JOURNAL OF ADOLESCENT HEALTH 2002;31:82– 89
SUPPLEMENT OVERVIEW
Health Futures of Youth II: Pathways to Adolescent
Health, Executive Summary and Overview
CHARLES E. IRWIN, JR., M.D. AND PAULA M. DUNCAN, M.D.
Health Futures of Youth II: Pathways to Adolescent
Health, a national invitational conference, was con-
vened on September 14 –16, 1998, in Annapolis,
Maryland. The Office of Adolescent Health (OAH) in
the Maternal and Child Health Bureau (MCHB) of
the Health Resources and Services Administration,
U.S. Department of Health and Human Services
(DHHS) sponsored the conference. Collaborating
with OAH in the development of the conference was
a non-Federal planning committee co-chaired by Drs.
Charles E. Irwin, Jr. and Paula M. Duncan. The
structure of the meeting was similar to the Health
Futures of Youth conference sponsored by MCHB in
1986 at Daytona Beach, Florida. The recommenda-
tions developed at the 1986 meeting played a major
role in shaping public health policy for youth during
the past decade [1]. The 124 participants at Health
Futures of Youth II Conference included many of the
Nation’s leading experts on Adolescent Health from
fields as diverse as communications, economics, ed-
ucation, law, medicine, nursing, nutrition, psychol-
ogy, health policy, public policy, social work and
sociology. Participants were charged with reviewing
the most current research regarding major Adoles-
cent Health issues and then developing recommen-
dations designed to advance knowledge about, and
improve, the health status and well-being of our
adolescents. Recommendations on priorities for fu-
ture research, training, and demonstration projects
developed at the meeting, were intended to consti-
From the University of California, San Francisco, San Francisco,
California (C.E.I.); and the University of Vermont, College of Medicine,
Burlington, Vermont (P.M.D.).
Address correspondence to: Charles E. Irwin, Jr., M.D., Box 0503 LH
245, University of California, San Francisco, CA 94143-0503. E-mail:
cirwin@itsa.uscf.edu.
Manuscript accepted August 22, 2002.
1054-139X/02/$–see front matter
PII S1054-139X(02)00513-X Published by Elsevier Science Inc., 360 Park Avenue South, New York, NY 10010
tute an Adolescent Health agenda for the next de-
cade. Work at the conference emphasized asset
building and successes in Adolescent Health, but
participants were also urged to find ways to improve
the well-being of all adolescents — such as youth
with special needs — and to include multiple per-
spectives in their deliberations.
Participants met in six working groups to discuss
broad topical areas and formulate sets of recommen-
dations with rationales. Background papers were
prepared to help focus the discussion of the work
group participants. The four plenary presentations
(and their corresponding papers as published in this
volume) were included to highlight important cross-
cutting issues relevant to all of the work groups.
On the final day of the conference, the work
groups reported their recommendations in a general
session and received responses from representatives
of the public and philanthropic sectors. The final
reports of the six working groups as reported in this
volume reflect the integrated responses generated at
this last session.
The members of the Planning Committee are
listed on the title page, and the Appendix lists all the
participants in attendance at the conference.
Plenary Sessions
Two plenary papers [2,3] focused on the individual
level, with overviews of the conceptual models for
studying adolescent development and a summary of
demographic and health-status data on adolescents
in the United States. The second two plenary papers
[3,4] addressed influences on adolescent health and
possible ways to enhance healthy adolescent devel-
opment. Presentations focused on reasons to invest
© Society for Adolescent Medicine, 2002
December 2002 EXECUTIVE SUMMARY 83

in adolescents and the effect of the media on adoles- tems and Applied Development Science” empha-
cent health behaviors. sized the need to look at adolescence in the context of
the entire lifespan and also from an assets based
approach [3]. In his paper in this supplement, he
America’s Adolescents: Where Have We Been, emphasizes the critical importance of these assump-
Where Are We Going? tions and how they have important implications for
research and application. For example, the interrela-
Dr. Charles Irwin’s paper, “America’s Adolescents:
tionship between levels of the developmental system
Where Have We Been, Where Are We Going?”
calls for the design of policies and programs based
presents a comprehensive overview of the current
on an integrative approach that is attentive to the
national data and trends over the past two decades
complexity of adolescent-context relations at all lev-
on demography, risk behaviors, and health status of
els of organization, ranging from micro (e.g., indi-
youth [2]. Dr. Irwin noted that at the 1986 Health
vidual) to macro (e.g., community, society). Re-
Futures of Youth conference, statistics on mortality
searchers can use policies and programs conducted
were the only relevant national data available on
in real-world settings as tools to explore whether
adolescents [1]. Today, national data sets provide
certain variations in adolescent-context relations pro-
unprecedented opportunities to understand patterns
mote the desired developmental trajectories. Evalu-
of mortality, utilization of health services by insur-
ation of the outcomes of these contextual changes
ance status, health risk behaviors, and the environ-
may elucidate theoretical issues pertaining to plas-
mental context of adolescents. However, the use of
ticity in human development and the extent to which
available data is still limited by problems such as
policy and program interventions can alter and en-
varying cohort age ranges, homogenized data about
hance the course of human development in adoles-
race and ethnicity, race and ethnicity used as proxies
cence and throughout the lifespan. Such research
for socioeconomic status, and issues related to the
based on the developmental systems perspective is
duration and frequency of tracking trends over time.
an example of a new field of research known as
Nevertheless, national data sets can provide valuable
applied developmental science (ADS). ADS is the
insights into the social and environmental context of
systematic synthesis of research and applications to
youth. Highlights of data and trends reported by
describe, explain, and promote optimal developmen-
Irwin and his colleagues indicate positive trends as
tal outcomes in individuals and families as they
well as areas of concern. Irwin notes that after two
develop throughout the life cycle. ADS provides a
decades of unprecedented investment in both policy
framework for the advancement of understanding
and program initiatives and improved data collec-
about adolescent development and explores ways to
tion, there are some major improvements in the
enhance the development of individuals whose qual-
health status of all adolescents. In spite of the major
ity of life is being challenged by normative develop-
improvements, however, African-American, His-
mental problems and risks associated with the cur-
panic, Native American and impoverished youth are
rent historical moment.
still being left behind in a number of areas. There do
remain continuing challenges in the field which
include societal ambivalence about adolescents; a Reasons to Invest in Adolescents
lack of willingness in health initiatives to prioritize
Dr. Martha Burt’s presentation and paper in this
adolescents; and a weak connection between data,
volume entitled “Reasons to Invest in Adolescents”
research, policy, and program. Irwin emphasizes the
presents convincing arguments for prioritizing in-
need to consider how data can be used to drive
vestments in adolescents and describes types of
research, and how resultant policy developed from
preventive and developmental programs that have
research and demonstration projects can be used to
produced positive outcomes for this age group [4].
drive the development and sustenance of programs.
Because adolescents suffer from few life-threatening
conditions, they are often ignored by public health
investments. Burt’s thesis maintains that adolescence
Contemporary Development Theory of is a time period with great plasticity when the
Adolescence: Developmental Systems and formation of harmful health habits can have long-
Applied Development Science term effects that will eventually exact a heavy toll on
Dr. Richard Learner’s paper, “Contemporary Devel- society, but where positive health habits may have
opment Theory of Adolescence: Developmental Sys- the opposite effect, and will lead to the health of the
84 IRWIN AND DUNCAN
country. Dr. Burt suggests that a focus on the quality
of life for adolescents and the rest of the community
rather than merely on morbidity and mortality might
be a more effective strategy for convincing policy-
makers of the need for investment in adolescents.
Policymakers need to understand the value of invest-
ing in the future health and productivity of adoles-
cents and the need for holistic rather than problem-
focused programming for youth. Efforts to help
adolescents become contributing members of society
rather than “resource absorbers” have the potential
to foster economic productivity. Holistic programs
for youth need positive developmental opportunities
that are appropriate to adolescents’ age and experi-
ence, families and environments, and the overall
context in which their behavior occurs.
Policymakers also need to know what strategies
work for adolescents. One useful model provides a
conceptual framework for designing programs for
youth by explicating the connections between risk
antecedents, protective factors, system markers,
problem behaviors, and outcomes. Such a model can
help policymakers decide where investments in sup-
plying protective factors could be made most effec-
tively to produce specific targeted outcomes. One
way of describing the importance of investing in
Adolescent Health in a comprehensive way is to
consider the consequences of not making invest-
ments. There are compelling examples of the economic
cost of risky behaviors in adolescents that may help
overcome the resistance of policymakers to investing in
interventions targeting youth. For example, in the
United States, $260 billion is lost in earnings and
forgone taxes for each-year’s cohort of high-school
dropouts, and $20 billion is spent annually in payments
for income maintenance, health care, and nutrition to
support families begun by teenagers. Burt maintains
that because decision makers value these potential
costs differently, such justifications for investments in
adolescents must take into account the personal and
societal outcomes that are most valued by the people
who are being asked to invest.
The Mass Media and American
Adolescents’ Health
Dr. Jane Brown’s presentation and paper entitled
“The Mass Media and American Adolescents’
Health” identifies how the media are contributing to
risky adolescent health behaviors and provides ways
to use the media as an ally in creating healthier
futures for youth [5]. She described a teenager’s
media diet pyramid, which conceptualizes adoles-
JOURNAL OF ADOLESCENT HEALTH Vol. 31, No. 6S
cents’ use of the mass media according to scales of
passive to interactive use and to levels of involve-
ment in the common culture or realms of individual
self-expression. A bi-directional model developed by
Steele and Brown to depict adolescents’ media prac-
tice assumes that teens are active users of the media
and bring with them a set of experiences and moti-
vations that will affect what media they choose as
well as how it will be incorporated into their lives.
Brown reviewed research that focused almost exclu-
sively on television. This research provides evidence
indicating that the media affect adolescents’ health in
a negative manner. Examples include desensitization
to violence, aggressive behavior as a means to solve
conflicts, premarital sex as acceptable, depiction of
the use of contraceptives as rare, food advertisements
that encourage adolescents to eat “unhealthy foods”,
female beauty as synonymous with being thin, alcohol
advertisements that encourage positive attitudes about
drinking and the sophisticated marketing strategy of
cigarette advertisements to young adults.
Given that adolescents will continue to be major
consumers of the media, Brown identifies some
promising approaches for investigators and the pub-
lic to consider as we attempt to build liaisons with
the media. Several of these strategies have been
utilized over the past few years to minimize the
media’s potential negative effect on adolescents’
health. More research is needed on the effects of the
media (including music, magazines, and especially
the Internet) on Adolescent Health, particularly sex-
ual behavior and body consciousness. Public Health
Campaigns need to be using the paid media to
counter prevailing no-consequence messages to
teens. These approaches will be costly but may be
some of the most effective in promoting healthy
behaviors. Media advocacy may help create a more
positive environment for our youth through a re-
framing of youth and their health issues. The enter-
tainment industry may present us with an opportu-
nity to embed socially responsible health messages
within entertainment programming. Role models in
the popular media may be helpful in presenting
responsible healthy behavior. Finally, there is a need
to educate our youth through media literacy. Youth
and their families need to learn how to critically
analyze the media and assist health professionals to
develop positive media messages about youth.
Conference Recommendations
The full details of the recommendations developed
in each working group can be found in the six papers
December 2002
summarizing the deliberations of each working
group within this volume [6 –11]. The overarching
message that developed from the meeting was the
need for a major paradigm shift. Instead of adoles-
cents being viewed as the problem, and adolescence
as a distinct life stage with little relevance to the
remainder of the life cycle, adolescence needs to be
viewed as a positive period of the life cycle with
unique opportunities for developing assets and pro-
moting healthy development. A healthy adolescence
is essential for a healthy and productive adulthood.
The following summaries of each working group
represent a synthesis of the recommendations devel-
oped at the conference.
Work Group I: Developing Models of Healthy
Adolescent Physical Development
Work Group I [6] addressed the physiologic and
behavioral changes that occur during adolescence
and how they may affect health throughout the
lifespan. Specific recommendations focus on four
priority research areas including a further under-
standing of: (a) the neurophysiology of puberty
using the “new technologies”; (b) the complex roles
of the hormonal changes of puberty and its relation-
ship to a number of physical and mental health
disorders with their onset during adolescence; (c) the
complex area of sleep and its affect on adolescents;
and (d) nutrition research.
The specific recommendations for each of these
four areas are further identified below.
1. Recommendations for research in neuroendocrine
physiology address the need for studies on the
following areas:
• The regulation of the onset of puberty and the
neurobiological mechanisms that synchronize
the activity of hypothalamic GnRH neurons.
• The structural and molecular plasticity of the
hypothalamic pulse generator.
• The complex modulators of the pubertal endo-
crine process (e.g., diet, stress, and obesity).
• Brain maturation in children and adolescents as
they progress through puberty using neuroim-
aging and electrophysiologic techniques.
2. Recommendations for research on growth and
puberty call for:
• The temporal characterization of the physical
onset of puberty and its tempo of progression.
• New longitudinal studies on the role in the
maturational process of estrogen, leptin, adre-
EXECUTIVE SUMMARY 85
nal androgens, and IGF I and II and their family
of binding proteins.
• Studies on the continuum of intrauterine
growth retardation, premature adrenarche,
obesity, functional ovarian hyperandrogenism,
and a later adult syndrome of heightened car-
diovascular risk.
3. Recommendations for sleep research include the
need for:
• Studies on the influence of neuroendocrinologic
pubertal changes on sleep and the conse-
quences of inadequate sleep on adolescents.
• The development of guidelines using existing
data to educate the public and health profes-
sionals about the importance of sleep during
adolescence.
4. Recommendations for research on nutrition in-
clude studies to increase our understanding of:
• Adolescent obesity and type II diabetes.
• Risk factors for osteoporosis and possible pre-
vention strategies in adolescence.
• Issues related to nutrition, exercise, obesity, and
dieting behavior.
Work Group II: Developing Models of Healthy
Adolescent Psychosocial Development
Work Group II [7] examined adolescent psychosocial
development, including cognitive, social, emotional,
and affective development issues. A developmental
systems perspective was used in developing the
recommendations. The identified recommendations
focus on five priority areas related to healthy adoles-
cent psychosocial development. Action steps were
suggested for each recommendation. A few exam-
ples of these action steps are provided in the follow-
ing summary.
1. Adopt a developmental systems perspective in
research, policy, program development, and
practice.
This recommendation is intended to promote a more
integrative and dynamic systems perspective on
adolescent development, encompassing biological,
psychological, and social development in relation to
the multiple, diverse, and changing contexts and
cultures in which development is embedded and
from which developmental pathways emerge. Exam-
ples of action steps include developing and dissem-
inating change-sensitive methods and measures and
86 IRWIN AND DUNCAN
encouraging more research on diversity of settings
and people.
2. Encourage adults to take greater responsibility for
adolescents and their development.
The goal of this recommendation is to educate and
challenge all adults to foster the positive develop-
ment of adolescents in their actions, in their institu-
tions, in their policies, and in their programs. Exam-
ples of action steps include developing protocols on
adolescent development that can be disseminated
directly to people who work with adolescents and
encouraging school policies and curriculum activi-
ties that promote cooperation and a sense of
community.
3. Encourage adolescents to be engaged as active
participants.
This recommendation is intended to foster greater
opportunities for adolescents to be active, construc-
tive agents in their own development and to encour-
age their engagement in all policies and programs
that focus on adolescent well-being and healthy
development. Examples of action steps include de-
veloping more peer programs and integrating ado-
lescent input into all intervention, prevention, and
training programs, as well as all research efforts
related to adolescents.
4. Pay more attention to the critical transitions in the
lives of adolescents.
The goal of this recommendation is to facilitate
successful transitions in the lives of adolescents and
understand ways that these transitions are promoted
in diverse cultural, educational, religious, and social
settings. Examples of action steps include fostering
more successful adolescent transitions to work, es-
pecially for adolescents who are not going to college
directly after high school, and developing alternative
ways of measuring successful outcomes other than
college attendance and completion.
5. Help adolescents overcome challenges to healthy
psychosocial development.
This recommendation is intended to promote the use
knowledge about psychosocial development to pre-
vent and ameliorate problems that confront adoles-
cents in today’s society. Examples of action steps
include implementing programs for pre-adolescents
and identifying ways to keep adolescents in school.
Work Group III: Identifying Effective Strategies
for Improving Adolescent Health at the
Individual Level
Work Group III [8] focused on strategies to improve
interventions at the individual level, with the goal of
JOURNAL OF ADOLESCENT HEALTH Vol. 31, No. 6S
enabling adolescents to advocate for themselves and
reach their full potential. To achieve this goal, the
work group organized its recommendations around
four areas: (a) research; (b) practices and services; (c)
the translation and dissemination of research and
best practices; and (d) policy.
1. Recommendations for research address the need
for:
• All future research on early intervention to
encourage the use of models that are contextu-
ally and culturally appropriate.
• Longitudinal studies to determine the develop-
mental interplay of what occurs prior to ado-
lescence and the relationship between risk and
protective factors.
• Further development of adolescent preventive
services research, including an emphasis on
economic analysis.
• Analyses of evidence-based, cost-effective prac-
tices to develop evaluation tools that accurately
reflect observed changes.
• Prioritization of data collection and analyses
that include underrepresented minority
groups.
2. Recommendations for practice and services
include:
• Ensuring access for all adolescents to a full
range of culturally competent and developmen-
tally appropriate health services, including pre-
vention and early intervention services.
• Using interdisciplinary practice and manage-
ment models to inform prevention and early
intervention services.
• Ensuring that practice models demonstrate the
effectiveness of process and outcome indica-
tors.
• Promoting and nurturing mentor-rich environ-
ments in all adolescent services.
3. Recommendations for translation and dissemina-
tion of research and best practices call for:
• Developing effective social marketing strategies
for disseminating basic and applied research
findings to inform adolescents, their families,
and the general public as well as various pro-
fessional and administrative audiences.
• Promoting and supporting the development of
interdisciplinary and culturally appropriate
training models for adolescent services provid-
ers, including health professionals.
December 2002
• Developing, promoting, and supporting train-
ing models for researchers and providers that
are based on principles of positive youth devel-
opment, prevention, and early intervention.
4. Recommendations in the area of policy include:
• Building policy on evidence-based principles
and best practices of youth development, pre-
vention, and early intervention. To achieve this
goal, research findings need to be translated
into theory, principles, and best practices that
define priorities for funding to support the
needs of youth at greatest risk.
Work Group IV: Increasing the Capacity of
Parents, Families, and Adults Living With
Adolescents to lmprove Adolescent
Health Outcomes
Work Group IV [9] focused on recommendations
concerning the development of strategies for build-
ing the capacity of parents, families, and other care-
givers to promote Adolescent Health and for dissem-
inating information to educate parents about
adolescence. The recommendations originating from
this group included those that were directed to the
Office of Adolescent Health within the Maternal and
Child Health Bureau, public and private agencies,
and general recommendations that cut across all
facets of society.
1. Recommendations for the Office of Adolescent
Health (OAH) include:
• Providing national leadership for the dissemi-
nation of information about the importance of
parents, families, and other caregivers in Ado-
lescent Health and development.
• Promoting research on the utility and cost-
effectiveness of capacity-building strategies for
parents and other caregivers to enhance Ado-
lescent Health.
• Identifying and developing strategies for dis-
seminating research results to the public with a
special emphasis on families with adolescents.
• Including adolescents and their caregivers in
the development of strategies to design, de-
liver, and disseminate programs and informa-
tion to increase the capacities of families to
foster healthy adolescent development.
• Urging federal agencies, such as the Agency for
Healthcare Research and Quality (AHRQ) to
consider conducting a projected cost-benefit
EXECUTIVE SUMMARY 87
analysis for implementing the recommenda-
tions from Health Futures of Youth II.
• Encouraging OAH to assume the leadership in
making recommendations to DHHS on the role
that the OAH and other DHHS agencies should
play in fulfilling the Health Futures of Youth II
recommendations.
2. Recommendations for public and private agencies
address the need to:
• Encourage and support research to improve the
dissemination through the media of informa-
tion on parenting adolescents.
• Encourage and support programmatic efforts to
strengthen the relationship between experts on
adolescence and parenting and people who
work within the media.
• Support research on parental characteristics
and family circumstances that affect the capac-
ity of parents and other caregivers to promote
Adolescent Health and well-being.
3. Other recommendations call for:
• Reflecting the diversity of the American adoles-
cent population in all policies, programs, prac-
tices, and research designed to enhance par-
ents’ capacity to promote Adolescent Health.
• Training all professionals who work with ado-
lescents or their parents and caregivers to as-
sess and strengthen parents’ and caregivers’
capacity to foster healthy adolescent develop-
ment.
• Educating employers and other purchasers of
health care about the importance of providing
programs for parental capacity building.
• Enlisting the support of partnerships and col-
laborations of community institutions in efforts
to inform and assist parents of adolescents.
• Providing information about adolescent devel-
opment to parents of adolescents in special
circumstances.
Work Group V: lncreasing the Capacity of
Schools, Neighborhoods, and Communities To
Improve Adolescent Health Outcomes
Work Group V [10] addressed how communities can
build their capacity to foster healthy adolescent
development through programs that provide ser-
vices to youth. Recommendations were focused on
four central capacities that need to be strengthened:
(a) the capacity to enhance what we know (research
88 IRWIN AND DUNCAN
and evaluation); (b) the capacity to develop and
implement effective interventions (training); (c) the
capacity to ensure sustainability of successful inter-
ventions (policy and advocacy); and (d) the capacity
to conduct other activities that support the interven-
tions (infrastructure).
1. Recommendations for research and evaluation
call for:
• Developing a new theoretical model of positive
youth development.
• Testing the validity of the model through the
analysis of extant databases and retrospective
analyses of promising practices, programs, col-
laborations, and partnerships.
• Conducting prospective studies that compare
the validity or effectiveness and costs of various
strategies based on the positive youth develop-
ment model and the deficit model.
• Conducting randomized controlled studies to
determine the efficacy of programs, when ap-
propriate.
• Developing reliable and valid process and out-
come indicators that can be used to plan pro-
grams, establish efficacy (accountability), and
demonstrate effectiveness.
2. Recommendations for training address the need
to:
• Provide technical training and support to local
adolescent development planning councils.
• Disseminate and market information about suc-
cessful and effective community programs to
local adolescent development planning coun-
cils.
• Disseminate and market information about
how communities can take effective programs
to scale.
• Disseminate and market tools for monitoring
and evaluating community-based, youth-fo-
cused interventions.
3. Recommendations for policy and advocacy call
for:
• Developing a unified policy statement with
regard to development, implementation, evalu-
ation, and monitoring of the multitude of effec-
tive programs.
• Developing a unified advocacy strategy for
ensuring investment in youth.
4. Recommendations for infrastructure focus on:
JOURNAL OF ADOLESCENT HEALTH Vol. 31, No. 6S
• Creating and supporting a national adolescent
development planning council consisting of a
full range of national stakeholders.
• Creating local adolescent development plan-
ning councils consisting of a full range of local
stakeholders.
• Creating regional training and technical sup-
port centers.
• Identifying and recruiting leaders to sustain the
effective programs, evaluation, and advocacy.
Work Group VI: Exploring the Influence of Law
and Public Policy on Adolescent Health
Work Group VI [11] examined the effects of law and
public policy on Adolescent Health in the United
States and sought to identify ways to influence the
development of laws and policies for the benefit of
youth. In addition to supporting recommendations
made in the four background papers prepared for
the conference, Work Group VI identified two over-
arching recommendations: (a) Reframe the public
discourse regarding adolescence to create a more
balanced image of youth, and (b) Protect and expand
adolescents’ access to a wide range of health services.
Under each of these recommendations, three priority
strategies were identified.
1. Reframe public discourse regarding adolescence
to create a more balanced image of youth.
• Develop and implement a communications
strategy to educate and inform the public, poli-
cymakers, parents, and youth about the
strengths, assets, and contributions of youth.
• Develop national, state, and local sources of
asset-oriented data on adolescent development,
health, and well-being. These data sources
should help assess youth strengths, assets, and
contributions.
• Develop constituencies and coalitions at the
Federal, state, and local levels to prioritize,
advocate for, and monitor policies addressing
salient adolescent issues and problems.
2. Protect and expand adolescents’ access to a wide
range of health care services.
• Protect and monitor the implementation of ex-
isting funding streams for Adolescent Health
care (e.g., Medicaid, State Children’s Health
Insurance Programs) at the state and Federal
levels.
December 2002
• Ensure confidential access for minors to sensi-
tive services such as reproductive health, sub-
stance abuse, and mental health services.
• Develop and advocate for the funding and
delivery of a comprehensive range of mental
and behavioral health services for adolescents,
including preventive, assessment, and treat-
ment services.
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Where have we been, where are we going? J Adolesc Health
2002;31(Suppl):91–121.
3. Lerner RM, Castellino DR. Contemporary developmental the-
ory and adolescence: Developmental systems and applied
developmental science. J Adolesc Health 2002;31(Suppl):122–
35.
EXECUTIVE SUMMARY 89
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