest burden in Southeast Asia (6.3 million) and the African Region (3.3 million) [ 21 ]. China and the USA are the sole nations amongst the top ten with the highest prevalence of cognitive impairment represented in one systematic review that targeted prevention of cognitive impairment. This single systematic review explored prevention of cognitive impairment in preterm neonates and found prophylactic erythropoietin (rhEPO) reduced the risk of neurocognitive impairment at 18–26 months [ 29 ]. There were no studies disaggregated for children under five with cognitive impairment regarding early detection or inclusive early intervention and rehabilitation.

Hearing loss

There were over 14 million (95% UI 12,036,835–16,216,298) children under five with hearing loss, with the highest burden in Sub-Saharan Africa (4.4million) and South Asia (3.9million) [ 21 ]. Amongst the two reviews that examined prevalence, identification or intervention for hearing loss, only one was of high quality and neither included data from the regions with the highest prevalence. Infants with universal newborn hearing screening (UNHS) demonstrated a significantly elevated relative risk (RR) of identifying permanent bilateral hearing loss (PBHL) before 9 months, along with an average 13.2 months earlier age of PBHL identification compared to those without UNHS [ 23 ].

Attention deficit/hyperactivity disorder (ADHD)

Globally, approximately 1.4 million (95% UI 898,677–1,947,054) children under 5 years were affected by ADHD in 2019, and half of this cohort was situated within the regions of East Asia (0.5 million) and South Asia (0.2 million) [ 21 ]. There were no studies that examined prevention or early detection. The one review that examined early intervention included data from China, Iran and the USA which rank within the top ten highest prevalence countries [ 37 ]. The review determined that neurocognitive and behavioural interventions resulted in reduced ADHD symptoms and a positive effect on working memory.

Autism spectrum disorder (ASD)

Globally, the burden of ASD was estimated to be nearly 3 million (95%UI 2,418,074–3,461,585) children, with Sub-Saharan Africa accounting for approximately 0.8 million cases and the East Asia and Pacific region contributing 0.7 million cases each [ 21 ]. Amongst the seven moderate- to high-quality reviews that examined early identification and intervention for ASD, none included data from sub-Saharan Africa, the region with the highest burden. There were no studies on prevention of ASD. The review of 18 screening tests for early detection of ASD found that while diagnostic tools were helpful, their sensitivity and specificity varied [ 36 ]. Early intervention studies explored diverse approaches to enhance outcomes for children with developmental challenges and ASD. Spoken word interventions improved spoken language outcomes [ 32 ], and community-based interventions enhanced adaptive behaviour [ 33 ]. Parent-mediated interventions improved communication [ 34 ], although this review was of low quality. Intensive behavioural interventions improved adaptive behaviour [ 35 ] and behavioural and social communication interventions enhanced reciprocity of social interaction [ 38 ]. The Early Start Denver Model also demonstrated a significant effect on ASD symptoms [ 39 ], indicating the potential of these approaches in addressing ASD symptoms and improving outcomes.

We summarised findings from 18 systematic and umbrella reviews that explored evidence-based prevention, early detection, early intervention and rehabilitation for 1,273,444 children with or at risk of developmental disabilities from 251 studies in 30 countries. The majority of reviews ( n  = 12, 67%) focussed on evidence for early intervention. Half of the reviews ( n  = 9) focussed on behavioural disorders, with six (33%) focused on evidence for motor impairment such as cerebral palsy and developmental coordination disorder, and only two reviews (11%) targeted children with hearing impairment. The fewest number of studies were identified for children with cognitive impairment ( n  = 1). Of the 30 countries represented, 20 were high-income countries (67%), ten were middle-income countries (33%) and none were from low-income countries where the prevalence of developmental disabilities was frequently highest. The quality of included reviews was predominantly medium and high.

The synthesis of reviews on prevention for CP highlights the efficacy of interventions such as antenatal corticosteroids [ 26 ], magnesium sulfate [ 26 ], prophylactic caffeine [ 27 ] and neonatal therapeutic hypothermia [ 27 ] in reducing CP rates; additionally, early developmental interventions post hospital discharge [ 28 ] and environmental enrichment [ 26 ] demonstrate promising outcomes in enhancing motor skills and cognitive development for children under five. Moreover, cognitive impairment prevention in preterm infants found that prophylactic use of erythropoietin (rhEPO) [ 29 ] demonstrated a significant risk reduction, from 20 to 14%. With regard to hearing impairment, findings suggest that early hearing screening interventions, specifically UNHS, are associated with improved outcomes in identifying hearing loss in infants [ 23 ]. There were no meta-analyses for screening for vision, learning disabilities or epilepsy. Regarding ADHD, neurocognitive and behavioural interventions may reduce ADHD symptoms and positively influence working memory [ 37 ]. The findings suggest that diagnostic tools for ASD can be useful in early detection, but each test may have varying levels of sensitivity and specificity [ 36 ]. Early intervention studies encompassed a range of strategies aimed at enhancing outcomes for children with developmental challenges and ASD, including interventions focusing on improving adaptive behaviour [ 33 , 35 ], enhancing communication [ 32 , 34 ] and social interaction [ 38 ] and reducing ASD symptoms [ 31 , 39 ].

The results of this review highlight the disparity between high-income countries and LMICs in terms of evidence availability and applicability to different settings. We identified geographical and disability-related inequities. There is a lack of evidence from outside high-income settings. There was also an absence of data specifically for children with vision loss, even though at least 6 million children under five around the world have a vision impairment [ 62 ]. There are also large gaps in early detection. In addition, no developmental screenings during well-child visits were identified in our study. Efforts are therefore needed to gather more data on interventions in LMIC disaggregated by disability type, as this information is crucial to tailoring targeted and appropriate prevention, early detection and rehabilitation interventions.

Our study findings have implications for research. To address study quality, meta-analyses should include an explicit statement regarding the establishment of review methods before conducting the review, a list detailing excluded studies and justifying these exclusions, and investigate publication bias. More generally, there is a lack of data on children under five. Disaggregation by age group and studies that specifically target this age group to inform early interventions are required. Bolstering disability research capabilities across diverse settings is vital to tackle the challenges faced by children with and at risk of developmental disabilities and their caregivers worldwide. Inclusive research practices should emphasise representation and active engagement of children with disabilities and their caregivers to ensure pertinent, considerate and all-encompassing research outcomes.

Our results carry policy and practice implications. We expose gaps in evidence for prevention, identification and early intervention and rehabilitation, along with a disparity between evidence and regions with high prevalence. This underscores the absence of essential evidence for effective strategies in settings with the greatest burden. Importantly, this matter is even more urgent because global financing for rehabilitation, disability and assistive technology is largely not health-led amongst international agencies. A historical emphasis on combatting infectious diseases within the framework of development assistance for health (DAH) has created structures that disenfranchise other health needs—like those of children with disabilities—from core leadership and resources in the sector, including complementary programming. The principal contributor to DAH, the USA [ 63 ], largely directs disability-inclusive health investments away from the Global Health Bureau at the United States Agency for International Development (USAID), instead focussing on disproportionately small investments for rehabilitation through its Democracy, Human Rights and Governance sector [ 64 ]. It is therefore crucial to align funding strategies with the principles set forth in the Paris Declaration on Aid Effectiveness (2005) [ 65 ], including locally led health assistance and prioritisation of health system development, to bridge these disparities and ensure equitable access to appropriate care and interventions for all children. In addition, while the current included reviews have contributed valuable insights into prevalence, interventions and regional disparities, our examination reveals an opportunity for future research to explicitly focus on innovative strategies that challenge societal norms, promote inclusivity and foster a transformative shift in addressing stigma and discrimination associated with developmental disabilities in early childhood.

Supporting all children with disabilities will not be possible without a focus on the integration of evidence-based interventions, inclusive health systems and comprehensive education programmes that prioritise equity, empowerment and inclusion. Access to comprehensive care and support for children with disabilities is crucial for their well-being and overall development. This requires establishing inclusive child health services that cater to diverse needs. By harmonising evidence-based interventions within existing health systems, we can create sustainable and scalable solutions that benefit a larger population.

Further exploration of the interaction between current Early Childhood Development (ECD) programmes and disability support is required. It is evident that many ECD programmes often exclude children with disabilities, which is a missed opportunity for promoting disability-inclusive health and education [ 3 ]. However, these ECD initiatives can serve as potential platforms for promoting inclusivity and providing early support to children with disabilities. Finding effective ways to bridge the gap between ECD programmes and disability support could lead to better outcomes and more comprehensive care for all children, regardless of their abilities. This also raises the question of competing agendas, particularly between the focus on human capital development in ECD and the promotion of human rights for children with disabilities. ECD initiatives are often driven by a human capital approach, seeking to enhance children’s skills and abilities for future economic productivity. However, this approach might inadvertently leave behind children with disabilities, as their needs might not align with the productivity-driven goals of human capital development. It is crucial to find a harmonious way to integrate ECD goals with disability rights perspectives, ensuring that all children, including those with disabilities, receive the support they need to thrive and reach their full potential. This integration will require thoughtful policy and programme design, acknowledging and addressing the unique challenges faced by children with disabilities while promoting inclusivity and equity in early childhood development initiatives.

Strengths and limitations

This paper fills an important gap in the literature with a focus on high burden settings, which previous reviews have lacked. Strengths of this umbrella review include its adherence to standardised guidelines for conducting umbrella reviews and quality assessment, such as following the Preferred Reporting Items for Overviews of Reviews (PRIOR) statement and the AMSTAR2 tool, which has provided methodological rigour, transparency and replicability. The comprehensive search of electronic databases, including relevant broad keywords, helped ensure that a wide range of relevant systematic reviews was identified from 30 countries. Data extraction and quality assessment were conducted independently by two reviewers, reducing bias and enhancing the reliability of the findings. However, there are also limitations to consider. Despite the comprehensive search, it is possible that some relevant systematic reviews might have been missed, particularly as broad search terms were used. For example, parenting interventions. A limitation of the data about ADHD may have arisen from variations in age criteria across settings, where some countries adhere to a lower age cut-off of 4 or 5 years, while the DSM-5 lacks a specified lower age limit, which may potentially result in a lower number of articles available for analysis. Additionally, the absence of disaggregated data for this specific age group poses an issue, potentially resulting in overlooked interventions targeting a broader age range. The decision to exclude certain types of interventions and outcomes, such as surgical interventions and invasive medical procedures that require hospitalisation, may limit the scope of the findings and not fully capture the entire range of interventions available for developmental disabilities.

This paper summarises the evidence base on effective strategies for prevention, detection and early intervention and rehabilitation for children under 5 years with developmental disabilities globally. We identify a disparity between the settings from which this evidence base comes and the regions where the prevalence is highest. By highlighting the geographical inequities in evidence, we aim to foster a conversation on the allocation of resources and the direction of future research and interventions. Ultimately, this holistic approach has the potential to improve the lives of children with developmental disabilities and their families globally.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Attention deficit/hyperactivity disorder

Assessment of Multiple Systematic Reviews

Autism spectrum disorder

Global Burden of Disease

Low- and middle-income countries

Permanent bilateral hearing loss

Sustainable Development Goals

Universal newborn hearing screening

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Acknowledgements

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Tracey Smythe receives funding from the National Institute for Health Research (NIHR) [NIHR Global Research Professorship (Grant Reference Number NIHR301621)] awarded to Prof. Hannah Kuper. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS, the UK Department of Health and Social Care or FCDO. Nathaniel Scherer is funded by the United Kingdom’s Foreign, Commonwealth and Development Office (PENDA project, grant PO8073). Carol Nanyunja is funded by Seneca Trust. Cally Tann is funded by The Medical Research Council, the Bill and Melinda Gates Foundation, Grand Challenges Canada and the Seneca Trust. Bolajoko O. Olusanya declares no funding.

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Excluded texts, with reasons for exclusion.

Additional file 2.

Quality assessment of studies, a summary of findings from the quality assessment of selected studies using AMSTAR 2.

Additional file 3.

Study characteristics of reviews with nonaggregate data, for children of any age.

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Smythe, T., Scherer, N., Nanyunja, C. et al. Strategies for addressing the needs of children with or at risk of developmental disabilities in early childhood by 2030: a systematic umbrella review. BMC Med 22 , 51 (2024). https://doi.org/10.1186/s12916-024-03265-7

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  • Children under five
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BMC Medicine

ISSN: 1741-7015

risk behavior literature review

The Intersection of Men's Sexual Violence Perpetration and Sexual Risk Behavior: A Literature Review

Affiliations.

  • 1 College of Nursing and Health Innovation, Arizona State University.
  • 2 Department of Psychology, University of Washington.
  • 3 Department of Psychology, University of Massachusetts - Boston.
  • 4 Institutional Research and Decision Support, University of California, Merced.
  • PMID: 30713462
  • PMCID: PMC6350826
  • DOI: 10.1016/j.avb.2018.04.001

According to the Confluence Model of Sexual Violence, men with a strong impersonal sex orientation (i.e., greater engagement in sexual activities with more casual sexual partners) are at increased risk of perpetrating sexual violence. Research from a variety of countries and samples has supported this proposition, finding that men who perpetrate sexual violence are also more likely to engage in risky sexual behavior. The present article reviews this literature, synthesizing research findings from both psychology and public health domains utilizing both domestic and international samples. In particular, this review focuses on the associations between men's perpetration of sexual violence and their sexual partners, condom use, and sexually transmitted infection status, as well as provides recommendations for future research directions and prevention and intervention programming.

Keywords: Sexual violence; condom use; sexual aggression; sexual risk behavior; sexually transmitted infections.

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  • R01 AA017608/AA/NIAAA NIH HHS/United States
  • R21 AA016283/AA/NIAAA NIH HHS/United States
  • Open access
  • Published: 27 January 2024

A scoping review of wildfire smoke risk communications: issues, gaps, and recommendations

  • Morgan H. Vien 1 ,
  • Susan L. Ivey 1 ,
  • Hollynd Boyden 1 ,
  • Stephanie Holm 1 , 2 , 3 &
  • Linda Neuhauser 1  

BMC Public Health volume  24 , Article number:  312 ( 2024 ) Cite this article

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Wildfire smoke exposure has become a growing public health concern, as megafires and fires at the wildland urban interface increase in incidence and severity. Smoke contains many pollutants that negatively impact health and is linked to a number of health complications and chronic diseases. Communicating effectively with the public, especially at-risk populations, to reduce their exposure to this environmental pollutant has become a public health priority.

Although wildfire smoke risk communication research has also increased in the past decade, best practice guidance is limited, and most health communications do not adhere to health literacy principles: readability, accessibility, and actionability. This scoping review identifies peer-reviewed studies about wildfire smoke risk communications to identify gaps in research and evaluation of communications and programs that seek to educate the public.

Four hundred fifty-one articles were identified from Web of Science and PubMed databases. After screening, 21 articles were included in the final sample for the abstraction process and qualitative thematic analysis. Ten articles were based in the US, with the other half in Australia, Canada, Italy, and other countries. Fifteen articles examined communication materials and messaging recommendations. Eight papers described communication delivery strategies. Eleven articles discussed behavior change. Six articles touched on risk communications for vulnerable populations; findings were limited and called for increasing awareness and prioritizing risk communications for at-risk populations.

This scoping review found limited studies describing behavior change to reduce wildfire smoke exposure, characteristics of effective communication materials and messaging, and communication delivery strategies. Literature on risk communications, dissemination, and behavior change for vulnerable populations was even more limited.

Conclusions

Recommendations include providing risk communications that are easy-to-understand and adapted to specific needs of at-risk groups. Communications should provide a limited number of messages that include specific actions for avoiding smoke exposure. Effective communications should use mixed media formats and a wide variety of dissemination strategies. There is a pressing need for more intervention research and effectiveness evaluation of risk communications about wildfire smoke exposure, and more development and dissemination of risk communications for both the general public and vulnerable populations.

Peer Review reports

Wildfire smoke events and their health impacts

Wildfire smoke exposure is a growing public health concern. Large wildfire events have increased [ 1 ] due to multiple factors including increased aridity and storms from climate change, and outdated fire suppression strategies. This increase has led to larger overall acreage burned and more smoke days per year [ 2 ]. Additionally, wildland urban interface (WUI) fires and homes in the WUI have increased [ 1 , 3 ]. A growing body of research over the past two decades has documented that such smoke contains many pollutants that negatively impact health, including over the long-term [ 4 ]. Wildfire smoke is linked to adverse cardiovascular, respiratory, dermatologic [ 5 , 6 , 7 ] and nervous system outcomes [ 6 , 7 , 8 , 9 , 10 ]; has metabolic effects linked to diabetes [ 8 ]; and contains toxins that can contribute to cancer [ 11 ]. The evidence for mortality effects (respiratory and all-cause) is particularly robust [ 6 , 10 , 12 , 13 , 14 ]. Additionally, recent research demonstrates that smoke may contribute to adverse pregnancy and birth outcomes such as low birthweight [ 15 , 16 ], infant wheezing [ 16 ], and infertility [ 17 ]. Other research also points to the psychiatric consequences of wildfire smoke [ 18 , 19 ].

Wildfire smoke is especially problematic for children, contributing to the development of asthma and increasing asthma exacerbations [ 7 , 16 , 20 , 21 , 22 ]. Children are known to be especially vulnerable, both because they are growing and also because they breathe more pollutants relative to their size compared to adults [ 3 , 23 ]. Recent reviews of wildfire smoke effects in children indicate a rapidly growing body of literature, with substantial evidence of respiratory, mental health, and birthweight effects in those exposed to wildfire smoke, in addition to some evidence for a variety of impacts on other conditions such as cardiac function [ 24 , 25 , 26 ]. Wildfire smoke has especially impacted vulnerable at-risk populations [ 2 ], including Black, Indigenous, and People of Color (BIPOC) [ 1 , 27 , 28 ] as well as rural farming communities [ 18 ]. Vulnerable adult populations are more likely to have several chronic conditions, such as diabetes and cardiovascular disease, which already impact certain populations more than others, e.g., Black/African Americans have more hypertension and stroke, certain Latino populations and Native Americans have higher risks for Type 2 diabetes [ 29 ]. Vulnerable populations are at higher risk for exacerbations of those conditions, such as experiencing myocardial infarctions and/or strokes, during wildfire smoke events [ 6 , 9 , 10 ]. Therefore, the need for effective risk communications regarding wildfire smoke is especially critical for these vulnerable populations.

Current state of wildfire smoke risk communications

As the incidence and severity of wildfire smoke events increase and the serious health impacts become better understood, communicating effectively with the public to reduce their exposure to this environmental pollutant is a priority for public health interventions, especially for the most at-risk populations. Wildfire smoke risk communication research and communication interventions have greatly increased during the past decade [ 7 , 30 , 31 , 32 ]. This includes messaging primarily by publicly-funded organizations such as the US Environmental Protection Agency (EPA), US Department of Health and Human Services, Centers for Disease Control and Prevention, and state, county, and city governments in the U.S [ 33 , 34 , 35 , 36 , 37 ]. as well as from community organizations in other countries [ 35 , 38 ], all of which have prioritized risk communication on wildfire smoke related health effects.

There are a number of concerns with existing risk communication materials. Wildfire (“forest fire” and “bushfire” are equivalent terms used in different parts of the world) smoke exposure is an emergency event which increases the challenge of timely, effective communications. Cowie et al. found that health communications during wildfire events are a major challenge; such communications lacked reference to health risk changes based on exposure level and ages, protective actions to limit exposure over periods of time, and effective reporting and dissemination pathways [ 2 ]. Walsh et al. found that caregivers of children aged 5–12 perceived smoke as a signal of wildfire danger rather than as a health hazard itself, and none of these caregivers had access to information about wildfire smoke intended to guard children’s health [ 1 ]. An additional issue is the general lack of alignment of wildfire smoke risk communication materials with accepted health literacy principles. Health literacy principles advocate for clear communication for the public; easy-to-understand materials to help people understand health information, make informed health decisions, and take health-promoting actions [ 39 ]. However, studies show that most health communications do not adhere to health literacy principles related to readability, accessibility, and actionability—a major problem for vulnerable populations [ 1 , 36 , 40 , 41 ]. Although the fields of risk communication and crisis communication provide a wealth of evidence-based guidance on communicating general and emergency health risks [ 42 , 43 ], wildfire smoke risk communication research has emerged mostly in the past decade and best practice guidance is still limited [ 13 , 44 ].

Objective of this scoping literature review

In 2021, members of our research team conducted an environmental scan [ 45 ] of existing and widely distributed wildfire smoke materials and determined that very few met the standards for good health literacy and clear communication. Given the gaps we found in our environmental scan, and the critical need for effective communication about wildfire smoke dangers and ways to reduce exposure, the need for a literature review in this area was clear. The objective of this scoping literature review is to identify: 1) relevant peer-reviewed studies about wildfire smoke risk communications, including communication resources for vulnerable, at-risk populations; 2) characteristics of effective communications, dissemination strategies, and gaps in the peer-reviewed literature; and 3) recommendations to improve wildfire smoke research and communication practices.

Inclusion criteria

This scoping review [ 46 ] focused on wildfire smoke risk communications for the public. Journal articles included in this scoping literature review were peer-reviewed, indexed in PubMed or Web of Science databases, available online, and available in English or Spanish. The search was not limited by years of publication.

Exclusion criteria

Journal articles excluded were those focused on wildfires rather than wildfire smoke risk communications, for example, protecting one’s property, preparing one’s household for a fire (e.g., “go bags”), or escaping from wildfires. Articles about effects of fires on health outcomes, mortality-related studies, chemical fires, post-fire interviews, and smoke plumes with satellite/remote sensing were also excluded. Gray literature, general Internet searches, and case studies were excluded.

We excluded articles if indicated articles were not within the scope of our topic, based on title review, then conducted abstract review, and finally full article review/reading/abstraction. We also scanned bibliographies of articles to identify any additional articles that should be included.

Search criteria

Article searches were conducted between October and December 2021 using PubMed and Web of Science databases. No limit was applied to the earliest date of publication to ensure the largest sample possible was collected. Search terms included: communication, communication strategies, education, effectiveness, environmental exposure, fire, risk communication, smoke, smoke exposure, wildfire smoke, and bushfire; various combinations of these terms were used. Bibliographies of articles were also reviewed for article inclusion.

Process of review

After each search, three members of the research team (MV, SI, HB) reviewed the titles and abstracts of the outputs from the searches. After the initial title and abstract review, twenty-four articles were distributed to one of four team members (the three original team members and an additional member (LN)) for review. Throughout the period of review and abstraction, the team members met biweekly to address questions, discuss the articles, and talk through disagreements.

Abstraction and analysis plan

The abstraction process included four categories for review: risk communication approaches, research design and methods, population in the study, and results and recommendations. These four categories were selected to ensure that data collected from articles were comprehensive, concise, and consistent. The category, “risk communication approaches”, organized information about risk communications programs, materials, and strategies. The category, “research design and methods”, was included to examine the quality and robustness of the articles. The category, “population in study”, provided context around population size, location, and sampling frame. The category, “results and recommendations”, contained key article findings and takeaways. After abstraction, the team determined that twenty-one articles would be included in the scoping review. A PRISMA Diagram depicts the flow of information (articles identified, included, excluded, and reasons) through the different phases of a review (see Fig.  1 ) [ 47 ].

figure 1

PRISMA diagram

Four members of the research team (MV, SI, LN, HB) conducted the qualitative thematic analysis. Data collected from articles during the abstraction process were coded and organized into categories. If category consistency was not reached, the research team discussed the issues and reached consensus. Analysis was an iterative process with additions or rearrangement of codes and categories. Themes were communication materials and messages, communication delivery strategies, behavior change, and communications for vulnerable populations. Categories were incorporated as subsections of the four themes. Google Workspace software [ 48 ] was used for this qualitative analysis.

Quality of articles

Articles were assessed for quality based on study design and methods (see Table  1 ). Within the final sample, study designs, in order of rigor were randomized controlled trial, quantitative study, mixed methods study, literature review, and qualitative study. Authors reviewed papers for qualitative indicators, such as robustness of study design, recruitment, randomization, sampling, and methods (e.g., intervention, survey, database searches, interviews) with the intent of ranking them by rigor within each category. However, due to the limited sample of available articles and methodological similarities among multiple articles in each study design category, authors made the decision to organize articles alphabetically within each of the study design categories. Table 1 describes study design and methods.

The final sample of this scoping review consisted of twenty-one articles. Table 1 is a summary of the articles (see Table  1 ). Ten were based in the United States, six in Australia, two in Canada, and one in Italy. Two more articles included multiple countries in the studies. The results below are grouped into four sections related to communications materials, dissemination strategies, behavior change, and communications for vulnerable audiences—with a focus on gaps and recommendations. Table 2 contains detailed information extracted from the articles (see Table  2 ).

Communications materials and messaging findings and recommendations

Fifteen articles examined communications materials and messaging, and they offered recommendations including discussion of messaging content and design (5 articles), approaches to communications (2), use of a mobile application (3), use of real-life video footage (1), use of mapping for information distribution (2), effectiveness of risk communications (6), and communication gaps (2).

General messaging content and design

Five articles recommended messaging that uses simple, direct, clear, current, accurate, and specific language [ 33 , 35 , 38 , 44 , 55 ]. Authors commented that it is important that the communications are well-recalled, understood, and followed. This messaging should include information about fire locations, timeframes, safety, where to get additional updates and actions that people can take [ 33 , 35 ]. Messages should also be timely, practical, consistent, and provide details about short-term and long-term health effects [ 38 , 55 ]. Marfori et al. also noted that participants remembered short messages and gained knowledge but expressed interest in having added messages that were about both the short-term and long-term health risks of wildfire smoke [ 38 ].

Two articles provided more guidance for risk communications [ 36 , 56 ]. Damon et al. called for ‘new’ materials to maintain public risk awareness year after year [ 56 ]. Messaging must be non-alarming and scientifically grounded. The public must be convinced of their self-efficacy to take recommended protective actions and must be notified to take actions against wildfire smoke exposure in a timely manner. Sugerman et al. discussed messaging that contains both non-technical actions, such as staying inside and closing windows, as well as technical actions, including use of home filtration devices or N95 masks [ 36 ]. They found that people’s non-technical recall, understanding, and compliance is high, but that technical messaging about High Efficiency Particulate Air (HEPA) filters and N-95 respirators should be better explained to the public.

Use of various media for communications

Three articles addressed the benefits and barriers of using the Smoke Sense mobile application, and assessed the knowledge gains from using the app [ 34 , 49 , 51 ]. Smoke Sense is a smartphone application, originally developed by the US EPA, that provides wildfire-related health risk resources and engages affected participants (“citizen scientists”) on wildfire smoke issues. Smoke Sense also shares information about daily air quality, maps of fire locations, and satellite images of smoke plumes [ 51 ]. In two different papers, Hano and their EPA colleagues concluded that it was a valuable app to provide general information about smoke risk for individuals, organizations, and communities, but that it needed improvement to provide population-specific information [ 34 , 51 ]. Authors found that the Smoke Sense app can support organizations that can disseminate information about wildfire smoke, as well as support community efforts to protect sensitive and vulnerable groups [ 34 , 49 , 51 ].

From these qualitative and quantitative studies, recommendations for messaging included increasing individuals’ knowledge about smoke risks to protect themselves or their families, building self-efficacy for reducing exposure and actions to take, linking exposures to symptoms and cost-benefit relationships as well as information related to individuals’ personal concerns, and emphasizing the impact that reducing exposure may have on what individuals care about, e.g., maintaining good health and fitness [ 34 , 51 ]. Furthermore, related to behavioral outcomes, an unblinded randomized controlled trial found that Smoke Sense app use among a specific vulnerable group – young adult participants with provider-diagnosed asthma – resulted in better asthma management during poor air quality days [ 49 ]. Postma et al. discussed the use of different features (e.g., peer message boards, daily spirometry readings, and air quality updates), which were integrated by technology partner Urbanova, within Smoke Sense, to increase engagement from participants and knowledge about smoke exposure/its effects on those with asthma [ 49 ].

One qualitative study found that showing real-life, vivid video footage of past wildfires could be a useful communication approach because it led to an increase in some desired behaviors, such as seeking knowledge, reducing exposure, finding more information about risk to home/area, and speaking with household and community members—actions linked to reducing exposure to wildfires and smoke [ 54 ].

Use of mapping for information dissemination

Studies by Stieb et al. and Cao et al. found that maps were effective for sharing information as well as increasing people’s knowledge about wildfire smoke and other environmental emergencies [ 37 , 50 ]. Steib et al. researched the use of mapping health risks from natural hazard exposures (floods, wildfires, and contamination of air and water) as a risk communication technique and found that maps were better understood and interpreted than text [ 37 ]. The authors concluded that app and map developers should engage in an iterative process to design maps. Inclusion of visual cognitive science features (e.g., color, position, patterns, motion) and actionable information was important to adapt maps for effective risk communications. Cao et al. recommended a hybrid approach that combines maps with selected text message information [ 50 ]. Appropriately designed maps also better communicated wildfire and wildfire smoke warning information, improved comprehension, elevated risk perceptions, and increased appeal to the public. These maps were best complemented by textual descriptions of safe shelters, such as landmarks, names, and addresses.

Effectiveness of risk communications: Overall, as described above, eight articles [ 34 , 36 , 37 , 38 , 49 , 50 , 51 , 54 ] in this category included assessments of effectiveness of risk communications for improving knowledge, behavior change, and health outcomes. Two articles noted that people effectively understood and recalled information from general messaging content and design [ 36 , 38 ]. Six articles found that the use of various media, such as Smoke Sense app, video with real-life footage, and maps (especially maps that include text linked to spatial features), helped to improve knowledge, behavior change, and health outcomes [ 34 , 37 , 49 , 50 , 51 , 54 ].

Gaps in communications

Two papers examined gaps in communications [ 60 , 62 ]. Van Deventer et al. found wide variation in message content [ 62 ]. The most common personal interventions included reducing activity and staying inside during wildfire smoke events. However, regarding information specific to vulnerable populations, less than half of 85 government sources (47 social media-based messages, 38 digital articles from website) and 188 media messages (all digital articles from news sources’ websites) examined contained information about wildfire smoke. Approximately half contained a reference to a trusted source of information, but high-efficiency particulate air (HEPA) filtration was not mentioned at all. They concluded that government and news media would benefit from improved coordination of information about health risks of smoke exposure, approaches to reduce exposure, input from vulnerable populations, and risk communication tools, templates, and resources. Riden et al. discussed limitations in safety precautions for farmworkers during wildfire smoke, including the need for protective masks or respirators, air quality monitors, and changes to work schedules during events, and suggested that better resources are needed to assist employers and supervisors in complying with wildfire smoke safety regulations [ 60 ]. Agricultural employers varied in their knowledge and experience relative to responding to poor air quality caused by wildfire smoke.

Communication delivery strategies: dissemination methods, pathways, and recommendations

Eight articles discussed communication delivery strategies, including traditional and digital communication strategies (7 articles), and allocation of resources within agencies specifically designated for communication and outreach measures (1 article).

Traditional and digital communications

Eight articles outlined common communication channels [ 33 , 35 , 36 , 38 , 44 , 52 , 55 , 56 ]; three of these articles were literature reviews [ 35 , 44 , 55 ].

Authors recommended communicating through a combination of channels: radio, television, internet, social media, social networks, hotlines, mass media, local papers, and phone to effectively deliver knowledge and encourage behavior change [ 33 , 35 , 36 , 44 , 55 , 59 ]. Burns et al. found that respondents older than 40 years of age tended to receive risk communications through emergency services and city councils, radio and local papers, and from members of local organizations or government [ 33 ]. However, in 2009 and 2010, respondents under 40 years of age most commonly used television, local papers, friends, family, and neighbors. More recently in 2020, Keegan et al. stated that traditional sources like television have been the preferred method of communication delivery but that a preference for online and smartphone-based communication has emerged among younger, female, and urban populations [ 55 ]. Additionally, authors recommended locations for communications, such as post offices, road signs, schools, retirement facilities, childcare areas, presentations at public events, and billboards [ 33 , 44 , 59 ]. They commented that communication from healthcare workers, texts, and social networks may be effective, but require further research.

Authors provided recommendations on timing for communications delivery. The review by Keegan et al. concluded that messages should be delivered as early as possible to give people time to plan and act in the case of a smoke event [ 55 ]. Damon et al. discussed disseminating information in a timely and effective manner and using “message blanketing” at all local media outlets, in addition to statements from local opinion leaders and organizations [ 56 ].

Articles included findings regarding the knowledge gain and recall of communications about wildfire smoke. Mott et al. discussed people’s recall of several interventions including public service announcements (PSAs) after a wildfire event and commented that participants more frequently recalled PSAs distributed via radio and by physician/clinical personnel [ 52 ]. In a qualitative study done by Marfori et al., participants recalled delivery strategies including media releases, digital information and social media posts from public health and emergency services, and word of mouth [ 38 ]. Participants reported that social media was a source that provided more information about smoke than the information on wildfires that dominated the other news platforms. Participants also shared that it was difficult to know which sources to rely on and that they trusted official communications from governments more than those shared on social media from non-government sources. Social media was found to allow real-time dialogue between authorities and the public, and amplified messages.

Resource allocation for wildfire smoke communications

Olsen et al. suggested prioritizing fire and smoke-related communications within agencies by allocating agency resources specifically for staff training in communication and outreach endeavors, and for coordinating messages across and within agencies [ 59 ]. Authors found that taking advantage of existing resources including informal social networks among the public, and building long-term relationships both between agencies as well as with the public were viewed as effective in distributing communications to audiences [ 44 , 55 , 59 ]. Olsen et al. warned against inconsistent messaging from different agencies and inadequate reach of messages [ 59 ]. Their recommendations included aligning internal priorities when communicating and building relationships with the public, as well as evaluating communications delivery to the intended number of people.

Effectiveness of risk communications

Overall, five articles in this category included assessments of effectiveness of risk communications for improving knowledge gains, behavior change, and health outcomes. These articles discussed traditional and digital communications that were effective for successful and timely dissemination of risk communications [ 33 , 44 , 52 , 55 , 59 ].

Motivating behavior change: knowledge acquisition and trust building

Eleven articles discussed behavior change, including motivating public behavior change through community-level interventions (5 articles), increasing knowledge about wildfire smoke risk exposure among practitioners serving the public (3 articles), and examining public trust (3 articles). All eleven articles assessed behavior and behavior change (but not behavior intention) in the context of reducing wildfire smoke exposure.

Community-engaged interventions

Five articles described in-person intervention approaches associated with behavior change [ 34 , 49 , 52 , 54 , 57 ].

Authors of two articles discussed community-level interventions for Indigenous populations. In their qualitative study, Dodd et al. interviewed members of three Tribal Nations in Canada [ 57 ]. They found that community-based initiatives could reduce the impact of smoke exposure on physical, mental, and emotional well-being. These initiatives included removing flammable materials from around houses, joining community social support time at the community hall, and improving food security and connection to land-based activities (e.g., berry harvesting, fishing). Mott et al. conducted a retrospective study of Hoopa Tribe members affected by the 1999 wildfire in Humboldt County, California (USA) [ 52 ]. The study focused on recall of multiple community-focused interventions: effectiveness of free masks, free hotel services to shelter from the smoke area, high-efficiency particulate air (HEPA) air cleaners (distributed to individuals with pre-existing conditions), and PSAs [ 52 ]. PSAs were the most effective intervention. Mask use was associated with increased time outdoors and therefore increased exposure, but evacuation to hotels was not conducive to continuing employment as many residents worked in fire camps to fight forest fires. As a result of PSAs, the most common action taken was to stay indoors, rather than leave the area, use a mask, or use an air cleaner. Participants had highest recall of PSAs distributed via radio compared to all other sources, some of which included physicians, social networks, television, newspaper, and the Tribal Council. Additionally, those who recalled any of the PSAs were less likely to report worsening respiratory symptoms.

Hano et al., Hano et al., and Postma et al. indicated that the Smoke Sense application may support behavior change at multiple societal levels [ 34 , 49 , 51 ]. At the individual level, to protect health and increase awareness out of concern for health of self and family. At the organizational level, to advance organizational efforts in the area by using the app to distribute new tools and resources regarding smoke. At the community level, to increase awareness of connections between wildland fire, smoke, air quality, and health [ 34 , 49 ].

In their case study, Chapple et al. found that study participants exhibited more protective behaviors and concerns for wildfire smoke after watching a video with real-life footage, compared to those who did not watch the video [ 54 ].

Knowledge among practitioners

Authors found that professionals with past experiences in wildfire-related work had significantly higher knowledge of wildfires/smoke exposure [ 53 ], had improved ability to make informed decisions in the face of an emergency [ 61 ], and better understood the current situation [ 61 ]. Spano et al. discussed that those with direct experience had, and also asked for, more information about these topics, indicating that practitioners/those experienced with wildfires can be an especially valuable source of knowledge for others [ 53 ]. Thomas et al. interviewed emergency risk communication professionals, who shared that working with the same group of people and stakeholders over long periods of time was helpful to the professionals to make informed, tailored decisions during smoke event emergencies [ 61 ]. Additionally, Errett et al. found that governmental agencies and academic organizations, participants at a state-wide wildfire smoke exposure symposium, proposed key research areas to increase the public’s knowledge of wildfire smoke risks [ 58 ]. They encouraged researchers and practitioners to study the following areas: smoke exposure, health risk, risk communications, behavior change and interventions, and legal and policy issues.

Public trust

Burns et al., Olsen et al., and Fish et al. all highlighted the necessity of trusted sources of information, the role of local agencies and governments, and the importance of communication sources [ 33 , 44 , 59 ]. Authors found that sources within the same social network influenced the value of fire and smoke messaging, and that neighbors and local residents were trusted sources of wildfire smoke communications [ 44 , 59 ]. In three articles, authors discussed building public trust and improving message effectiveness through credible information sources [ 33 ], communication channels [ 44 ], and re-tweets or re-shares of social media posts between official accounts [ 35 ]. Examples of sources trusted by the public include authoritative local sources, the local police, as well as the Red Cross and State Departments of Health Services.

Overall, ten articles in this category included assessments of effectiveness of risk communications for improving knowledge, behavior change, and health outcomes. Five articles discussed community-engaged interventions that were associated with behavior change [ 34 , 49 , 52 , 54 , 57 ]. Two articles assessed ways to increase knowledge among practitioners and the public [ 53 , 58 ]. Three articles suggested that effective communications included building public trust and using credible information sources [ 33 , 44 , 59 ].

Communications for vulnerable populations

Literature regarding risk communications for vulnerable populations to reduce wildfire smoke exposure was limited – only six articles were found. In general, authors found that communication resources for vulnerable populations were limited. For example, in Keegan et al., of twenty-six health protection messaging communications included in their study, only nine were relevant to vulnerable populations [ 55 ]. Specific resources relevant to pediatric populations were also found to be lacking [ 35 ].

Culturally and linguistically diverse groups, those with hearing, vision, and mobility-related disabilities, those living in high smoke-risk geographic locations, those with pre-existing chronic illnesses, those who are children or older adults, and those who are pregnant may benefit from targeted health recommendations about wildfire smoke exposure and resources on prevention/mitigation strategies [ 35 ]. Authors recommended prioritizing communications for communities that have greater exposure to smoke events [ 55 ], including actions to reduce wildfire smoke exposure instead of only updates about wildfire smoke situations [ 35 ], and providing communications to at-risk groups before the general population [ 44 ]. Mott et al. and Dodd et al. emphasized the importance of community-level initiatives for Indigenous populations in northwest Canada and in Hoopa Valley, California, to increase awareness and behavioral change [ 52 , 57 ].

Postma et al. found that among young adults ages 18–26 with asthma diagnosed by healthcare providers, the Smoke Sense mobile application use was effective in increasing air quality awareness knowledge and improving asthma management [ 49 ]. Specifically, young adult participants thought that the version of Smoke Sense with Urbanova’s integrated features for mapping smoke areas, air quality advisories, spirometry graphs, weekly reminders, and peer message boards, was easy to use.

Effectiveness of risk communications: Postma et al. noted that use of the Smoke Sense mobile application and its integrated features was effective to increase knowledge about air quality and wildfire smoke and positive behaviors to manage asthma [ 49 ]. Other articles in this category did not assess effectiveness of risk communications for vulnerable populations.

Wildfire smoke exposure is a serious public health challenge as wildfires are rapidly increasing in prevalence and intensity [ 3 , 36 , 51 , 59 , 62 ] and duration. Further, wildfire smoke exposure is an emergency event that adds challenges to providing timely, effective risk communications [ 52 ]. Wildfire smoke negatively impacts health in multiple ways, including over the long-term. This scoping review focused on peer-reviewed literature which evaluated wildfire smoke risk communications for public audiences, and identified gaps in the available literature, key communication issues, and recommendations for improvement. A total of 21 articles were included. We reviewed these studies in the following four thematic areas: 1) communications materials, messaging content and design, use of different media; 2) communication strategies, traditional and digital approaches, resource allocation for communications; 3) motivating behavior change, community-based interventions, knowledge acquisition among practitioners, public trust; and 4) communications for vulnerable populations. Although this review found that there are important assessments of the effectiveness of risk communications, most of those examined knowledge gains, rather than behavior intention, changes, and health outcomes.

Gaps in the literature

We found that peer-reviewed literature about wildfire smoke risk communications is still very limited but has notably increased in the past decade as reducing exposure to wildfire smoke has become a priority public health issue. Because of the limited literature, there are gaps in all areas related to wildfire smoke communication. Encouragingly, available literature shows exploration of many important risk communication areas, including experimentation with messages, media, participatory design, community interventions, and an increasing focus on assessing effectiveness of materials and strategies in domains that include increasing knowledge, reinforcing positive behavior intention and changes, and ultimately leading to better health outcomes.

A major current gap in the literature relates to studies about communications created with and for vulnerable populations. This is an important finding of this review because at-risk, vulnerable populations are those most in need of effective communications. Some specific vulnerable populations include those who have low connectivity, are low-income, less educated, rural, and/or limited English proficient. Additional vulnerable populations include Black, Indigenous, and People of Color (BIPOC), outdoor workers, Deaf or Hard-of-Hearing people, pregnant women, children (especially those with asthma) and others with existing chronic respiratory, cardiovascular, or diabetes conditions [ 3 , 7 , 52 , 62 , 63 ]. The few articles related to vulnerable populations were helpful to point out the need to prioritize these populations, to provide more targeted health messaging and to increase community-based initiatives to develop more successful approaches to support vulnerable groups [ 3 , 7 , 28 , 51 ]. However, specific messaging recommendations from these studies are still fairly generic. Another gap is that though some articles evaluated communications for accuracy, simplicity, and actionability, no articles explicitly examined health literacy—a central issue for high quality risk communications [ 33 ]. Finally, as in any relatively new research and practice area, there is a need for both more qualitative depth and context in the studies as well as quantitative rigor, including prospective research.

Recommendations from this review

Despite the gaps in the literature, existing studies do provide rich information about known weaknesses of current wildfire smoke communications and note many recommendations to improve them. Many key issues with wildfire smoke risk communications have been identified in the existing literature. These include issues related to community-engaged design, timeliness, understandability, visual and textual elements (including mapping), selection of communication mediums, trusted messengers, actionability of recommendations, and point of contact dissemination strategies. Although many articles in this review included some assessment of effectiveness of risk communications, more work is needed in this area to examine and increase knowledge, encourage behavior intentions and change, and improve health outcomes.

Important recommendations were identified in each of the four thematic areas we focused on in this review as summarized here:

Communication materials and messages: Use evidence-based messages and multi-media (print, internet, mobile applications, maps, videos, PSAs, etc.); include clear, specific, actionable ways to reduce wildfire smoke exposure; improve explanations for technical messaging, improve mapping techniques, and provide details about short- and long-term health effects.

Delivery strategies: Simultaneously disseminate messaging through multiple local media outlets such as through television, radio, newspaper, the internet, and social media.

Behavior change: Provide more information through trusted intermediaries, such as health and public safety providers, to increase the public’s knowledge about wildfire smoke and motivate behavior change; maintain consistent messaging between agencies, and build on existing communications from public officials to increase public trust and timely action.

Communications for vulnerable populations: Prioritize targeted communications for specific at-risk groups; use community-engaged design and testing with these groups to ensure that messages are relevant to the group’s needs, and are clear, actionable, and use preferred communication mediums.

Guidance from prior studies of risk communications in other areas indicates that simple and clear communications adapted to specific cultures, languages, health literacy levels, and other factors are essential so that risk communication meets the needs of groups most at risk [ 64 ]. It is important that all wildfire smoke communications are created with attention to health literacy principles, which also would likely benefit vulnerable populations. Recommendations for future research on wildfire smoke communication include evaluating the differential effectiveness of various kinds of messages and media, studying communications tailored for the diverse US populations, and co-developing communications using health literacy principles with vulnerable populations.

This is a scoping review of the peer-reviewed literature about risk communications related to wildfire smoke exposure. Scoping reviews are helpful prior to planning a study, to identify gaps in research, to tailor a study or design interventions, and to include multiple types of studies, not limited to randomized trials or quantitative studies. This can be especially important when there are few articles for unique populations, as we found in this review. There was no publication date limit selected to maximize collection of relevant articles. This scoping review also included articles from authors located in various countries affected by wildfire smoke.

Limitations

There was a limited number of articles from any one country, limiting the ability to make any country-specific conclusions. Available articles in languages other than English and Spanish were not included, given our a priori inclusion criteria. No studies were found in Spanish language which may indicate a critical gap in the evaluation of wildfire communications for Spanish-speaking populations. The biggest limitation was the limited literature in this area to date, which impacted interpreting the issues and recommendations in this review. However, we did note that there was often convergence among authors about important issues cited and recommendations for improved wildfire smoke risk communications.

Wildfire smoke exposure, with its detrimental effects on health, is a significant public health concern [ 3 ]. Given the growing magnitude of wildfire smoke exposure, there is a pressing need for more intervention and evaluation research about effectiveness of risk communications in this topical area. This scoping review examined peer-reviewed literature on wildfire smoke risk communication and identified gaps for additional research. Our review found limited studies describing characteristics of effective communication materials and messaging, and communication delivery strategies, and approaches to increase positive behavior intention, behavior change to reduce wildfire smoke exposure and, ultimately, improve health outcomes. Literature on these topics for vulnerable populations was even more limited. Although studies in the topical area of wildfire smoke messaging are still nascent, they provide important guidance for researchers and practitioners in developing and disseminating risk communications for the general public and for vulnerable populations.

Priority recommendations are that risk communications should be easy-to-understand, provide simple and direct messages, highlight specific actions to undertake to avoid smoke exposure, use mapping when relevant, use hybrid mixtures of formats (such as video, textual information, maps, mobile apps, etc.), and be customized to the needs of at-risk, vulnerable populations. These recommendations are similar to those for improving the quality and effectiveness of health communications in general. However, wildfire smoke exposure is also an emergency event that presents the added critical challenge of providing timely, effective communications from government and local community organizations. There is a lack of rigorous evaluation studies to demonstrate which communication strategies are most effective. This review could be augmented with a future review of studies in languages other than English and Spanish. The recommendations also propose using a wide variety of dissemination strategies relevant to the focal populations.

Availability of data and materials

All data generated or analyzed during this study are included in this published article [and its tables and figure].

Abbreviations

Wildland urban interface

Black, Indigenous, and People of Color

Environmental Protection Agency

High-efficiency particulate air

Public service announcements

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Acknowledgements

The authors express our gratitude to Dr. Jason Su and Dr. Winston Tseng for their support on our related research efforts, to Anthony Eleftherion and Rebecca D. Freed for their work on the environmental scan of existing wildfire smoke risk communication materials, and to Jessica Liu for her support in the initial proposed conception of this literature review.

EPA grant #84023901-0

This publication was funded by and developed under EPA STAR Assistance Agreement No. 84023901-0 awarded by the U.S. Environmental Protection Agency to University of California, Berkeley. It has not been formally reviewed by EPA. The views expressed in this document are solely those of the publication’s authors and do not necessarily reflect those of the Agency. EPA does not endorse any products or commercial services mentioned in this publication.

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MHV, SLI (Co-PI), and HB conducted the literature search and wrote the main manuscript text. MHV made substantial contributions in drafting and revising the manuscript, submitted the manuscript to the journal, and is corresponding author. SLI made substantial contributions in the organization of the manuscript and was heavily involved in revising the manuscript. HB prepared Figure 1 and revised the manuscript. MHV and HB prepared Table 1. MHV, HB, SLI, and LN prepared Table 2. SH provided subject matter expertise and was heavily involved in revising the manuscript. LN (PI) oversaw these processes, provided subject matter expertise, and was heavily involved in revising the manuscript. All authors have reviewed and approved the final manuscript.

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Vien, M.H., Ivey, S.L., Boyden, H. et al. A scoping review of wildfire smoke risk communications: issues, gaps, and recommendations. BMC Public Health 24 , 312 (2024). https://doi.org/10.1186/s12889-024-17681-0

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  • Risk communication
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