Journal of Pediatric Nursing (2010) 25, 126–137

An Integrative Model of Adolescent Health Risk Behavior

Heidi J. Keeler RN, BSN ⁎, Margaret M. Kaiser PhD, APRN-CNS

University of Nebraska Medical Center College of Nursing, Omaha, NE

Key words: Nursing research in adolescent health risk behavior is lacking because there are few comprehensive
Adolescent; nursing models to guide it. Nurses need to understand what influences adolescents to engage in health
Risk behavior; risk behavior or to refrain from it. The Integrative Model of Adolescent Health Risk Behavior was
Adolescent decision making; developed to guide adolescent nursing research using existing theoretical and empirical data.
Judgment; Components include protective/escalatory factors, risk stimulus, maturity of judgment (as a meditational
Protective factors; influence), and the risk decision (dichotomized into risk avoidance and taking). The model will facilitate
Risk avoidance development of nursing interventions to increase health protection by discouraging adolescents from
making unhealthy choices.
© 2010 Elsevier Inc. All rights reserved.

THE STUDY OF adolescent health risk behavior in
nursing is lacking because there are few nursing models to
guide research specific to adolescent health risk behavior.
Health risk behavior (those activities that increase one's
chance of loss of health status) contributes to the leading
causes of premature death and disability in adolescents and
young adults (Centers for Disease Control and Prevention
[CDC], 2007). Major interdisciplinary conceptual models
utilized in studying risk and vulnerability in adolescents
contain commonalities including the incorporation of three
major components (risk and protective factors, risk behavior,
and health outcomes), suggest a linear relationship among
the components, and propose that risk and protective factors
can have an indirect or direct effect on health risk behavior
(Ahern, 2006; Blum, McNeely, & Nonnemaker, 2002;
Jessor, 1991; Levitt, Selman, & Richmond, 1991; Rew &
Horner, 2003). Although existing frameworks have outlined
numerous variables responsible for risk behavior, the major
models do not incorporate recent research findings that
suggest that there are specific mediators that may influence
the avoidance or engagement in health risk behaviors
⁎ Corresponding author: Heidi J. Keeler, RN, BSN.
E-mail addresses: hkeeler@unmc.edu (H.J. Keeler),
mkaiser@unmc.edu (M.M. Kaiser).
(Aronowitz & Morrison-Beedy, 2004; Faucher, 2003).
Nurses need to understand what influences adolescents
either to engage in health risk behavior or to refrain from it as
health risk behavior can result in decreased health status or
injury, both immediate and cumulative. Evaluation of these
more complex relationships in an integrative model is needed
so that nursing interventions can draw upon existing
frameworks and multidisciplinary theoretical findings to
prevent adolescents from making unhealthy choices that may
result in adverse health outcomes.
The purpose of this article is to propose the Integrative
Model of Adolescent Health Risk Behavior (IMAHRB;
Figure 1). The IMAHRB was developed to organize and
advance adolescent health risk behavior research in nursing
and other practice disciplines. This IMAHRB was con-
structed from a review of the interdisciplinary literature
specifically to answer the question, “what processes influence
and encourage some adolescents to engage in or avoid risky
behavior?” The model encompasses existing theories and
places them within a broad framework that helps to organize
current research on risk behavior. It suggests that judgment,
as conceptualized and measured by Steinberg and Cauffman
(Cauffman & Steinberg, 2000; Steinberg & Cauffman, 1996),
may encapsulate the meditational factors suggested in
previous models and in recent research findings. By
advancing theoretical understanding of risk and mapping its

0882-5963/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.pedn.2009.01.005
An Integrative Model of Adolescent Health Risk Behavior
Figure 1
processes, the model will facilitate the development of
nursing interventions designed to reduce vulnerability to
negative health consequences and increase health protection.
In this model, preventing detrimental health risk taking would
be considered health protection, a key concept in nursing
practice (Pender, Murdaugh, & Parsons, 2006).
The National Initiative to Improve Adolescent Health,
developed from the Healthy People 2010 initiative, outlines
21 critical objectives for adolescents categorized under
mortality, unintentional injury, violence, substance abuse and
mental health, reproductive health, and the prevention of
chronic disease during adulthood that contribute to the most
serious health and safety issues facing this population
(Brindis et al., 2004). A midterm review of these objectives
revealed that there is relatively little progress in the
achievement of Healthy People 2010 objectives for adoles-
cents, especially among the areas of injury, violence, overall
mortality, and substance abuse (Park, Brindis, Chang, &
Irwin, 2008). This highlights the need for deeper theoretical
understanding of adolescent risk-taking behavior.
Conceptual Model
The IMAHRB (Figure 1) is a model to guide adolescent
nursing and interdisciplinary research. It maps out the
process of how adolescents either engage in or avoid risky
127
The IMAHRB.
health behavior and includes factors that encourage or
discourage health risk behaviors, mediating factors within
this process, and their resulting health outcomes. A review of
the components of the IMAHRB follows.
It is crucial to understand the conceptualization of risk
that forms the basis of the model. Historically, risk has been
used as a neutral term, defined as the possibility of loss or
gain (Stalker, 2003). The decision on whether to take the risk
would depend on the balance of what could be gained or lost
by the action. In contrast, risk in a health context is
commonly viewed in terms of the magnitude of the
possibility of loss, specifically the loss or decrease of health
status that either immediately or eventually results in higher
morbidity or mortality.
Engagement in activity or behavior that may result in
negative health consequences is referred to as health risk
behavior. The label health risk behavior has come to
represent the chance of some form of danger occurring
(Jacobs, 2000), with poor consequences always resulting
from engagement in the activity. However, this does not allow
for the consideration of the possibility of gain by engagement
in health risk behavior. Adolescent research has shown that
the decision to engage in risk depends on the balance of
perceived negative consequences versus the perceived
positive consequences (Gullone & Moore, 2000) or the
perceived benefits (Goldberg, Halpern-Felsher, & Millstein,
2002; Halpern-Felsher et al., 2001; Millstein & Halpern-
Felsher, 2002a; Millstein & Halpern-Felsher, 2002b) of risky
128
behavior. Without this focus on the balance of the decision to
risk loss for the possibility of personal gain, health
researchers are only considering half of the equation. Careful
consideration of the balance between perceived positive and
perceived negative benefits must be an essential focus of
research and intervention efforts.
Adopting the static view that all risk taking is counter-
productive and should be eliminated in adolescence ignores
the importance of normative development (Michaud, 2006),
role experimentation, and social approval that is needed for
identity formation (Harter, 1990). It has been said that
engagement in risky behavior is “normative, biologically
driven, and to some extent, inevitable” (Steinberg, 2007,
p. 58), suggesting that it does play a critical role in healthy
adolescent development. Health risk behavior, although not
necessary, may serve the same normative developmental
needs as risky behavior that is not associated with
detrimental health outcomes. For this model, engagement
in risky health behavior denotes a chance of loss or gain.
Jessor (1991) acknowledged that outcomes of risk can be
positive, such as acceptance by peers or the coping and
release of stress. Byrnes (2003) stated that risk taking is
performed despite possible negative consequences to further
personal gain and purported that rather than focusing on risk-
taking behavior, a better focus should rest on the adolescent's
ability to discriminate between risks that are beneficial and
risks that are harmful and should be avoided (Byrnes, 2003).
An adolescent's engagement in risky behavior does not
always result in immediate or long-term health conse-
quences. Conversely, experimental engagement in health risk
behaviors most commonly results in the opportunity for the
adolescent to progressively “master those situations that are
potentially detrimental to their health or impose specific
threats” (Michaud, 2006, p. 481). This is not to say that all
risk-taking behavior should be ignored and dealt with as
normative but that the tendency to label all risk behavior
patterns as detrimental despite different motivations for and
levels of engagement unfairly labels most of adolescents
without the full understanding of how such behaviors affect
developmental pathways.
The tendency to label all risk-taking behavior as detri-
mental is placed in question by the examination of
occasional versus frequent risk takers. Occasional risk
takers show sensation seeking and positive and negative
effects that are similar to risk avoiders, with little to no
psychological or social adjustment problems. Frequent risk
takers, on the other hand, are associated with more sensation
seeking and alterations of affect than are occasional risk takers
(Desrichard & Denarie, 2005). This would suggest that the
development of detrimental risky behavior patterns is dif-
ferent for different teens and that the affective and develop-
mental tendencies that may alter prudent decision making,
rather than the behavior itself, must be a focus of intervention.
The conditions under which health risk behavior becomes
nonnormative or leads to detrimental health outcomes are not
well understood. This highlights the need to reconsider
H.J. Keeler, M.M. Kaiser
adolescent risk as described, thus placing importance on the
identification of factors that influence the perception of gain
versus loss in situations involving risk. The integrative
framework proposed considers developmental components
and dichotomizes the outcomes of risk taking for both a
broader understanding of the process and an opportunity to
organize more specific lines of research into the process.
Protective and Escalatory Factors
It is widely demonstrated in the literature that certain
factors either discourage or encourage risk-taking behavior
in adolescents. Factors that discourage the engagement in
risky behavior are labeled protective factors (Blum
et al., 2002; Borowsky, Ireland, & Resnick, 2001; Resnick
et al., 1997; Resnick, Ireland, & Borowsky, 2004; Rew &
Horner, 2003). Jessor (1998) described protective factors as
those entities that lessen the likelihood of risk behavior
engagement and subsequently their adverse outcomes. The
identification and development of protective factors have
been discussed in the literature (Flay, 2003) and have
resulted in comprehensive models with specific variables to
depict the complexity and interrelatedness of protective
factors with risk behaviors (Ahern, 2006; Blum et al., 2002;
Jessor, 1991; Rew & Horner, 2003). Interventions that
develop and multiply protective factors in adolescents are
crucial in the prevention of detrimental risk behavior. Yet, at
this time, it is not fully understood what complex relation-
ships exist between protective factors and factors that
encourage risk and at what levels protective factors are
needed to reduce exposure to or deter the engagement in
risky health behavior.
In the proposed model, factors that encourage the
engagement in risk behaviors are labeled as escalatory
factors. The presence of escalatory factors increases the
likelihood that an adolescent may choose to engage in risky
behavior. Internal or external factors that increase the chance
that adolescents will engage in risk behavior that can lead to
negative developmental or health outcomes are known as
risk factors (Engle, Castle, & Menon, 1996). Although risk is
conceptualized in this model as a neutral term, the label risk
factors in the epidemiological sense encourages the view that
risk is always undesirable. Therefore, it is important to
consider an alternative label for risk factors in this model that
captures the possible negative effects of risk while
simultaneously retaining the label of risk as neutral and
necessary for the development of effective decision making
in the face of risk. The label escalatory factors encapsulates
this intent. Protective and escalatory factors are found in
boxes on the left of the model.
Protective and escalatory factors are organized into three
classifications: intrapersonal, interpersonal, and cultural and
environmental. The three classifications are depicted in the
model from the largest sphere of influence (cultural and
environmental) to the smallest sphere of influence (intra-
personal), which is similar to Bronfenbrenner's (1979)
An Integrative Model of Adolescent Health Risk Behavior
ecological systems classification. Each classification is
composed of multiple factors. Factors within each classifica-
tion used by various researchers will be dependent upon
discipline, health risk behavior, and current lines of research.
Factors that will be mentioned are offered only as examples
for clarity and are not representative of all possible protective
and escalatory factors as identified by previous researchers.
In addition, it is important to note that specific protective and
escalatory factors may differ depending on the health risk
behavior in question but that the three classifications
encapsulate these behavior-specific differences. The three
classifications will be discussed later from the smallest
sphere of influence to the largest sphere of influence.
Intrapersonal Factors
Intrapersonal factors are internally existing innate quali-
ties of each individual adolescent, as well as the manifesta-
tions of these qualities. These factors that incorporate the
personal makeup of the adolescent include (but are not
limited to) such characteristics as the physical self, genetics
(Jessor, 1991), pubertal development (Harrell, Bangdiwala,
Deng, Webb, & Bradley, 1998), mental capabilities, gender
(Rew & Horner, 2003), and personality traits and affective
tendencies (Cooper, Wood, Orcutt, & Albino, 2003; Tusaie,
Puskar, & Sereika, 2007). Manifestations of intrapersonal
factors occur because of the presence of these base innate
qualities. For example, an adolescent with a more optimistic
personality would be more likely to use the protective factor
of humor in dealing with risk situations than would one with
a less optimistic personality (Rew & Horner, 2003; Tusaie et
al., 2007). Due to the innate quality of intrapersonal factors,
they appear to be the factors most resistant to intervention
efforts; however, this does not mean that the behavioral
manifestations of these qualities cannot be redirected.
Interpersonal Factors
Interpersonal factors are relationships that exist between
the adolescent and other persons and the subsequent
activities that result from these relationships. This can
include any relationship with another individual or indivi-
duals, may be either high or low in quality, and may result in
some form of provision or removal of social support.
Examples of interpersonal relationships may include bonds
with parents, peers, teachers, or other adults (Blum et al.,
2002). Examples of activities that result from these relation-
ships include monitoring (Jacobson & Crockett, 2000),
involvement (Kerr, Beck, Shattuck, Kattar, & Uriburu,
2003), and communication (Eisneberg, Seiving, & Bear-
inger, 2006). An example of the effect that a strong
interpersonal relationship can have on an adolescent is
seen between an adolescent and an adult role model or
“mentor.” This bond has been shown to result in the
reduction of the odds of behaviors such as weapons carrying,
illicit drug use, smoking, and multiple-partner sexual activity
in a sample of youth aged 12 to 23 years (Beier, Rosenfeld,
Spitalny, Zansky, & Bontempo, 2000).
129
The inclusion of both the relationship and the subsequent
activities that result from the relationship is supported by
recent findings that demonstrate a mediating effect of
activities between quality parent–child relationship and
health outcomes (Hair, Moore, Garrett, Ling, & Cleveland,
2008). This would suggest that the same meditational effect
may occur within all of the categories of protective and
escalatory factors; yet, more research is needed to confirm
this possibility and highlights the need to identify other
existing meditational relationships within the risk process.
By making these relationships clear, intervention efforts
would become more directed and more effective.
Cultural and Environmental Factors
Cultural and environmental factors represent the external
conditions in which both intrapersonal and interpersonal
factors interact and the activities that ensue because of their
presence. Early research in sociology and anthropology
provides insights on the influence of culture and the
immediate environment on relationships and human devel-
opment (Benedict, 1980; Lewin, 1951; Mead, 1934). More
recent theories have incorporated culture and environmental
factors as a result (Bronfenbrenner, 1979; Lerner & Miller,
1993; Lewin, 1951). Culture and environmental character-
istics are known to be highly influential on adolescent
behavior, and the identification and understanding of these
factors and their relationships to other influences on risk
decisions represent a large area of potential nursing
intervention (Christopherson & Jordan-Marsh, 2004).
This category is expansive and can include any factor not
included in the first two categories, such as traditions,
socioeconomic status, family structure, ethnic values, quality
of the neighborhood and its resources, media influence, or
even access to a potentially risky substance, such as drugs or
firearms. Again, it is not just the presence of these factors but
also the activities that ensue because of their presence. For
example, access to risky substances such as cigarettes and
alcohol can be limited through purchase-age regulations.
Another example may include implementation of policies
that result from the outcomes of risky cultural and
environmental factors, such as the inclusion of additional
taxes on alcohol and tobacco, the reduction of cigarette
vending machines (Steinberg, 2004), and the placement of
family health clinics (Bishai, Mercer, & Tapales, 2005).
All three classifications of protective and escalatory
factors are interrelated and may cause alterations in the
factors present and the subsequent activities that result from
the presence of these factors. An identified factor may be
either an escalatory or protective factor, depending on where
it falls on the risk continuum (Bernat & Resnick, 2006). For
example, parent–child connectedness, a protective and
escalatory factor within the interpersonal classification,
may be classified as a protective factor if the level is high
or an escalatory factor if the level is low or nonexistent. The
activities that ensue from this parent–child relationship may
also become either protective or escalatory factors depending
130
on the status or quality of the factor itself. For example, if the
relationship or connectedness between the parent and child is
of poor quality, then the activities that result from this
relationship, such as parental monitoring (Hair et al., 2008),
would not be as effective as monitoring that resulted from a
healthy parent–child relationship, thus acting as an escala-
tory factor for the adolescent.
Risk Stimulus
Protective and escalatory factors are present in the
adolescent at all times. However, before the engagement in
or avoidance of the risk behavior, an opportunity to engage
in risk must present itself that then causes deliberation within
the adolescent concerning whether to engage or avoid the
situation. This is labeled risk stimulus and is represented by a
dotted box to the right of protective and escalatory factors.
Examples of risk stimuli could be an invitation to ride with a
drunken friend, encouragement to drink alcohol at a party, or
pressure to engage in intimate activities without adequate
protection. The risk stimulus is highly contextual and
situational, invoking reactions that depend largely upon
previous experience and expected feelings about potential
outcomes (Loewenstein, Weber, Hsee, & Welch, 2001).
During this time, the adolescent perceives the potential risk
in engagement in the activity (Millstein, 2003). This evokes
a decision-making process (Byrnes, 2002) that is influenced
distally by the existing protective and escalatory factors and
immediately by emotional responses, such as fear, anger, or
optimism, which can then cause alterations in risk perception
(Lerner & Keltner, 2001) and will result in either engage-
ment or avoidance of the risky behavior. This highly
complex process of deciding to engage or not to engage in
risky behavior has been labeled judgment (Steinberg &
Cauffman, 1996).
Judgment
Judgment is represented by the dashed box in the middle
of the model. Judgment includes the process of decision
making and the cognitive and psychosocial factors that
influence this process. The cognitive factors have been
labeled collectively as logical reasoning, and the psychoso-
cial factors have been labeled psychosocial maturity (Cauff-
man & Steinberg, 2000). The concept of judgment does not
refer to any actual choices made or decision outcomes but
rather to the actual process and factors that influence the
process of arriving at a decision. It is important then to
acknowledge the expansive research findings on adolescent
decision making by placing it within the proposed model of
risk behavior.
Judgment is theorized to be highly mutable, develop-
mental, and potentially altered by protective and escalatory
factors. In theory, an adolescent with more protective factors
will have higher capacity for the development of more
H.J. Keeler, M.M. Kaiser
mature judgment. Conversely, the presence of more
escalatory factors in an adolescent's life would diminish
opportunities for the development of mature judgment. An
adolescent with more mature judgment would tend to make
better decisions regarding the engagement in risky behavior
(Cauffman & Steinberg, 2000).
Although there is support for a direct relationship
between the process of decision making under risk and
risk-taking decisions, it appears that other factors influence
the process of deciding to engage in risk. In this model,
judgment is conceptualized as a mediator in the relationship
between protective and escalatory factors and health risk
behaviors. Mediation implies a causal linkage whereby a
change in the mediator of judgment influences change in
health risk behavior (MacKinnon, Lockwood, Hoffman,
West, & Sheets, 2002). This meditational effect of judgment
on the relationship between protective and escalatory
factors and health risk behavior is based upon existing
theory. A meditational affect was reflected in the original
problem behavior theory model structure of Jessor and
Jessor (1977), where the relationship between antecedent–
background variables (which resemble protective and
escalatory factors) and health behaviors (such as alcohol
and marijuana use) was both directly and indirectly affected
by social–psychological variables. Jessor's (1991) revised
framework for adolescent risk behavior also acknowledges
the presence of meditational effects among risk and
protective factors and/or risk behaviors on the relationships
between risk and protective factors and health outcomes but
does not label specific mediators. Rew's (2001) framework
of sexual health practices among homeless adolescents
generated through grounded theory proposes that cogni-
tive–perceptual factors mediate variables in the relationship
between population characteristics and postintervention
health-related outcomes (Rew, Thomas, & Yockey, 2001).
Both Jessor's and Rew's findings of cognitive and
psychological mediating variables between an adolescents
preexisting factors and health behaviors and outcomes
support the idea of mediation within the adolescent risk-
taking and risk-avoidance process. As a result, the
IMAHRB asserts that the relationship between protective
and escalatory factors and health outcomes is not direct but
rather mediated by factors comprising a complex decision-
making process, labeled judgment.
The IMAHRB proposes that the impact of existing
protective and escalatory factors, situational influences
contained within the risk stimulus, and the components of
judgment (logical reasoning ability and psychosocial matur-
ity) are all essential elements of the risk process. The
exclusion of these elements in research may explain why
decision-making tests alone do not explain adolescent risk-
taking behavior (Aklin, Lejuez, Zvolensky, Kahler, &
Gwadz, 2005; Steinberg, 2004) and strengthens the need to
include the components in an integrative model to facilitate
future research. Judgment has been theorized and demon-
strated to consist of a complex interaction of two components,
An Integrative Model of Adolescent Health Risk Behavior
logical reasoning and psychosocial maturity (Cauffman &
Steinberg, 2000).
Logical Reasoning
Logical reasoning is the cognitive component of judg-
ment. Logical reasoning includes the development and use of
cognitive abilities that allow recognition and assessment of
risky situations (Millstein, 2003; Norris, 1988). Cognitive
development has been studied for many years, and theories
that have developed as a result have influenced decision-
making research. Examples of base theories that have
influenced the theoretical underpinnings of logical reasoning
include genetic epistemology (Inhelder & Piaget, 1958),
which discusses the process of how knowledge develops;
social cognitive theory (Bandura, 1986), which focuses
primarily on the development of thought processes; and
behavioral willingness (Gibbons, Gerrard, Ouellette, &
Burzette, 1998), which is a more risk-specific theory that
involves the cognitive reactions of a person to the
opportunity to engage in risky behavior. Examples of
decision-making theories that have influenced adolescent
risk behavior research include conflict theory (Janis & Mann,
1977), self-regulation theory (Byrnes, 1998), and the
transtheoretical model (Prochaska & Velicer, 1997). These
theories, as well as numerous empirical studies on adolescent
decision making, have aided researchers in identification of
factors that are influential in the decision-making process.
Studies involving logical reasoning capabilities of
adolescents have been conducted in settings that are not at
all similar to real-life situations in which the decision in
question is actually experienced (Steinberg, 2004). There-
fore, the situational and psychosocial influences that interact
with and in some cases negate logical-reasoning abilities are
excluded from the process. It is important to investigate all
factors that influence judgment as the exclusion of factors
that affect risk behavior is detrimental to understanding and
intervening in the risk process.
Psychosocial Maturity
Greenberger developed the concept of psychosocial
maturity in adolescence by extending research on psychosocial
development first described by Erikson (1963). Greenberger
defined psychosocial maturity as the capacity to function ade-
quately on one's own, to contribute to social cohesion, and
to interact adequately with others (Greenberger & Sorensen,
1974). The concept of psychosocial maturity was then ex-
panded by placing it within a decision-making context and
dividing its characteristics into three dispositions (perspective,
responsibility, and temperance; Steinberg & Cauffman, 1996).
Perspective. Perspective is the capacity to place a decision
within a temporal and social context, such as the ability to
consider long-term consequences of actions (Steinberg &
Cauffman, 1996). Many theories have dealt with elements of
perspective, such as how adolescents develop the ability to
consider alternative possibilities to approaching problems
131
(Inhelder & Piaget, 1958); egocentrism, or how to distin-
guish between the mental occupations of the self-and those
of other people (Elkind, 1967); and social perspective taking,
which is the ontogenetic process by which a child comes to
understand the way psychological points of view between
self and the other are coordinated (Gurucharri, Phelps, &
Selman, 1984; Selman, 1980; Selman, Beardslee, Schultz,
Krupa, & Podorefsky, 1986). Moral judgment includes the
importance of the ability to take another's perspective in
decision making regarding his or her own behavior in ethical
situations and its relationship to developmental maturation
(Gilligan, 1993; Kohlberg & Hersh, 1977). It is important to
note that, although the theories above contain a cognitive
component, they also contain additional developmental
attributes that extend beyond simple reasoning ability, thus
placing it within the psychosocial domain of perspective.
Research has identified individual components of per-
spective that relate directly to adolescent risk behavior. The
component of future time perspective, which is the overall
importance a person places on the future (Lewin, 1951), has
been shown to be directly negatively associated with risk
behaviors (Keough, Zimbardo, & Boyd, 1999; Nurmi, 1991;
Nurmi, 2005). Loewenstein et al. (2001) showed that
anticipated emotional reactions to perceived future outcomes
did change the cognitive evaluation of a risk opportunity.
Aronowitz and Morrison-Beedy (2004) demonstrated that
future time perspective was found to mediate the relationship
between mother–child connectedness (an interpersonal
factor) and sexual health risk behavior (Aronowitz &
Morrison-Beedy, 2004).
An essential nursing component of perspective is hope,
which is described in adolescents as the degree to which an
adolescent believes that a personal tomorrow exists (Hinds,
1984). Hopelessness, the lack of the ability to envision
positive thoughts about the future, can affect perspective that
thus encourages the engagement in present risk opportunities
rather than taking into account the future consequences the
present behaviors. In a study of African American urban
adolescents, hopelessness, as represented by a belief that
their death would occur within the next 2 years, was
significantly related to higher involvement in alcohol use,
drug use, crime, and violent activities (Valadez-Meltzer,
Silber, Meltzer, & D'Angelo, 2005).
Responsibility. Responsibility is the capacity for autono-
mous and independent behavior. The obtainment of one's
identity and development of one's ego is central to the
ability to display autonomous and independent behavior
(Cauffman & Steinberg, 2000; Steinberg & Cauffman,
1996). Autonomous behavior can be described as the ability
to act for one's self-(Beckert, 2005). Self-reliance and self-
efficacy are important for one's capacity for autonomous
behavior. Self-reliance is defined as an absence of excessive
dependency on others, a sense of control over one's life, and
ability for initiative (Greenberger & Bond, 1984; Steinberg,
2007). Self-efficacy is defined as confidence in one's ability
132
to do something or learn something new (Bandura, 1986). If
one does not possess the confidence that one can complete
an action that one desires to do, one will not have the ability
to manage his or her own activities without external
influence. An individual with higher self-efficacy is more
likely to initiate and maintain behavior change (Gorin &
Arnold, 1998). This is important when adolescents are faced
with or find themselves susceptible to peer pressure.
Adolescents who are confident and able to make decisions
based on their own value system and do not give in to peer
pressure by making choices based on what others want
reflect autonomous behavior.
The formation of identity is crucial to the development of
responsibility. Identity is defined as an individual's compre-
hension of himself or herself as a discrete, separate entity
(Erikson, 1968; Gilligan, 1993; Marcia, 1980). The ability to
formulate one's identity that is separate from others,
especially from the parents in the adolescent population, is
crucial and includes such lines of research as detachment
(Blos, 1979) and individuation (Grotevant & Cooper, 1986).
More specific theories that address the formation of gender,
sexual, race, and ethnic identities have additional implica-
tions for one's ability to form a clear sense of one's identity.
Ego development is the development of one's sense of self
and contributes to one's sense of responsibility (Blos, 1979;
Loevinger, 1976; Westenberg & Gjerde, 1999). It is perhaps
a better predictor of social reasoning than age or logical
reasoning ability (Steinberg & Cauffman, 1996).
The study of self as a part of one's identity involving self-
concept and self-schemas is an area of nursing and psy-
chological research that has connected elements of psycho-
social maturity with risk behavior. Self-concept is a complex,
multidimensional system that is composed of a collection of
conceptualizations of oneself, referred to as self-schemas
and possible selves (Markus & Wurf, 1987). In the
adolescent population, low self-concept has been associated
with increased smoking behaviors (Faucher, 2003), and
positive self-schemas have been related to increased sexual
intercourse, alcohol use, smoking, and decreased grade point
average in school (Stein, Roeser, & Markus, 1998). Self-
esteem is also related to one's sense of self-identity.
Numerous research studies have found correlations with
different dimensions of self-esteem and multiple risk
behaviors, such as smoking, alcohol and drug use, inter-
personal and intrapersonal violence, and risky sexual
behaviors (Wild, Flisher, Bhana, & Lombard, 2004).
Temperance. Temperance is the capacity to regulate one's
impulses, avoid extremes in decision making, and evaluate a
situation thoroughly before acting to include the ability to
restrain behavior and seek advice from others when
appropriate (Cauffman & Steinberg, 2000; Steinberg &
Cauffman, 1996). The inability to control impulses may lead
to a lack of consideration of other options and thus to poorer
decision making (Byrnes, 1998; Byrnes, 2002; Byrnes,
Miller, & Reynolds, 1999), especially in the face of risk. In
H.J. Keeler, M.M. Kaiser
adolescence, temperance has been studied in relation to the
ability to control one's actions, known as self-regulation
(Bandura, 1986; Erikson, 1963); sensation seeking (Giam-
bra, Camp, & Grodsky, 1992; Zuckerman, Eysenck, &
Eysenck, 1978); the progression of physiological changes
within the adolescent (Susman & Rogul, 2004); and age-
specific emotionality and moodiness (Larson & Richards,
1994). The ability to exhibit self-control and limit impulsiv-
ity is grounded in emotional regulation (Eisenberg, 2000).
The ability to control emotional reactions is an essential
component of temperance. It has been shown that the emotion
of anger causes more risk-seeking choices, and the emotion
of fear causes more risk-averse decision making (Lerner &
Keltner, 2001). Temperance includes not only the behaviors
of controlling one's impulses and exhibiting self-control but
also the emotional stimuli that precede the behaviors.
Development of Judgment
The factors that comprise judgment do not develop and
mature at the same rate. In early adolescence, both logical
reasoning and psychosocial factors are not at adult levels
and are considered immature. In middle adolescence, at
approximately the age of 15 years, processing speed and
response inhibition, essential components of logical reason-
ing, reach mature levels comparable with those of adults
(Luna, 2004; Steinberg, 2004). However, the psychosocial
component of judgment increases more slowly, reaching
mature levels at approximately the age of 22 years. This
gradual increase in psychosocial abilities is referred to as
psychosocial maturation. Because of the differences
between cognitive and psychosocial maturation, a large
gap in the factors that influence judgment occurs. This gap
may allow an adolescent to reason at adult levels but may
not have the accompanying psychosocial experience to
match, thus influencing the ability of the individual to
arrive at safe decisions involving risky behavior (Steinberg,
2007). For this reason, the development of psychosocial
maturity must be understood to guide an adolescent toward
the avoidance of a behavior that may potentially cause
decreases in health status.
The results of interactions between existing intrapersonal,
interpersonal, and cultural and environmental factors are
important in the development of adolescent judgment
(Bronfenbrenner, 1979; Lewin, 1951). Bronfenbrenner
(1979) acknowledged that “human development is a product
of interaction between human beings and their environment”
(p. 16). The importance of these interactions is reflected in
the theory of developmental contextualism that states that
interindividual and intraindividual changes are characteristic
of normal adolescent development (Lerner & Galambos,
1998). This way of thinking about the decision to engage in
risk suggests the importance and the influence of psychoso-
cial experience in addition to the use of cognitive processes.
Unfortunately, there is little research on the effects and
interactions of logical-reasoning ability and level of psy-
chosocial development on decision making in the context
An Integrative Model of Adolescent Health Risk Behavior
of health risk behavior as conceptualized here and is an
area in much need of future research.
Risk-Avoidance and Risk-Taking Behavior
The processes of health risk avoidance and health risk
taking, collectively called health risk behavior, are repre-
sented by the ovals on the right of the model. Health risk
avoidance and health risk taking are processes that consist of
two components: the decision and the action that results in
the behavior. Under the influence of existing protective and
escalatory factors, risk stimulus, and elements of judgment, a
decision to not engage in or to engage in the particular
behavior is reached (represented by the box within the ovals
on the right of the model). The decision reached consists of
one of two possibilities, either, “no, I will not engage in risky
behavior or risk avoidance,” or “yes, I will engage in risky
behavior or risk taking.” The risk-avoidance and risk-taking
ovals overlap the decision box in the model, thus
symbolizing how either action can originate from each
decision made. It is important to acknowledge that these two
outcomes are possible because this highlights the fact that
not all risk opportunities result in the risk-taking behavior,
and thus the opportunity to sway the adolescent toward a
healthier choice exists. The processes of health risk
avoidance and health risk taking result, respectively, in a
positive or negative health outcome.
Outcomes
In this model, engagement in health risk behaviors or
health risk taking (represented in the model as a box to the
right of the risk taking oval) and outcomes of the
nonengagement in health risk behaviors or health risk
avoidance (represented by a box to the right of the risk
avoidance oval) consists of three major outcomes. First, a
decrease or loss of health status may occur through risk
taking; conversely, the maintenance or increase in health
status may occur through the practice of risk avoidance.
Second, morbidity and mortality, either immediate or
delayed, may be increased with risk taking or decreased
with risk avoidance. Third, a normative developmental need
may either be satisfied or not satisfied through the choice of
risk avoidance or risk taking. If the satisfaction of a
developmental need occurs through health risk taking without
an immediate accompanying detrimental health outcome,
changes in risk perception may occur, resulting in the
continuation of the health-risk-taking behavior (Millstein,
2003). This altered risk perception may then lead to habitual
behaviors and possible long-term health outcomes (Ellickson,
Tucker, & Klein, 2001; Gorin & Arnold, 1998; Smith &
Fiore, 1999; Trim, Meehan, King, & Chassin, 2007) that are
not immediately obvious to the adolescent. Alternatively,
continuous risk avoidance may actually delay the satisfaction
of a developmental need, resulting in an undesirable outcome
such as anxiety or social isolation (Maner & Schmidt, 2006).
133
It is crucial to include both risk taking and avoidance as poles
of the risk taking continuum and to realize that the attempts to
prevent risk-taking behavior may actually affect development
if these needs are not met through another avenue.
Model Use
The IMAHRB organizes adolescent health risk variables
into a common model using the categories of protective and
escalatory factors, judgment, health risk taking and avoid-
ance, and their behavioral outcomes. The use of a common,
integrated model facilitates the detection of health risk
patterns, a deeper understanding of what factors exist within
adolescent health risk process, and highlights areas that are
most effective in prevention efforts. To demonstrate the
model usefulness, consider the following scenario:
A 12-year-old girl named Mary arrives at the office of a
busy pediatric nurse practitioner (NP) for a routine checkup.
During a physical exam, the nurse notices advanced pubertal
development. Mary lives in an affluent neighborhood, and
she informs the NP that she has easy access to drugs and
alcohol in this community. Mary informs the nurse during
their conversation that she has been fighting with her mother
for some time and does not feel that she can connect with her
mother to ask for health advice. Mary's parents are divorced,
and consequently, she does not have a relationship with her
father. When asked about school, she replies that she enjoys
it, gets good grades, and likes her teachers. She participates
in sports after school and has a particularly strong connection
with one of her coaches. Mary informs the nurse that her
friends smoke and have used alcohol and that she
occasionally smokes as well. She has a boyfriend but is
not sexually active at this time.
Using results from the literature, the nurse can input
various facts gathered about Mary into the model (Figure 2).
The nurse can see that there are three potential risk behaviors
that Mary may engage in at this time: smoking, drinking
alcohol, and unprotected sexual activity. Looking at the first
health risk behavior of smoking, Mary possesses several
protective factors that are identified in the literature, such as
higher socioeconomic status (Harrell et al., 1998), school
connectedness (Bond et al., 2007; Scal, Ireland, & Borowsky,
2003), connectedness with her adult coach (Scal et al., 2003),
and participation in an active pastime (Van Den Bree,
Whitmer, & Pickworth, 2004). However, Mary also possesses
escalatory factors that increase her likelihood to engage in
smoking behavior, such as easy access to cigarettes (Widome,
Forster, Hannan, & Perry, 2007), low maternal connectedness
(Hill, Hawkins, Catalano, Abbott, & Guo, 2005), single-
parent household (Scal et al., 2003; Tilson, McBride, Lipkus,
& Catalano, 2004), peer smoking (Faucher, 2003), female
gender (Clayton, 1991; Scal et al., 2003), and advanced
pubertal development (Harrell et al., 1998).
The knowledge of these protective and escalatory factors
is not entirely sufficient to predict or influence Mary's risk
134
Figure 2 Scenario-specific smoking variables inserted into the IMAHRB.
(smoking) avoidance. These factors, combined with a risk
stimulus (opportunity to smoke with friends at a party, for
example), can affect Mary's existing judgment when
deciding to smoke. Mary's judgment to smoke or not to
smoke would depend on her level of logical reasoning and
psychosocial maturity. Mary's maturity of judgment would
then lead to the decision to either risk taking (smoking) or
risk avoidance (not smoking) and their subsequent outcomes.
The NP can use the IMAHRB to identify and organize the
protective and escalatory factors present in Mary's life. By
using the IMAHRB, the NP has a more comprehensive view
of the adolescent risk process. However, many questions have
arisen from Mary's visit. How can the nurse measure and
affect Mary's judgment (levels of perspective, responsibility,
or temperance)? How exactly do the protective and escalatory
factors identified affect Mary's psychosocial maturity? What
level of change in psychosocial maturity is needed to lead to
the action of risk avoidance? These are all questions for a
researcher to examine using information collected by
practitioners. We know from the literature that protective
and escalatory factors affect risk behavior, but how exactly
does this happen? The IMAHRB is designed to lend structure
and congruence to studies to answer these questions.
Conclusion
Nurses must understand the entire process of what
influences adolescents to either engage in risky behavior or
H.J. Keeler, M.M. Kaiser
to refrain from it. Adolescence is a time when the
development of decision making about health and attitudes
and health practices that can affect their current safety and
well-being into adulthood occurs (CDC, 2004). There are
many influences on this process, such as parents, peers,
media, and culture, which may increase adolescent vulner-
ability to engaging in risky health behavior. Exploration or
role experimentation in the presence of peers is common and
essential for normal development (Sadler & Caltrone, 1983).
However, exploration of some risky behaviors can have
negative and long-term health consequences. Adolescent
behaviors result in most morbidity and mortality for this
population (CDC, 2007). Therefore, it is essential for nursing
to understand the adolescent health risk behavior process in
its entirety.
Several aspects of the risk process cause great difficulty
in constructing an integrative model for adolescent risk
behavior. The presence of interdisciplinary research invol-
ving similar concepts with differing terminology, use of
overlapping existing theories, and use of only certain
concepts within specific disciplines have presented chal-
lenges for research. The IMAHRB model is intended to map
the broad process of health risk behavior. The model is
inclusive of existing health risk behavior theory, and its
conceptual configuration shows relationship between related
concepts that have been suggested but never placed within
one comprehensive framework. Despite the fact that labels
between disciplines may differ among disciplines, the
configuration of the components of the IMAHRB has been
placed as shown in an attempt to conceptually link many of
An Integrative Model of Adolescent Health Risk Behavior
the variables that may be interrelated. It is the hope of the
authors that by placing these factors into an integrative
model, more standardized interdisciplinary usage of factor
labeling will occur.
The model dichotomizes health risk taking and health risk
avoidance, acknowledging that there are identifiable factors
that can influence both destructive and constructive behavior.
Dichotomizing the pathways of health risk behavior into risk
taking or risk avoidance acknowledges that, in every risk
situation, the opportunity for either behavior exists. It is
crucial to understand how the pathways operate so that
effective nursing interventions can be constructed to
discourage the decision to engage and encourage the
decision to avoid health risk behavior.
The IMAHRB has been developed in an effort to combine
various perspectives of adolescent risk research into one
integrative model and has been constructed from theoretical
formulations and specific empirical research in an effort to
place more specific lines of research into the greater risk
process. However, the model needs to be evaluated in
descriptive–correlational research to confirm the proposed
linkages. If the proposed configuration of the IMAHRB
proves to contain the essential components of adolescent risk
behavior, it can provide a framework that considers the entire
process of adolescent health risk behaviors that will help
direct nursing interventions and outcomes research.
Acknowledgments
The authors acknowledge the University of Nebraska
Medical Center College of Nursing faculty members
Katherine Kaiser, PhD APRN, BC, and Susan Noble Walker,
EdD, RN, FAAN, for their expert advice and assistance in
draft editing of this article.
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