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PURPOSE: The study was carried out to investigate the effect of motivational interviewing on peer bullying and cyberbullying among adolescents. DESIGN: A parallel-group randomized controlled trial. METHODS: The study population consisted of ninth-grade (aged 14 years) high school students (n = 200). The study was completed with 48 participants (intervention: 24; control: 24). The data were collected using the Participant Information Form, the Stages of Change Questionnaire, the Peer Bullying Scale, and the Cyberbullying Scale. The intervention group received a preparatory session and five weekly motivational interviewing sessions. Instruments were administered to both groups before the intervention, at the end of the last motivational interviewing session (post-test), and at 3rd- and 6th-month follow-ups. The data were analyzed using chi-square test, independent sample t-test, and two-way mixed-design ANOVA with Bonferroni's test. RESULTS: In the pre-test, no statistically significant difference was observed between the intervention and control groups regarding mean scores for peer bullying and cyberbullying (p > 0.05). Following the motivational interviewing sessions, adolescents in the intervention group had a significantly lower mean score for peer bullying and cyberbullying than the control group at the post-test and follow-up tests (p < 0.001). CONCLUSION: The present study concluded that motivational interviewing effectively reduced peer bullying and cyberbullying behaviors among adolescents. CLINICAL RELEVANCE: Nurses would implement motivational interviewing to prevent bullying behaviors in schools.
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Acoso Escolar , Ciberacoso , Entrevista Motivacional , Grupo Paritario , Humanos , Adolescente , Masculino , Femenino , Entrevista Motivacional/métodos , Acoso Escolar/prevención & control , Acoso Escolar/psicología , Ciberacoso/psicología , Ciberacoso/estadística & datos numéricos , Conducta del Adolescente/psicología , Encuestas y CuestionariosRESUMEN
BACKGROUND: Mental problems that may lead to many adverse health outcomes are increasing among adolescents. Interventions are needed to prevent mental problems in adolescents. PURPOSE: The present study aimed to assess the effect of progressive muscle relaxation in reducing stress, anxiety, and depression levels in adolescents. DESIGN AND METHODS: A quasi-experimental design was performed. The study population consisted of 12th-grade students studying in two high schools in Turkiye. Adolescents were allocated to intervention and control groups in a ratio of 1:2, considering their preferences. A total of 88 students (intervention = 31; control = 57) completed the study. Depression, Anxiety and Stress Scale (DASS-42) were used to collect the data. Online progressive muscle relaxation was implemented in the intervention group over eight weeks. RESULTS: There was a statistically significant difference between the intervention and control groups regarding stress, anxiety, and depression pre-test mean scores. The correction of DASS-42 pre-test mean scores was performed by covariance analysis. There was a statistically significant difference in the post-test stress, anxiety, and depression mean scores of the adolescents in the intervention group according to the corrected DASS-42 pre-test mean scores. CONCLUSION: The study concluded that progressive muscle relaxation reduced stress, anxiety, and depression in adolescents. PRACTICE IMPLICATIONS: School nurses could implement progressive muscle relaxation to support adolescents in managing stress, anxiety, and depression.
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PURPOSE: This study was conducted to determine adolescents' nomophobia behaviors, eHealth literacy levels, and their predictive factors. DESIGN AND METHODS: A cross-sectional design was used. The population consisted of ninth, 10th, and 11th-grade adolescents (aged 14-17) in a high school in Turkiye (N = 1013). The study was completed with 719 voluntary adolescents. A questionnaire, the eHealth Literacy Scale, and the Nomophobia Questionnaire were used to collect data. Multiple linear regression was run for data analysis. RESULTS: Of the adolescents, 44.9% were found to have moderate, and 14.8% had severe nomophobia behaviors. Adolescents who were girls, the ninth and 10th graders, who used smartphone two hours or more daily, social media users, who watched videos on the smartphone and surfed on the Internet had higher nomophobia behaviors. Adolescents who were boys, who searched for health information online, found health information on the Internet helpful, and found accessing health resources on the Internet important had higher eHealth literacy levels. CONCLUSION: Adolescents should be educated about rational smartphone and Internet usage to comprehend the accuracy of health-related information. PRACTICE IMPLICATIONS: School nurses could design activities to increase eHealth literacy to encourage adolescents. Nurses could help proactively prepare nomophobia severity map and an eHealth literacy enhancement curriculum for adolescents to form functional preventive interventions. Nurse leaders can contribute to developing policies and strategies to prevent nomophobia behaviors among adolescents.
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Alfabetización en Salud , Telemedicina , Masculino , Femenino , Humanos , Adolescente , Estudios Transversales , Encuestas y Cuestionarios , Escolaridad , InternetRESUMEN
AIM: The research was conducted to measure the effect of health literacy-grounded web-based education program on health literacy, nutrition and exercise behaviours in adolescents. BACKGROUND: The increasing prevalence of obesity in adolescents is explained by a sedentary lifestyle and unhealthy diet. Health literacy is essential for adolescents to maintain their healthy behaviours. METHODS: The research was conducted as a parallel group randomized controlled trial. The study was completed by 114 adolescents (experimental = 42, control = 72). The Personal Information Form, the Health Literacy Scale for School-Age Children and the Nutrition and Exercise Subscales were used to collect data. A web-based education program was implemented. Two-way mixed design ANOVA with Bonferroni test was used to examine the group, time and group * time interaction of the measurements. RESULTS: There was no statistically significant difference between the experimental and control groups regarding health literacy level, nutrition and exercise behaviours pre-test mean scores (p > 0.05). In the post-test, the mean scores of health literacy and nutrition behaviours in the experimental group were higher than the control group (p < 0.001). However, there was no significant difference in exercise behaviours (p > 0.05). The power and effect size in mean scores changes for health literacy (99.8%, η2 = 0.039) and nutrition (99.8%, η2 = 0.039) were moderate. CONCLUSION: The study concluded that health literacy-grounded web-based education program increased the health literacy levels of adolescents and improved their nutritional behaviours; however, there was no sufficient change in exercise behaviours.
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OBJECTIVE: This study was designed to measure health promotion behaviors, health literacy (HL) levels, and their predisposing factors among adolescents. DESIGN: A cross-sectional design was used. SAMPLE: The study was completed by 1046 students aged 11-14 years. MEASUREMENTS: Data were collected via the HL for School-Aged Children Scale and the Adolescent Health Promotion Scale. RESULTS: HL was significantly associated with gender, participation in sport activities, and health promotion behaviors. There was no confounding factor for HL. Adolescent health promotion behaviors were significantly associated with academic level, weight perception, participation in sport activities, and HL. CONCLUSIONS: Nurses could improve communication and decision-making skills related to health behaviors and learn how to obtain health-related knowledge to promote the health of adolescents.
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Alfabetización en Salud , Niño , Humanos , Adolescente , Estudios Transversales , Conductas Relacionadas con la Salud , Promoción de la Salud , CausalidadRESUMEN
OBJECTIVE: This study was performed to investigate fatalism tendency and health beliefs about medication use and to identify predisposing factors of these variables among older adults. METHODS: A predictive correlational design was used. The study was completed with 500 older adults. A personal information form, the Fatalism Tendency Scale, and the Drug Use Health Beliefs Scale were used to collect data. Univariate and multiple linear regression analysis was performed for data analysis. RESULTS: Fatalism tendency was found to be high in older adults who used medications prescribed by the physician in different ways, used the medications more than the recommended amount, and used medications at random intervals. Older adults who used over-the-counter medications and discontinued the medications before the due date had lower health beliefs about conscious and prescription medication use. CONCLUSIONS: The study concluded that characteristics regarding medication use predicted both fatalism tendencies and medication use health beliefs. Health perception was found to be one of the predisposing factors of medication use health beliefs, whereas education level was another predictive factor of fatalism tendency.
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Conocimientos, Actitudes y Práctica en Salud , Médicos , Humanos , Anciano , EscolaridadRESUMEN
BACKGROUND: The novel coronavirus disease 2019 has caused psychological distress such as anxiety and fear among nurses worldwide. Nurses are a creditable source of vaccine-related information and have a primary role in building confidence regarding vaccines. AIM: The present study was designed to investigate the fear and anxiety of nurses regarding novel coronavirus disease 2019 (COVID-19) and their attitudes towards the COVID-19 vaccine. The predictors of fear, anxiety and attitudes towards the vaccine were also investigated. METHODS: A descriptive and correlational design was used. The study was conducted in three public hospitals from different parts of the Turkey, and 405 nurses from the three hospitals were recruited by stratified sampling. RESULTS: Anxiety and negative attitudes towards the vaccine were positively related to fear of COVID-19. Age and fear were also positively associated with anxiety related to COVID-19. Nurses who had received the vaccine and those who were fearful had a positive attitude towards the vaccine. CONCLUSION: Psychosocial support programmes should be implemented to improve psychological resilience and coping strategies in nurses and organized education programmes are needed to increase positive attitudes towards vaccination.
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OBJECTIVE: This study aimed to determine the effect of a home visit program on the perceived care burden of family caregivers of adults with asthma. DESIGN: A single-blind randomized controlled trial. SAMPLE: The study was conducted with 30 participants in both the intervention and control groups. MEASUREMENTS: Care burden was measured via the Zarit Caregiver Burden Scale during the first interview at the pulmonology outpatient clinic and after the last home visit. INTERVENTION: A nurse-led home visit program with five visits over three months included education and health counseling with the intervention group. Control group received standard education given in the outpatient clinic. RESULTS: The mean Zarit Caregiver Burden Scale scores of the intervention group in the post-test were significantly lower than the control group. CONCLUSIONS: The current study revealed that the nurse-led home visit program, including education and health counseling, was effective in reducing the care burden for family caregivers of adults with asthma. Nurses can play an active role in preventing the negative effects of caregivers' burden of care, protecting their sense of control, and improving their health. Home visits integrated into the health care system could be effective in reducing the care burden of family members.
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Asma , Cuidadores , Humanos , Adulto , Cuidadores/psicología , Carga del Cuidador , Visita Domiciliaria , Método Simple Ciego , Rol de la Enfermera , Asma/terapia , Calidad de VidaRESUMEN
AIMS & OBJECTIVES: This study was conducted with family members of patients' in the intensive care unit (ICU) to identify their anxiety level, social support and satisfaction with the ICU. BACKGROUND: Admission of critical patients to the ICU usually involves the participation of family members. DESIGN: A descriptive-correlational design was used and reported according to the STROBE checklist. METHODS: The sample consisted of 250 family members in ICUs in a city of Turkey. Data were collected by the Multidimensional Perceived Social Support Scale, the State-Trait Anxiety Inventory and the Family Satisfaction in the Intensive Care Unit scale. RESULTS: A negative correlation was found between family satisfaction of the ICU and state anxiety (r = -0.349, p < 0.001), and a negative relationship between the satisfaction of the ICU and trait anxiety of the participants (r = -0.151, p < 0.05). There was a significant relationship between the state anxiety level (Adjusted R² = 0.080, F = 8.247, p < 0.001), trait anxiety level (Adjusted R² = 0.185, F = 19.821, p < 0.001), the perceived social support (Adjusted R² = 0.094, F = 9.640, p < 0.001) and satisfaction (Adjusted R² = 0.013, F = 4.161, p < 0.001) of family members and their sociodemographic characteristics. CONCLUSIONS: The study concluded that anxiety levels of relatives of the families were high, their social support and satisfaction with the intensive care unit were at a moderate level. There was a correlation between anxiety levels, satisfaction with the intensive care unit, and the perceived social support of families. RELEVANCE TO CLINICAL PRACTICE: Holistic care for the psychosocial needs of families who have a member in the ICU should be planned to increase satisfaction. Nurses should observe families closely for anxiety, allow them to ask questions and include them in the care of their family member.
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Satisfacción Personal , Relaciones Profesional-Familia , Ansiedad/epidemiología , Ansiedad/psicología , Familia/psicología , Humanos , Unidades de Cuidados Intensivos , Satisfacción del Paciente , Apoyo SocialRESUMEN
AIM: This study was conducted to determine media use, positive and negative emotions, and stress levels of adults during the COVID-19 pandemic. BACKGROUND: Using media tools in the pandemic process has impacted the mental health of individuals. As the COVID-19 outbreak is a new disease fear, anxiety and stress about this situation can cause strong emotions in adults. METHODS: The research was carried out using a cross-sectional design. The sample consisted of 1541 adults. The Positive and Negative Emotion Scale, and the Perceived Stress Scale were used to collect the data. RESULTS: The Positive Emotion Scale mean scores were lower (p < 0.05) for those people whose daily media use time was more than 4 h and who followed the developments about COVID-19 through the media once a day. It was found that those with daily media use of more than 4 h/day had higher Perceived Stress Scale scores than those with lower use (p > 0.05). CONCLUSION: This study concluded that the use of media in adults increased during the COVID-19 outbreak and that media use was associated with positive and negative emotions and stress levels. Health professionals should assess the effect of the COVID-19 outbreak on mental health in various community groups and develop interventions to prevent negative consequences of increased media use.
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COVID-19 , Adulto , Ansiedad/epidemiología , COVID-19/epidemiología , Estudios Transversales , Emociones , Humanos , Pandemias , Turquía/epidemiologíaRESUMEN
AIM: The aim of this study was to determine the effect of health education on prevention of low back pain for health caregivers and cleaning workers. BACKGROUND: Low back pain is a common health problem in the workplace. Health education is important in the prevention and recurrence of low back pain. METHODS: A quasi-experimental design with a pre-test and post-test control group was used. The population of the study consisted of health caregivers and cleaning workers working in a university hospital in Turkey. A total of 120 participants, 60 in the intervention group and 60 in the control group, were included in the study. Data were collected between October 2016 and April 2017. A questionnaire, the Oswestry Low Back Pain Scale and the Knowledge Evaluation Form were used to collect data. Health education was given to the intervention group. RESULTS: Following the health education, the mean scores of the Oswestry Low Back Pain Scale in the intervention group were significantly lower than the control group and had a larger effect size. CONCLUSION: This study provides evidence for the effectiveness of health education in the prevention of low back pain in health caregivers and cleaning workers.
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Dolor de la Región Lumbar , Cuidadores , Educación en Salud , Humanos , Dolor de la Región Lumbar/prevención & control , Encuestas y Cuestionarios , Lugar de TrabajoRESUMEN
OBJECTIVE: The study aimed to determine the effect of breastfeeding support through social media on women's breastfeeding self-efficacy. METHODS: A randomised controlled trial was conducted in the maternity unit of Aksaray University Education and Research Hospital, Turkey. Education and counselling on breastfeeding were given via WhatsApp to women in the intervention group. Women in the control group received routine breastfeeding teaching before discharge from hospital. The Breastfeeding Self-Efficacy Scale-Short Form (BSES-SF) was administered to both groups immediately after birth and at 3 and 6 months postpartum. The study was completed by 31 women in the intervention group and 37 women in the control group. RESULTS: At 3 and 6 months there was a statistically significant difference in BSES-SF mean scores between the intervention and control groups (p < 0.05). BSES-SF scores in the intervention group were higher at 3 and 6 months compared with baseline, while BSES-SF scores in the control group were lower at 6 months compared with baseline. CONCLUSION: Women's breastfeeding self-efficacy was improved through a social media-based teaching and counselling intervention. Health care professionals should make use of social media tools to improve women's breastfeeding self-efficacy and encourage continuity of breastfeeding.
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Lactancia Materna , Medios de Comunicación Sociales , Femenino , Humanos , Embarazo , Psicometría , Reproducibilidad de los Resultados , Encuestas y CuestionariosRESUMEN
OBJECTIVE: Traditional children's games can protect the physical, emotional, and mental health of children. This study was conducted to determine the effect of traditional children's games on internet addiction, social skills, and stress level. METHODS: A pre-test/post-test quasi-experimental design with a control group was used. The population of the study consisted of a fifth- and sixth-grade students studying at two secondary schools in a city of Turkey. A total of 42 students - 20 in the intervention group and 22 in the control group - were included in the study. The Family-Child Internet Addiction Scale, the Social Skills Assessment Scale, the Social Skills Scale, and the Perceived Stress Scale in Children (8-11 years) were used to collect the data. The intervention group received eight weeks of traditional children's games. RESULTS: There was no significant difference between the intervention and control groups in terms of internet use, social skills, and stress level in the pre-test (p > 0.05). There was a statistically significant difference between groups in terms of daily and weekly internet use in the post-test (p < 0.05). The mean scores regarding social skills of the intervention group increased after the games compared with the control group (p < 0.05). There was no statistically significant difference between the groups in terms of stress-level mean scores (p > 0.05). CONCLUSIONS: The results showed that traditional children's games may be effective in reducing internet use and increasing social skills, however they do not affect stress level. Childhood is important for physical, cognitive, and psychosocial development. Therefore, in the school settings, traditional children's games can be used for the protection and promotion of children's health.
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Trastorno de Adicción a Internet , Habilidades Sociales , Niño , Familia , Humanos , Internet , Instituciones Académicas , Estudiantes/psicologíaRESUMEN
This study aimed to examine the fear of coronavirus and the health literacy levels of older adults during the pandemic. The sample consisted of 304 older adults from five family health centers in Turkey between April and May 2021. The data were collected using the Fear of COVID-19 Scale and the Health Literacy Scale. The fear of COVID-19 was found to be higher in women, those with chronic diseases, and those who found the epidemic measures insufficient (p < 0.05). The health literacy level was found to be higher in those with high education level, those in the 65-74 age group, and those with not using regular medicine (p < 0.001). The health literacy of older adults was a slightly above moderate level and the fear of COVID-19 was at a moderate level. Health literacy levels of older adults may be increased with written, visual, and verbal health trainings.
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COVID-19 , Alfabetización en Salud , Anciano , Miedo , Femenino , Humanos , Pandemias , SARS-CoV-2RESUMEN
BACKGROUND: Professional values in nursing are the foundation of ethical practice affecting patient care quality. AIM: The purpose of the present study was to evaluate the development of professional values and ethical sensitivities among new nurses during the COVID-19 pandemic. METHODS: A prospective observational study with a pre-test and post-test design was used. The sample constituted students (n = 302). The Nurses Professional Values Scale-Revised and Modified Moral Sensitivity Questionnaire for Student Nurses were used for collecting data. RESULTS: Professional values post-test mean scores of participants were significantly higher than the pre-test scores (p < 0.001). No significant difference was determined between the pre-test and post-test mean scores of ethical sensitivity (p > 0.05). CONCLUSION: The current study concluded that the professional values of newly graduated nurses developed during the COVID-19 pandemic, but there was no change in ethical sensitivities. IMPLICATIONS FOR NURSING AND HEALTH POLICY: This study provides one of the first pieces of evidence for nursing educators and managers to assess the professional values and ethical sensitivities of newly qualified nurses who may have been affected both during and after the outbreak. Newly qualified nurses should are valued members of the health care institutions, and orientation programmes should be implemented to improve their perceptions of the profession.
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COVID-19 , Enfermeras y Enfermeros , Estudiantes de Enfermería , Humanos , COVID-19/epidemiología , Pandemias , Docentes de Enfermería , Principios Morales , Encuestas y CuestionariosRESUMEN
BACKGROUND: The attitude towards the nursing is reflected in a person's behaviour within the nursing profession. Peers can help develop and refine emotional support skills through interpersonal relationships, thus also promoting mutual caring skills. The present study aimed to evaluate the impact of an internship on nursing students' attitudes towards nursing profession and peer caring behaviours. METHODS: This prospective observational study was conducted in nursing departments at two universities in Turkey. Totally, 293 nursing students (156 from the first university and 137 from the second university) were included in the study. The questionnaire, the Attitude Towards Nursing Profession Scale, and the Peer Caring Behaviour Scale were used to collect the data. In the first university nursing education, internship is implemented. Peer caring behaviours and their attitude towards nursing were evaluated before and after the internship. RESULTS: After the internship, the mean scores obtained from the Peer Caring Behaviour Scale and physical and emotional assistance sub-dimensions in the first school students increased significantly compared with the second school (P < .05), but no significant difference was found in terms of attitude towards the nursing profession (P > .05). CONCLUSION: This study emphasizes that nursing internship positively affects peer caring behaviours. An internship can be added to the nursing education curriculum.
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Internado y Residencia , Estudiantes de Enfermería , Actitud del Personal de Salud , Humanos , Encuestas y Cuestionarios , TurquíaRESUMEN
A negative birth experience affects the woman's subsequent pregnancy, and delivery processes negatively, decreases patient satisfaction, and the high anxiety/stress experienced during pregnancy/delivery is transferred to the next generations by epigenetic transmission. In this study, women's birth experiences of Syrian refugees in Turkey aimed to describe in-depth. It was designed as a descriptive phenomenological qualitative study. Fifteen refugee women included in the sample gave birth in Turkey, living in Turkey's southern city. In-depth interviews were conducted with women. Six themes were formed in the results: "quantitatively enough but unsatisfactory service," "not providing autonomy," "think that she was neglected," "no respect to privacy," "feeling loneliness/fear in the delivery room," and "prejudice." The factors that negatively affect the pregnancy and birth experiences of Syrian refugee women are language/communication barriers, the provision of care services that are incompatible with their religious and cultural values, and their prejudice regarding discrimination.
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Refugiados , Femenino , Humanos , Parto , Embarazo , Investigación Cualitativa , Siria , TurquíaRESUMEN
AIM: The aim of this study was to determine the effect of health literacy education given to nursing students on health literacy level. BACKGROUND: Health literacy has become an important issue in the field of health. Health literacy is an issue of interest to health professionals as well as individuals. METHODS: The study was conducted as a randomized controlled trial. A total of 206 nursing students, 103 in the intervention and 103 in the control group, were included in the study. The intervention group received four weekly training sessions of health literacy education. The research was registered at ClinicalTrials.gov with the registration number NCT04868487. RESULTS: On the baseline assessment, there were no statistically significant differences between the intervention and control group in terms of health literacy level (p > 0.05). In the 1st- week and 12th-week measurements, the health literacy level of the intervention group was significantly higher than control group (p < 0.05). CONCLUSION: Health literacy education was effective in increasing the health literacy level of the students. Therefore, the concept of health literacy should be added to the nursing education curriculum.
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Educación en Enfermería , Alfabetización en Salud , Estudiantes de Enfermería , Curriculum , Escolaridad , HumanosRESUMEN
PURPOSE: This research was conducted to investigate the prevalence of internet addiction and psychosocial problems and associated factors among adolescents during the COVID-19 pandemic. DESIGN AND METHODS: A cross-sectional study was conducted in Turkey. The population was composed of 9th and 10th grade students. The sample consisted of 1572 participants. Data were collected from parents of the students through a questionnaire, the Pediatric Symptom Checklist, and the Parent-Child Internet Addiction Test. RESULTS: The prevalence of psychosocial problems was 20.7%. A few (4.8%) of adolescents had limited internet addiction symptoms. The psychosocial problems risk was significantly higher in adolescents whose fathers did not work, whose family income was less than expense, and whose daily internet use time was more than 3 h and more (p < 0.05). The risk of problematic internet use was significantly higher in males, whose mother's education level was high school and lower, whose family income was less than expense, and whose duration of internet use was 5 years and more (p < 0.05). There was a positive correlation between internet addiction and psychosocial problem mean scores (p < 0.05). CONCLUSION: Most of the adolescents were internet users and one in five adolescents was at risk of psychosocial problems. Internet addiction and psychosocial problems were associated with several sociodemographic factors. PRACTICE IMPLICATIONS: This study emphasizes the need for the prevention of excessive internet use and psychosocial problems during COVID-19 pandemic among adolescents. Nurses should organize online trainings for internet addiction and psychosocial problems for adolescents and their parents during the quarantine process.
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Conducta Adictiva , COVID-19 , Adolescente , Conducta Adictiva/epidemiología , Niño , Estudios Transversales , Humanos , Internet , Trastorno de Adicción a Internet , Masculino , Pandemias , SARS-CoV-2 , Factores Sociodemográficos , Encuestas y CuestionariosRESUMEN
PURPOSE: This study was conducted to determine the health literacy and health promotion behaviors of adolescents. DESIGN AND METHODS: This study used cross sectional and correlational design. The population of the study consisted of 6th, 7th, and 8th grade students from three different secondary schools selected from high, middle, and low income levels. The sample consisted of 2498 students. RESULTS: The mean score of the health literacy scale of the students was 30.26. The mean score of the adolescent health promotion scale was 143.75. The mean scores of health literacy and adolescent health promotion scores of the students in high income level, sixth grade, and have parents with a baccalaureate or graduate degree were significantly higher (p < 0.005). A moderate positive correlation was found between the school age health literacy scale and the adolescent health promotion scale (p < 0.001). CONCLUSIONS: Adolescents' health literacy, and their health promotion behaviors were at moderate level. By integrating a basic health knowledge and healthy lifestyle behaviors course into the student curriculum, health literacy of the students could be increased. PRACTICE IMPLICATIONS: The determination of health literacy and health promotion behaviors in adolescents by nurses in the schools will be a guide for the promotion of enhanced adolescent health.