With this issue of the Journal of Adolescent Health, we bring you a landmark supplement highlighting the progress that has been made to improve the health and well-being of adolescents in China, where there are some unique opportunities to focus on young people in novel ways [[1]Liu L. Improving adolescent survival, health & well-being in China.J Adolesc Health. 2020; 67: S1-S2Scopus (1) Google Scholar]. Six original articles in this supplement review the historical mortality of young people in China [[2]Dong Y. Hu P. Song Y. et al.National and subnational trends in mortality and causes of death in Chinese children and adolescents aged 5–19 years from 1953 to 2016.J Adolesc Health. 2020; 67: S3-S13Abstract Full Text Full Text PDF Scopus (7) Google Scholar]; highlight the current status of adolescent health, including those young people who are most marginalized [3Luo X. et al.Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.J Adolesc Health. 2020; 67: S32-S37Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 4Zhang et al.Financing adolescent health in China: how much, who pays, and where it goes.J Adolesc Health. 2020; 67: S38-S47Abstract Full Text Full Text PDF Scopus (3) Google Scholar, 5Zhou Y. et al.Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.J Adolesc Health. 2020; 67: S48-S54Abstract Full Text Full Text PDF Scopus (9) Google Scholar]; and point to the future, as systems are being developed now that will monitor health status and improve healthcare delivery systems [[6]Dong B. et al.Adolescent health and healthy China 2030: a review.J Adolesc Health. 2020; 67: S24-S31Abstract Full Text Full Text PDF Scopus (19) Google Scholar,[7]Xu R. et al.Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.J Adolesc Health. 2020; 67: S14-S23Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. In 2016, the Chinese government set out to develop the Healthy China 2030 Planning Outline, a strategic plan for the entire Chinese health sector that incorporated the UN 2030 Agenda for Sustainable Development Goals. In 2018, Beijing reaffirmed its commitment to working toward achieving these goals for the entire population. Embedded in these goals was a specific focus on improving the health and well-being of young people. Some of the areas that were included in the goals for young people include nutrition, substance abuse, road traffic injuries, and other noncommunicable diseases (NCD) [[7]Xu R. et al.Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.J Adolesc Health. 2020; 67: S14-S23Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. The supplement’s lead editorial by Dr. Li Liu highlights many of the changes that have been made to improve the survival, health, and well-being of adolescents [[1]Liu L. Improving adolescent survival, health & well-being in China.J Adolesc Health. 2020; 67: S1-S2Scopus (1) Google Scholar]. She challenges China to use this opportunity to develop a broader system of measures that may be better able to identify the progress that has been made and provide opportunities for the government to make greater strides in improving the health of adolescents. In reviewing the past, Dong et al. [[2]Dong Y. Hu P. Song Y. et al.National and subnational trends in mortality and causes of death in Chinese children and adolescents aged 5–19 years from 1953 to 2016.J Adolesc Health. 2020; 67: S3-S13Abstract Full Text Full Text PDF Scopus (7) Google Scholar] document the trends in mortality from 1953 to 2016. This period has seen monumental decrements in mortality for children and adolescents (5–19 years), from 366/100,000 to 27.2/100,000—a 90% reduction in mortality—with the largest reduction among adolescents 15–19 years. Even with these remarkable declines in mortality, however, the authors acknowledge the need to refocus on road traffic injury, drowning, self-harm, and NCD, including cancer identification and treatment. In reviewing the present state of adolescent health in China, 3 articles outline different parameters for the growing focus on the second decade: the current delivery system [[3]Luo X. et al.Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.J Adolesc Health. 2020; 67: S32-S37Abstract Full Text Full Text PDF Scopus (3) Google Scholar], the financing system [[4]Zhang et al.Financing adolescent health in China: how much, who pays, and where it goes.J Adolesc Health. 2020; 67: S38-S47Abstract Full Text Full Text PDF Scopus (3) Google Scholar], and the plight of children left behind by migrant worker parents [[5]Zhou Y. et al.Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.J Adolesc Health. 2020; 67: S48-S54Abstract Full Text Full Text PDF Scopus (9) Google Scholar]. Luo et al. [[3]Luo X. et al.Barriers to adolescent health care in maternal and children’s healthcare hospitals: based on a national survey in China.J Adolesc Health. 2020; 67: S32-S37Abstract Full Text Full Text PDF Scopus (3) Google Scholar] review the distribution of the adolescent–healthcare system, which is primarily embedded within the Maternal and Children’s Healthcare Hospitals (MCH), with a minority of these having identified adolescent clinics. In interviews with providers and healthcare administrators, there were major differences in the perspectives of the providers and the administrators of the MCH systems. Clinicians focused on the demands of providing high-quality care to young people and administrators on costs of operation for adolescent clinics in the MCH system. The most valuable component of this exploratory work was the development of strategic priorities to guide the development of the adolescent–healthcare system in China, with strong linkages among health, education, and community systems to develop comprehensive approaches beyond sexual and reproductive health. A key component of these recommendations is an emphasis on workforce development. Zhang et al. [[4]Zhang et al.Financing adolescent health in China: how much, who pays, and where it goes.J Adolesc Health. 2020; 67: S38-S47Abstract Full Text Full Text PDF Scopus (3) Google Scholar] conducted a critical analysis of the health financing system by focusing on 3 questions: How much does adolescent healthcare cost? Who pays for the services? and Where does the money go? In 2014, adolescent health expenditures accounted for 2.6% of healthcare expenditures in China, with over 70% focusing on curative care and 10% on preventive care. Out-of-pocket spending was a major source of funding for adolescent health, accounting for more than half of total spending. These data offer some opportunities for reframing how we develop adolescent–healthcare systems and for what and where we allocate resources. The distribution and burden of these costs weigh heavily on young people and their families’ ability to pay for the needed services. Zhang et al. emphasize the critical importance of looking at the total costs for healthcare, with an emphasis on investing in sexual and reproductive health and prevention of NCD, in an effort to reduce the costs of curative care. The third paper on the current state of adolescent health in China focuses on the persistent impact of disparities among left-behind children, who have been left to fend for themselves as their parents pursue work [[5]Zhou Y. et al.Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.J Adolesc Health. 2020; 67: S48-S54Abstract Full Text Full Text PDF Scopus (9) Google Scholar]. Zhou et al. [[5]Zhou Y. et al.Emotional and behavioral problems of left-behind children in impoverished rural China: a comparative cross-sectional study of 4th grade children.J Adolesc Health. 2020; 67: S48-S54Abstract Full Text Full Text PDF Scopus (9) Google Scholar] report on a cross-sectional study of children who are under 16 years old and who no longer have parents in their lives. They compared them with children who had at least one parent at home, finding that the left-behind children group had higher prevalence of insomnia, loneliness, sadness, self-harm behavior, and academic stress. The supplement’s final 2 papers build on the previous 4 and pave the way for future of improvements in adolescent healthcare in China [[6]Dong B. et al.Adolescent health and healthy China 2030: a review.J Adolesc Health. 2020; 67: S24-S31Abstract Full Text Full Text PDF Scopus (19) Google Scholar,[7]Xu R. et al.Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.J Adolesc Health. 2020; 67: S14-S23Abstract Full Text Full Text PDF Scopus (3) Google Scholar]. Dong et al. [[6]Dong B. et al.Adolescent health and healthy China 2030: a review.J Adolesc Health. 2020; 67: S24-S31Abstract Full Text Full Text PDF Scopus (19) Google Scholar] explore the differences between the current health status of adolescents and the targets that have been set by the China 2030 initiative. Two data sources—the Global Burden of Disease Study (1990–2016) and the Chinese National Survey on Students’ Constitution and Health (1985–2014)—were used to analyze time trends of health indicators for adolescents (10–19 years) in China. In looking toward 2030, Dong et al. highlight the fact that even though mortality among adolescents has been halved over the past 25 years, new emergent problems such as road injuries, drowning, obesity, decrements in physical fitness, and self-harm must be part of the strategy for 2030. Taking on these new problems while maintaining a focus on traditional problems such as poor vision, stunting, and sexual/reproductive health will require targeted prevention and intervention programs that recognize the unique needs of those in their second decade of life. The final paper in this supplement, by Xu et al. [[7]Xu R. et al.Towards a comprehensive national surveillance for adolescent health in China: priority indicators and current data gaps.J Adolesc Health. 2020; 67: S14-S23Abstract Full Text Full Text PDF Scopus (3) Google Scholar], underlines the need for a system of adolescent health indicators. This critically important paper supports the old adage, “What gets measured gets done.” Close monitoring of Xu et al.’s proposed indicators will enable continuous opportunities for shifting efforts to meet the defined goals of China 2030. This paper raises the bar for developing an indicator system by using the Global Burden of Diseases 2015, policy documents from the State Council of China, and published literature reviews to identify 100 indicators (72 of them are available in national data systems). These were then categorized around 5 dimensions: health outcomes, health knowledge, skills and risk behaviors, demographics, responsiveness of health systems, and the physical and social environments. This comprehensive review with clearly identified indicators and data systems in place bodes well for opportunities to improve the health and well-being of adolescents in China.

In this issue of the Journal of Adolescent Health, we are fortunate to publish the first three review articles originating from the Adolescent and Young Adult Health Research Network, a collaborative transdisciplinary research network recently established by the Maternal and Child Health Bureau (MCHB). Dating back to the early 1960s, the MCHB has a long history of advancing the field of adolescent health and medicine with support for training programs for physicians. By 1977, these efforts had led to the interdisciplinary training program now known as Leadership in Adolescent Health Training. Originally focused on training health professionals to provide better clinical care to adolescents in academic and community-based settings, the Leadership in Adolescent Health Training Program has recently expanded to include program evaluation and research training. In 1987, the MCHB built upon its initial investment in training by supporting the Healthy Futures I state-of-the-art conference; Healthy Futures II followed in 2002. Proceedings of these meetings were published in New Directions for Child Development [[1]Irwin Jr., C.E. Adolescent Social Behavior and Health. New Directions for Child Development, No 37. Jossey-Base, San Francisco1987Google Scholar] and Journal of Adolescent Health [2Journal of Adolescent HealthHealth futures of youth.J Adolesc Health. 1988; 9: 1S-69SGoogle Scholar, 3Irwin Jr., C.E. Duncan P.M. Health futures of youth II: Pathways to adolescent Health: Executive summary and overview.J Adolesc. 2002; 31: 82-89Scopus (6) Google Scholar]. The Healthy Futures conferences identified priorities for improving clinical services, training health professionals, and informing state and federal policies, as well as opportunities for interdisciplinary research based on biopsychosocial development, including positive youth development. In the early 1990s, based on recommendations from the Office of Technology Assessment's Report on Adolescent Health [[4]U.S. Congress, Office of Technology AssessmentAdolescent health Volume I: Summary and policy Options. (OTA-H-468). U.S. Government Printing Office, Washington, D.C.1991Google Scholar], the MCHB established a series of Adolescent Health Resource Centers. The primary purpose of these resource centers was to improve adolescent and young adult health by supporting analysis and technical assistance that would improve the integration of public health and clinical delivery systems; the first, the National Adolescent Health Information Center (NAHIC), was started in 1994. NAHIC began with an exclusive focus on adolescent health, later growing to include the health of young adults. One of NAHIC's early reports documented the necessity of collaborative research networks to advance meaningful outcomes of clinical interventions [[5]Millstein S.G. Ozer E.J. Ozer E.M. et al.Research priorities in adolescent Health: Analysis and Synthesis of research recommendations. University of California, San Francisco, National Adolescent Health Information Center, San Francisco, CA1999Google Scholar]. Since then, the MCHB has supported two national studies from the Institute of Medicine (now known as the National Academy of Medicine) that led to two landmark reports: Adolescent Health Services: Missing Opportunities [[6]Institute of Medicine and National Research CouncilAdolescent health Services: Missing opportunities. National Academies Press, Washington, D.C.2008Google Scholar] and Investing in the Health, Well-being and safety of Young Adults [[7]Institute of Medicine and National Research CouncilInvesting in the health and well-being of young adults. National Academies Press, Washington, D.C.2015Google Scholar]. Both identified key research needs in the field of adolescent and young adult health. In 2014, the MCHB took another major step forward in its commitment to advancing research by establishing the Adolescent and Young Adult Health Research Network (AYAH-RN). AYAH-RN is based at the University of California, San Francisco with Dr. Elizabeth Ozer as the principal investigator and has collaborators at the Center for the Developing Adolescent at the University of California, Berkeley; Boston Children's Hospital/Harvard University; Indiana University; Johns Hopkins University; University of Alabama; University of Minnesota; University of Washington; and the Society for Adolescent Health and Medicine. Its primary mission is to establish a research agenda for the field of adolescent and young adult health, with an emphasis on developing collaborative transdisciplinary research that utilizes developmental science to improve the lives of young people. In pursuit of that mission, AYAH-RN has contributed the three review articles appearing in this issue of the journal. The first, “Leveraging Neuroscience to Inform Adolescent Health: The Need for an Innovative Transdisciplinary Development Science of Adolescence,” outlines the role that developmental neuroscience might play in informing prevention and intervention efforts to improve adolescent health [[8]Suleiman A.B. Dahl R.E. Leveraging neuroscience to inform adolescent health: The need for an innovative transdisciplinary developmental science of adolescence.J Adolesc Health. 2017; 60: 240-248Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar]. The authors Suleiman and Dahl propose that the period of brain development beginning with puberty and extending through adolescence offers unique opportunities for learning and experiences. Comparing adolescent brain development to that of early infancy, when the brain anticipates and learns from visual stimuli, the authors describe the unique learning periods of early adolescence. Unlike brain development during infancy, which has been studied in great detail, the utility of the relationship between brain development and puberty has not been fully explored. Suleiman and Dahl identify two critical health issues of adolescence: pubertal changes in sleep/circadian regulation and social and affective changes at puberty relevant to anxiety and depression. The focused discussion of these two issues demonstrates how advancing integrative developmental science can help to identify leverage points and modifiable factors that can be targeted as key inflection points along the developmental trajectories of health problems.See Related Articles on pps. 240, 249 and 261 See Related Articles on pps. 240, 249 and 261 The second article, “Research on clinical preventive services for adolescents and young adults: where are we and where do we need to go?” provides a comprehensive review of our understanding of clinical preventive services for adolescents and young adults [[9]Harris S.K. Aalsma M.C. Weitzman E.R. et al.Research on clinical preventive services for adolescents and young adults: Where are we and where do we need to go?.J Adolesc Health. 2017; 60: 249-260Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar]. Harris and her coauthors identify system-, clinician-, and visit-level strategies to optimize the clinical encounter and the efficacy of preventive interventions. Parents, too, have a critical role to play, and technology offers unprecedented ways to expand the clinician's reach. The article explores not just the distinct issues associated with preventive services for adolescents but also of those for young adults, a group that is not often addressed in prevention science. An overview of the critical role that the Patient Protection and Affordable Care Act has played in providing coverage for evidence-based services for adolescents, young adults, and young women offers readers a useful perspective on policy. The article provides an important roadmap for future research on adolescent and young adult clinical preventive services, recommending research to optimize system-level clinical strategies, enhance parent engagement, expand the evidence base for preventive interventions, and continue to develop innovative uses for technology. The third and final review article in this issue, “Research in the Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic Review,” explores what our clinical delivery systems are doing to improve health outcomes for young people with behavioral health issues [[10]Richardson L.P. McCarty C.A. Radovic A. Suleiman A.B. Research in the integration of behavioral health for adolescents and young adults in primary care settings: A systematic review.J Adolesc Health. 2017; 60: 261-269Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar]. Richardson et al. conducted an elegant systematic review to identify the efficacy of three types of well-established delivery systems for adults: coordinated care, co-located care, and integrated care. Most of the randomized clinical trials were based on the coordinated care and integrated care systems. The paucity of research in this area is surprising given the prevalence of behavioral disorders among adolescents and young adults and the large number of studies of adult populations documenting evidence in support of integrated delivery systems. These three articles from the Adolescent and Young Adult Health Research Network provide us with new opportunities to improve our understanding of adolescence and young adulthood; optimize the utility of the clinical preventive visit; expand delivery systems that provide or coordinate a full range of physical and behavioral health care; and educate investigators and providers. The next step is for researchers to consider how the innovative research directions outlined in this issue of the journal might inform our efforts to improve adolescent and young adult health. Research in the Integration of Behavioral Health for Adolescents and Young Adults in Primary Care Settings: A Systematic ReviewJournal of Adolescent HealthVol. 60Issue 3PreviewDespite the recognition that behavioral and medical health conditions are frequently intertwined, the existing health care system divides management for these issues into separate settings. This separation results in increased barriers to receipt of care and contributes to problems of underdetection, inappropriate diagnosis, and lack of treatment engagement. Adolescents and young adults with mental health conditions have some of the lowest rates of treatment for their conditions of all age groups. Full-Text PDF Open AccessLeveraging Neuroscience to Inform Adolescent Health: The Need for an Innovative Transdisciplinary Developmental Science of AdolescenceJournal of Adolescent HealthVol. 60Issue 3PreviewIn this article, we consider how to leverage some of the rapid advances in developmental neuroscience in ways that can improve adolescent health. We provide a brief overview of several key areas of scientific progress relevant to these issues. We then focus on two examples of important health problems that increase sharply during adolescence: sleep problems and affective disorders. These examples illustrate how an integrative, developmental science approach provides new insights into treatment and intervention. Full-Text PDF Open AccessResearch on Clinical Preventive Services for Adolescents and Young Adults: Where Are We and Where Do We Need to Go?Journal of Adolescent HealthVol. 60Issue 3PreviewWe reviewed research regarding system- and visit-level strategies to enhance clinical preventive service delivery and quality for adolescents and young adults. Despite professional consensus on recommended services for adolescents, a strong evidence base for services for young adults, and improved financial access to services with the Affordable Care Act's provisions, receipt of preventive services remains suboptimal. Further research that builds off successful models of linking traditional and community clinics is needed to improve access to care for all youth. Full-Text PDF Open Access

We appreciate the concerns raised by Dr. Riley with regard to the use of inclusive language when referring to physicians and other health care professionals providing direct services to adolescents and young adults. The broad purview of our Journal is the health and well-being of adolescents and young adults. This mission necessarily involves professionals of many disciplines; not only clinicians and health care providers but also researchers, policy analysts, developmental specialists, nutritionists, and many others. Given the community we serve, the editors have a particular responsibility to promote inclusive language in our Journal. We encourage our authors to clearly describe the professionals that are discussed in their manuscripts. When appropriate, we encourage inclusive terms such as clinician, health care provider, and adolescent health professional. Using Inclusive Language in Articles Published in Journal of Adolescent HealthJournal of Adolescent HealthVol. 58Issue 5PreviewI am a family medicine physician and have been a member of Society for Adolescent Health and Medicine (SAHM) for many years. As someone who is very invested in the field of adolescent medicine, I am writing to give feedback on your journal. Several times over the past year I've noticed noninclusive language for family physicians in Journal of Adolescent Health editorials. Full-Text PDF

The Journal of Adolescent Health has expanded its Editorial Board to be more reflective of our global mission to improve the health and well-being of adolescents and young adults. As Patton and Michaud have pointed out in these pages, it is increasingly clear that we must refocus our efforts on young people throughout the world, especially those in low- and middle-income countries [1Patton G.C. Viner R.M. Linh L.C. et al.Mapping a global agenda for adolescent health.J Adolesc Health. 2010; 47: 427-432https://doi.org/10.1016/j.jadohealth.2010.08.019Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 2Michaud P.A. Berg T.D. Irwin C.E. The International Journal of Adolescent Health.J Adolesc Health. 2010; 47: 421-422https://doi.org/10.1016/j.jadohealth.2010.08.017Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar]. Given that >50% of the manuscripts submitted to our Journal come from outside of the United States, the editors have decided to expand our Editorial Board to include a broader range of disciplines, countries, and continents. Disciplines represented by our Board members now include Anthropology, Economics, Medicine, Biostatistics, Nursing, Nutrition, Pharmacy, Public Health, Public Policy, Social Welfare, Sociology, and Psychology. Whereas our Board once consisted only of Americans, Canadians, Europeans, and Australians, we now have representatives from Africa, Asia, South Asia, Central America, South America, and Oceania, as well. Our editorial board should not be viewed as “carved in stone.” It is a work in progress, and we shall continue to consider our Editorial Board in the same way that we consider the articles that we publish: as a reflection of the very best research and practices committed to improving the health and well-being of adolescents and young adults from all parts of the world. Our mission depends on the high-quality scientific research submitted by our authors, the insightful and professional reviews by our peer reviewers, and the commitment and leadership of our editors. We thank our readership and the Society for Adolescent Health and Medicine for their support of the Journal.

On July 1, 2009, the Journal will end its practice of double-blind peer review. Instead, authors' identities will be revealed to reviewers, although reviewers will remain anonymous. Then-editor Dr. Iris Litt instituted double-blind review at JAH nearly 20 years ago, and it has remained a proud tradition at the Journal since then. Double-blind review is a rarity among scientific journals, but JAH has persisted because of the perceived objectivity and fairness of the process. Indeed, in a recent survey of 3,000 reviewers and editors, 56% of respondents preferred double-blind review over other forms of peer review, and 71% viewed it as the most effective form of peer review [[1]Publishing Research Consortium Peer Review in Scholarly Journals (Mark Ware Consulting, Bristol, 2008). Available at: http://www.publishingresearch.net/PeerReview.htm. Accessed April 22, 2009.Google Scholar]. But the evidence does not support these perceptions. At the close of the last century, a flurry of research into the efficacy of double-blind review failed to show a clear advantage in the quality of the reviews [[2]Jefferson T. Alderson P. Wager E. Davidoff F. Effects of editorial peer review.JAMA. 2002; 287: 2784-2786Crossref PubMed Scopus (266) Google Scholar]. Even those studies showing a positive effect to blinding authors' and reviewers' identities were hampered by methodological issues that limited the interpretation of the results. Which brings us to our reasoning for ending double-blind review at JAH. Masking authors' identities is complicated and time-consuming. It requires that authors submit multiple documents to the editorial office, and that the editors carefully screen (and often correct) these documents for any inadvertent unmasking. Furthermore, reviewers frequently make assumptions and guesses about authors' identities, particularly in a relatively small field such as adolescent health. Ten years ago, JAMA published a study of masking success, showing that reviewers were able to correctly guess the identity of a masked author 40% of the time [[3]Cho M.K. Justice A.C. Winker M.A. et al.Masking author identity in peer review.JAMA. 1998; 280: 243-245Crossref PubMed Scopus (66) Google Scholar]. Of even greater concern are the incorrect guesses and mistaken assumptions. Finally, we believe that we can make better use of our reviewers' time and expertise by fully informing them of a manuscript's origin and backing. Reviewers who are aware of authors' identity will be better able to uncover instances of plagiarism, repeat publication, and conflict of interest. The editors did consider fully open review. Revealing reviewers' identities to authors holds the promise of greater accountability, and thus, objectivity. Our concern is that many reviewers would be unwilling to review if they were denied anonymity [[4]Van Rooyen S. Godlee F. Evans S. et al.Effect of open peer review on quality of reviews and on reviewers' recommendations: a randomised trial.BMJ. 1999; 318: 23-27Crossref PubMed Scopus (308) Google Scholar]. Currently, a little over half of our review invitations are declined, for various reasons. An increase in that rate of decline would have an unwelcome effect on the speed and efficiency of JAH's review process. As we evaluate and consider the effect of this latest change to our review process, we may revisit the possibility of open review in the future, as well as other review innovations, such as postpublication review. Ultimately, the Journal's editors are committed to publishing high-quality science that moves the field of adolescent health forward. We will implement the peer review process that best enables us to do just that. We welcome your comments and feedback. Blind Leading the Blind?Journal of Adolescent HealthVol. 45Issue 6PreviewTo the Editor: Full-Text PDF

To the Editor:I note with interest the announcement (and Editorial) in the July 2009 issue of Journal of Adolescent Health indicating that “Blind Review” is no longer the Journal's policy [[1]Berg T.D. Irwin Jr., C.E. Blind No More.J Adolesc Health. 2009; 45: 7Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. More correctly, “Double-Blind Review,” in contrast with the time-honored policy of most peer-reviewed journals is to protect the identity of the reviewer. What is at issue here, rather, is the practice which I implemented when I assumed the Editorship in l990 of “blinding” the reviewer to the identity and affiliation of the author.It may be useful to revisit my rationale for so doing. At that time, not only was Adolescent Health a young field, but even more importantly, so were the many researchers. When they submitted their work to the more established journals, many experienced the rejection letters as suggesting that it was their junior status, reputation of their mentors and/or that of their institutions were being reviewed, rather than their research itself. It was not only the junior investigators who were disadvantaged, however, as one experience of my own would demonstrate. One Editor's acceptance letter stated, “This paper is acceptable, but I expected better from Iris Litt.”At the time, only 5% of medical journals followed the process of “double-blind” review, despite research that demonstrated that the standard process of review clearly disadvantaged junior researchers, women, and those from less prestigious institutions. The argument that “everyone can tell who the author is” may be true in some limited sub-specialty fields or when authors intentionally insert clues about their identity (e.g., referencing their own work in excess, describing the setting, etc) but in a field like Adolescent Health, the research community is multi-disciplinary and broad, making such identification less likely. The point is, however, that those researchers who wish to be known have many ways of doing it. Moreover, should the identity be revealed, that rare researcher is no worse off than if he/she had submitted their paper to a more conventional journal that practices “single-blind” review—nothing lost, much potentially gained by leveling the playing field. Regardless of the validity of the claim that some authors are disadvantaged by such a process, clearly there is the perception that such a bias exists. A recent study demonstrated that “less experienced authors…were significantly more likely to prefer concealing author names, but even the most experienced respondents had a 54% preference for author concealment.”[[2]Regehr G. Bordage G. To blind or not to blind? What authors and reviewers prefer.Med Educ. 2006 Sep; 40: 830-831Crossref PubMed Scopus (50) Google Scholar]I would be reassured if there were data to show that the need for a “double-blind” peer-review process no longer exists—I doubt that is the case. To the Editor: I note with interest the announcement (and Editorial) in the July 2009 issue of Journal of Adolescent Health indicating that “Blind Review” is no longer the Journal's policy [[1]Berg T.D. Irwin Jr., C.E. Blind No More.J Adolesc Health. 2009; 45: 7Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar]. More correctly, “Double-Blind Review,” in contrast with the time-honored policy of most peer-reviewed journals is to protect the identity of the reviewer. What is at issue here, rather, is the practice which I implemented when I assumed the Editorship in l990 of “blinding” the reviewer to the identity and affiliation of the author. It may be useful to revisit my rationale for so doing. At that time, not only was Adolescent Health a young field, but even more importantly, so were the many researchers. When they submitted their work to the more established journals, many experienced the rejection letters as suggesting that it was their junior status, reputation of their mentors and/or that of their institutions were being reviewed, rather than their research itself. It was not only the junior investigators who were disadvantaged, however, as one experience of my own would demonstrate. One Editor's acceptance letter stated, “This paper is acceptable, but I expected better from Iris Litt.” At the time, only 5% of medical journals followed the process of “double-blind” review, despite research that demonstrated that the standard process of review clearly disadvantaged junior researchers, women, and those from less prestigious institutions. The argument that “everyone can tell who the author is” may be true in some limited sub-specialty fields or when authors intentionally insert clues about their identity (e.g., referencing their own work in excess, describing the setting, etc) but in a field like Adolescent Health, the research community is multi-disciplinary and broad, making such identification less likely. The point is, however, that those researchers who wish to be known have many ways of doing it. Moreover, should the identity be revealed, that rare researcher is no worse off than if he/she had submitted their paper to a more conventional journal that practices “single-blind” review—nothing lost, much potentially gained by leveling the playing field. Regardless of the validity of the claim that some authors are disadvantaged by such a process, clearly there is the perception that such a bias exists. A recent study demonstrated that “less experienced authors…were significantly more likely to prefer concealing author names, but even the most experienced respondents had a 54% preference for author concealment.”[[2]Regehr G. Bordage G. To blind or not to blind? What authors and reviewers prefer.Med Educ. 2006 Sep; 40: 830-831Crossref PubMed Scopus (50) Google Scholar] I would be reassured if there were data to show that the need for a “double-blind” peer-review process no longer exists—I doubt that is the case. Blind No MoreJournal of Adolescent HealthVol. 45Issue 1PreviewOn July 1, 2009, the Journal will end its practice of double-blind peer review. Instead, authors' identities will be revealed to reviewers, although reviewers will remain anonymous. Full-Text PDF The Editors reply:Journal of Adolescent HealthVol. 45Issue 6PreviewIt's always a pleasure to hear from Dr. Litt, the former editor-in-chief of the Journal. She is correct to point out that while we have ceased the practice of double-blind review, the Journal still maintains anonymity for its reviewers [1]. Full-Text PDF

Eleven years ago the American Medical Association (AMA) published the Guidelines for Adolescent Preventive Services (GAPS), a systematic and comprehensive approach to providing preventive care to adolescents and young adults between the ages of 11 and 21 [[1]Elster A.B. Kuznets N. Guidelines for Adolescent Preventive Services (GAPS) Recommendations and Rationale. American Medical Association, Chicago, IL1994Google Scholar]. The advent of GAPS prompted a flurry of activity from professional organizations and government agencies in support of the concept [2Green M. Palfrey J.S. Bright Futures Guidelines for Health Supervisions for Infants, Children and Adolescents. 2nd edn. National Center for Education in Maternal and Child Health, Arlington, VA2000Google Scholar, 3Stein M. Health Supervision Guidelines. 3rd edn. American Academy of Pediatrics, Elk Grove Village, IL1994Google Scholar, 4American College of Obstetrics and GynecologyHealth care for adolescents. 2003Google Scholar, 5American Academy of PediatricsBright futures. 2005Google Scholar, 6National Committee for Quality AssuranceThe Health Plan Employer Data and Information Set (HEDIS). 2005Google Scholar]. In 1997, the National Committee for Quality Assurance (NCQA), through its Health Employer Data and Information System (HEDIS), affirmed the importance of the annual visit for adolescents by adding this yearly visit to its measurement battery [[6]National Committee for Quality AssuranceThe Health Plan Employer Data and Information Set (HEDIS). 2005Google Scholar]. In spite of the consistency of the recommendations and the commitment by NCQA to encourage health insurance plans to embrace preventive services for this age group, the health professional community has been slow to adopt the guidelines within their clinical practices. In this issue of the Journal of Adolescent Health, Rand and her colleagues, in analyses of both the National Ambulatory Medical Care Survey (NAMCS) and the National Hospital Ambulatory Medical Care Survey (NHAMCS), report on the frequency of preventive counseling at both well-care and acute visits [[7]Rand C.M. Auinger P. Klein J.D. Weitzman M. Preventive counseling at adolescent ambulatory care visits.J Adolesc Health. 2005; 37: 87-93Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar]. Not highlighted in their report is the fact that less than 7% of adolescents received a well-care visit during the study period. Given the low frequency of these visits, there are few adolescents receiving the recommended annual visit. Of interest in the study is the fact that many of the recommended areas for screening and counseling (e.g., diet, exercise, sexually transmitted infections and family planning counseling) were more likely to occur during an acute care visit that was focused on these areas than during a general well-care visit. Even though counseling is more likely to take place during the acute, condition-specific visit, the only areas that exceeded the 50% threshold for counseling were diet (72%) and exercise counseling (52%) when the visit focused on obesity. The analyses provided by Rand and her colleagues are limited to a point in time and do not give us information on whether the reported rates of screening have improved over the decade since the initial guidelines were issued. To help us with trends over time, in the Journal last month Ma and her colleagues, using the same data sets that were used by Rand et al. reported on trends from 1993–1996 to 1997–2000 [[8]Ma J. Wang Y. Stafford R.S. U.S. adolescents receive suboptimal preventive counseling during ambulatory care.J Adolesc Health. 2005; 36: 441Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar]. The proportion of all adolescent General Medical Examination (well-care) visits in which no preventive counseling took place increased over time from 53% to 61%. The majority of adolescents being seen in both time periods received no preventive screening or counseling. There are some cautionary notes with the data sets used in both studies: the data track physician-reported behavior, which may result in either overreporting or underreporting their delivery of these services; the national data do not allow us to assess the quality of the care that is being delivered to adolescent and certain confidential areas addressed may not lend themselves to query if a parent or guardian is present at the visit. Still, the limitations of the data sets do not erase a fundamental problem: adolescents and young adults are not receiving preventive care during clinical visits. These two studies provide further evidence that clinical guidelines and the HEDIS monitoring system are only the first steps in getting services to adolescents [7Rand C.M. Auinger P. Klein J.D. Weitzman M. Preventive counseling at adolescent ambulatory care visits.J Adolesc Health. 2005; 37: 87-93Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar, 8Ma J. Wang Y. Stafford R.S. U.S. adolescents receive suboptimal preventive counseling during ambulatory care.J Adolesc Health. 2005; 36: 441Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar]. The barriers to implementation of GAPS have been well documented in the literature and frameworks for overcoming these barriers have been developed [[9]Cabana M.D. Rand C.S. Power N.R. et al.Why don’t physicians follow clinical preventive guidelines? A framework for improvement.JAMA. 1999; 283: 1458-1465Crossref Scopus (5186) Google Scholar]. In spite of these frameworks and mechanisms for increasing the delivery of the services, we have only a few studies reporting successful implementation [10Klein J.D. Allan M.J. Elster A.B. et al.Improving adolescent preventive care in community health centers.Pediatrics. 2001; 107: 318-327Crossref PubMed Scopus (104) Google Scholar, 11Ozer E.M. Adams S.H. Lustig J.L. Increasing the screening and counseling of adolescents for risky health behaviors a primary care intervention.Pediatrics. 2005; 115: 960-968Crossref PubMed Scopus (127) Google Scholar, 12Ozer E.M. Adams S.H. Gardner L.R. et al.Provider self-efficacy and the screening of adolescents for risky health behaviors.J Adolesc Health. 2004; 35: 101-107Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar, 13Bethell C. Klein J. Peck C. Assessing health system provision of adolescent preventive services the Young Adult Health Care Survey.Med Care. 2001; 39: 478-490Crossref PubMed Scopus (79) Google Scholar]. A few investigators are now reporting on successful interventions to increase preventive screening across multiple risk behaviors through skills-based training and the addition of tools [10Klein J.D. Allan M.J. Elster A.B. et al.Improving adolescent preventive care in community health centers.Pediatrics. 2001; 107: 318-327Crossref PubMed Scopus (104) Google Scholar, 11Ozer E.M. Adams S.H. Lustig J.L. Increasing the screening and counseling of adolescents for risky health behaviors a primary care intervention.Pediatrics. 2005; 115: 960-968Crossref PubMed Scopus (127) Google Scholar, 12Ozer E.M. Adams S.H. Gardner L.R. et al.Provider self-efficacy and the screening of adolescents for risky health behaviors.J Adolesc Health. 2004; 35: 101-107Abstract Full Text Full Text PDF PubMed Scopus (61) Google Scholar]. These successful implementation studies have consistent characteristics: skills-based learning for clinicians on how to incorporate preventive strategies within their practices and tools for charting and screening. The results from these studies are promising, yet we need continued advocacy from professional organizations to reach acceptable levels of provision of services. Often clinicians raise the question of whether delivery of these services will lead to improvement in health status of the population being served. Until successful levels of implementation are achieved, the question of health outcomes will remain elusive at best. There remain some impediments to the delivery systems that need attention: adolescents are underrepresented in outpatient visits relative to their population proportion and are least likely to utilize outpatient care on a per-capita basis; well-care visits account for less than 10% of adolescent visits to clinicians; well-care visits last approximately 16 minutes; and preventive counseling does occur in acute visits [[8]Ma J. Wang Y. Stafford R.S. U.S. adolescents receive suboptimal preventive counseling during ambulatory care.J Adolesc Health. 2005; 36: 441Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar]. In spite of these limitations, there is documented evidence that 73% of adolescents have a clinical encounter each year [[14]Newacheck P.W. Brindis C.D. Cart C.U. et al.Adolescent health insurance coverage recent changes and access to care.Pediatrics. 1999; 104: 195-202Crossref PubMed Scopus (128) Google Scholar]. Improvements in the public financing system over the past decade eliminate some of the barriers to access, but insurance represents only one barrier to implementation [14Newacheck P.W. Brindis C.D. Cart C.U. et al.Adolescent health insurance coverage recent changes and access to care.Pediatrics. 1999; 104: 195-202Crossref PubMed Scopus (128) Google Scholar, 15Newacheck P.W. Park M.J. Brindis C.D. et al.Trends in private and public health insurance for adolescents.JAMA. 2004; 291: 1231-1237Crossref PubMed Scopus (66) Google Scholar, 16Mulvihill B.A. Jackson A.J. Mulvihill F.X. et al.The impact of SCHIP enrollment on adolescent-provider communication.J Adolesc Health. 2005; 35: 94-102Abstract Full Text Full Text PDF Scopus (9) Google Scholar]. The Society for Adolescent Medicine’s position statements on Access to Care and Confidentiality outline mechanisms to further improve access [17Society for Adolescent MedicineConfidential health care for adolescents position paper of the Society for Adolescent Medicine.J Adolesc Health. 2004; 35: 160-167Abstract Full Text Full Text PDF PubMed Scopus (183) Google Scholar, 18Society for Adolescent MedicineAccess to health care for adolescents and young adults position paper of the Society for Adolescent Medicine.J Adolesc Health. 2004; 35: 342-344Crossref PubMed Google Scholar]. Advocating the inclusion of prevention in acute visits is one possible solution for improving access to prevention. However, until clinicians and systems of care begin to deliver the services to those adolescents who walk through the door, it is difficult to lead a campaign to get adolescents through the doors [[19]Erten J. Zaman I. Importance of routine health checkups in young adults.J Adolesc Health. 2004; 34: 2Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar]. Clinicians need to make certain that every clinical encounter is health promoting.

For the past several decades, the field of Adolescent Medicine and Health has tended to focus on many of the health and medical problems associated with dieting and starvation. Our adolescent and young adult hospital-based programs throughout Canada, the United States, Western Europe, and Australia have developed state-of-the art programs for anorexia nervosa and bulimia nervosa. The Society for Adolescent Medicine (SAM) has recognized the importance of eating disorders in adolescents and young adults by developing an official position paper highlighting the epidemiology, treatment guidelines, and preventive interventions for eating disorders during the second decade of life [1].

This issue of the Journal is devoted exclusively to articles in the area of adolescent sexuality and reproductive health. These 14 articles highlight a number of the critical issues associated with the emergence of sexuality during adolescence and young adulthood. To put these papers in perspective, the most recent United States data on adolescent sexuality and reproductive health (11 of the 14 papers in this issue of the Journal are from the United States) is encouraging, with some specific caveats. I would welcome hearing from our international colleagues to help our readers gain a more global view of adolescent sexuality and reproductive health. Adolescent pregnancy rates are at their lowest level in over decade with a rate of 85.6 per 1,000. This rate represents a 27% decrement over the past decade from 116.9 per 1,000 in 1990. Associated with this decrease in pregnancy rate, the birth rate has dropped to 48.7 per 1,000, and the abortion rate has also fallen to 24.7 per 1,000 (1Ventura S.J Abma J.C Mosher W.D Henshaw S Revised pregnancy rates, 1990–97, and new rates for 1998–99 United States.National Vital Statistics Reports. 2003; 52: 1-15Google Scholar). The good news about the pregnancy rates is accompanied by good news in the area of postponement of initiation of sexual intercourse, and use of contraception: more adolescents are delaying the initiation of sexual intercourse and those who are initiating are more likely to use some form of contraception. Data from the current Youth Risk Behavior Surveillance System (YRBSS) report that 45.6% of high school students have had sexual intercourse once and that of those who have initiated sexual intercourse, almost 58% have used a condom at last intercourse (2Brener N Lowry R Kann L et al.Trends in sexual risk behaviors among high school students —United States, 1991–2001.MMWR Morb Mortal Wkly Rep. 2002; 5: 856-859Google Scholar, 3Grunbaum J.A Kann L Kinchen S.A et al.Youth risk behavior surveillance— United States, 2001.MMWR Morb Mortal Wkly Rep. 2002; 5: 1-62Google Scholar). Once again, rates of initiation of sexual intercourse have dropped by 16% over the past decade. This good news cuts across all racial and ethnic groups; however, Black and Hispanic adolescents have much higher rates of pregnancy than their same age White peers. Rates of initiation of sexual activity gathered by the YRBSS indicate that by 9th grade, Black and Hispanic adolescents are much more likely to have reported sexual intercourse than their White peers. However, by 12th grade, the differences among racial and ethnic groups are far less pronounced, with all racial and ethnic groups appearing more similar. With regard to condom use, Black adolescents report the highest rates of condom use of any racial and ethnic group and White Nonhispanic adolescents are the most likely to use oral contraceptives (3Grunbaum J.A Kann L Kinchen S.A et al.Youth risk behavior surveillance— United States, 2001.MMWR Morb Mortal Wkly Rep. 2002; 5: 1-62Google Scholar). The data on sexually transmitted infections (STIs) is mixed. Rates of reported gonorrhea in adolescents have fallen dramatically over the past decade; dropping to a rate of 476.4 per 100,000 in 2002 as compared to 1,114.4 per 100,000 in 1990. This is a 57% decrease in a little over ten years. The decreasing rate cuts across all ethnic and racial groups, although Black adolescents still account for over three-quarters of the adolescent cases (4Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2003. Tables 12B, 22B, 35B. Available at http://www.cdc.gov/std/stats/toc2002.htm, Accessed March 09, 2004Google Scholar, 5Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 1994. Tables 9B, 21B. Available at http://wonder.cdc.gov/wonder/STD/Title3000.html. Accessed March 08, 2004Google Scholar). With regard to Chlamydia, the rates of reported infection continue to rise. In 2002, the rates were reported at 1,483 per 100,000, a 37% increase since 1996 (4Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2003. Tables 12B, 22B, 35B. Available at http://www.cdc.gov/std/stats/toc2002.htm, Accessed March 09, 2004Google Scholar, 6Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2001. Table 11B. Available at http://www.cdc.gov/std/stats00/toc2000.htm. Accessed March 09, 2004Google Scholar). The increase is probably due to a number of different factors: the institution in 2000 of universal reporting of Chlamydia as a reportable STI to public health departments, better screening techniques and the institution of screening for Chlamydia as a Health Plan and Employer Data Information Set (HEDIS) measure as a quality of care indicator for health plans (4Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2003. Tables 12B, 22B, 35B. Available at http://www.cdc.gov/std/stats/toc2002.htm, Accessed March 09, 2004Google Scholar, 6Centers for Disease Control and Prevention, Sexually transmitted disease Surveillance Report, 2001. Table 11B. Available at http://www.cdc.gov/std/stats00/toc2000.htm. Accessed March 09, 2004Google Scholar, 7National Committee on Quality Assurance: HEDIS 2002: Technical Specifications, Volume 2. Washington, D.C.: National Committee on Quality Assurance, 2002Google Scholar). Vesely and her colleagues in this issue of the Journal offer a theoretical explanation for the good news on sexual behavior and its outcomes (8Vesely SK, Wyatt VH, Oman RF, et al. The potential protective effects of youth assets from adolescent sexual risk behaviors. J Adolesc Health 2004;34:356–65Google Scholar). This paper supports a growing body of literature on the importance of positive youth development and the protective factors that these assets may have on promoting a delay in the initiation of sexual intercourse. Equally important, the study provides a more expansive view on the value of positive youth development in encouraging responsible sexual behavior, the use birth control use with the onset of sexual activity. These cross sectional data do not provide causal links, but give us a roadmap for further investigative work. Two other papers in the Journal continue to affirm the high rates of STIs in “at-risk” populations and the need for improving outreach, education and continuous screening in our most vulnerable adolescents. DiClemente and his colleagues studying a group of African-American pregnant adolescents reported a prevalence rate of 23.5% for one of the three STIs assessed by nucleic acid amplification testing or for syphilis as assessed by RPR (9DiClemente RJ, Wingood GM, Crosby RA, et al. A descriptive analysis of STD prevalence among urban pregnant African-American teens: Data from a pilot study. J Adolesc Health 2004;34:376–83Google Scholar). Even though most adolescents were knowledgeable about the use of barrier methods to prevent STIs, these pregnant adolescents were ineffective at using condoms to prevent STIs. In another study from Canada, Shields and her colleagues report a prevalence rate for Chlamydia of 8.6% in street youth, a rate almost 9 times higher than that reported in the general Canadian youth population (10Shields SA, Wong T, Mann J, et al. Prevalence and correlates of chlamydia infection in Canadian street youth. J Adolesc Health 2004;34:384–90Google Scholar). An Adolescent Health Brief in the Journal this month helps us to further understand how to access at-risk populations and make certain that they get screened. Chacko and her colleagues propose the use of a Transtheoretical Model to understand strategies to improve STI screening. Even though this model may be helpful in assisting with the process of self disclosure and screening, one of the study's important findings is the critical importance of the need for privacy in STI screening (11Chacko MR, Von Sternberg K, Velasquez MM. Gonorrhea and chlamydia screening in sexually active young women: The process of change. J Adolesc Health 2004;34:424–27Google Scholar). Privacy may itself not enable adolescents to utilize the resources that are traditionally used in the Transtheoretical Model. Ford and her colleagues recently examined the possible use of self-test urine screen tests for STIs in nontraditional settings. Clearly, these settings may facilitate the opportunity for privacy in screening since the young person can initiate the testing herself/himself outside of the traditional clinical setting (12Ford CA, Jaccard JJ, Millstein SG, et al. Young adults' attitudes, beliefs and feelings about testing for curable STDs outside of clinic settings. J Adolesc Health 2004;34:266–9Google Scholar). Given that many of the adolescents who need to be tested are high risk, the use of these self-tests presents some positive opportunities to screen youth. However, these tests pose some logistical problems in making certain that we develop effective outreach programs for treatment and follow up for our most vulnerable youth. Two additional papers and one commentary from the International Community further emphasize the importance of community-based programs, school-based interventions, and explicit government policies. Lou and his colleagues in China demonstrate the positive effect of a comprehensive sex education and reproductive health program on increasing contraceptive use at the onset of sexual intercourse for both males and females (13Lou CH, Wang B, Shen Y, et al. Effects of a community-based sex education and reproductive health service program on contraceptive use of unmarried youths in Shanghai. J Adolesc Health 2004;34:433–40Google Scholar). The unique qualities of this intensive program include information, counseling and skills building with sustainable results 20 months following conclusion of the program. In a study from Zambia, Agha and Van Rossem find much more modest effects from a single session school-based peer sexual health intervention (14Agha S, Van Rossem R. Impact of a school-based peer sexual health intervention on normative beliefs, risk perceptions and sexual behavior of Zambian adolescents. J Adolesc Health 2004;34:441–52Google Scholar). A commentary about Uganda highlights the effectiveness of a national strategy to reduce human immunodeficiency virus (HIV) (15Blum R.W Uganda AIDS Prevention: A,B,C and politics.J Adolesc Health. 2004; 34: 428-439Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar). Assisting young people to make responsible decisions will require efforts that are comprehensive and culturally sensitive if we intend to achieve outcomes that are sustained over time (15Blum R.W Uganda AIDS Prevention: A,B,C and politics.J Adolesc Health. 2004; 34: 428-439Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar, 16Lerner R.M Castellino D.R Contemporary developmental theory and adolescence Developmental systems and applied developmental science.J Adolesc Health. 2002; 31: 122-135Abstract Full Text Full Text PDF PubMed Scopus (188) Google Scholar). Collectively the papers in this issue of the Journal raise a series of ongoing issues that need further elucidation: the importance of mandated programs in achieving more optimal outcomes as reported by immunization rates by Jacobs and Meyerhoff (17Jacobs RJ, Myerhoff AS. Effect of middle school entry requirements on hepatitis B vaccination coverage. J Adolesc Health 2004;34:420–23Google Scholar), the disparity between national data and local data showing that even with the good news overall nationally, we have large numbers of adolescents who are adversely affected by unsafe sexual behavior (9DiClemente RJ, Wingood GM, Crosby RA, et al. A descriptive analysis of STD prevalence among urban pregnant African-American teens: Data from a pilot study. J Adolesc Health 2004;34:376–83Google Scholar, 10Shields SA, Wong T, Mann J, et al. Prevalence and correlates of chlamydia infection in Canadian street youth. J Adolesc Health 2004;34:384–90Google Scholar, 18Gwadz MV, Clatts MC, Leonard NR, et al. Attachment style, childhood adversity and behavioral risk among young men who have sex with men. J Adolesc Health 2004;34:402–413Google Scholar); the role of sexual identity in determining risk status for unsafe sexual behavior (18Gwadz MV, Clatts MC, Leonard NR, et al. Attachment style, childhood adversity and behavioral risk among young men who have sex with men. J Adolesc Health 2004;34:402–413Google Scholar); and how to more effectively introduce positive youth development programs to assist with postponement of initiation of sexual behavior and the encouragement of responsible sexual behavior (8Vesely SK, Wyatt VH, Oman RF, et al. The potential protective effects of youth assets from adolescent sexual risk behaviors. J Adolesc Health 2004;34:356–65Google Scholar, 19Catalano R.F Hawkins J.D Berglund M.L et al.Prevention Science and Positive Youth Development Competitive and Cooperative Frameworks?.J Adolesc Health. 2002; 31: 230-239Abstract Full Text Full Text PDF PubMed Scopus (295) Google Scholar).