During the past 20 years there has been a dramatic increase in societal interest in preventing disability and death in the United States by changing individual behaviors linked to the risk of contracting chronic diseases. This renewed interest in health promotion and disease prevention has not been without its critics. Some critics have accused proponents of life-style interventions of promoting a victim-blaming ideology by neglecting the importance of social influences on health and disease. This article proposes an ecological model for health promotion which focuses attention on both individual and social environmental factors as targets for health promotion interventions. It addresses the importance of interventions directed at changing interpersonal, organizational, community, and public policy, factors which support and maintain unhealthy behaviors. The model assumes that appropriate changes in the social environment will produce changes in individuals, and that the support of individuals in the population is essential for implementing environmental changes.

An Ecological Perspective on Health Promotion Programs

I review existing knowledge, unanswered questions, and new directions in research on stress, coping resource, coping strategies, and social support processes. New directions in research on stressors include examining the differing impacts of stress across a range of physical and mental health outcomes, the "carry-overs" of stress from one role domain or stage of life into another, the benefits derived from negative experiences, and the determinants of the meaning of stressors. Although a sense of personal control and perceived social support influence health and mental health both directly and as stress buffers, the theoretical mechanisms through which they do so still require elaboration and testing. New work suggests that coping flexibility and structural constraints on individuals' coping efforts may be important to pursue. Promising new directions in social support research include studies of the negative effects of social relationships and of support giving, mutual coping and support-giving dynamics, optimal "matches" between individuals' needs and support received, and properties of groups which can provide a sense of social support. Qualitative comparative analysis, optimal matching analysis, and event-structure analysis are new techniques which may help advance research in these broad topic areas. To enhance the effectiveness of coping and social support interventions, intervening mechanisms need to be better understood. Nevertheless, the policy implications of stress research are clear and are important given current interest in health care reform in the United States.

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Stress, coping, and social support processes: where are we? What next?

Background: Combination antiretroviral therapy with protease inhibitors has transformed HIV infection from a terminal condition into one that is manageable. However, the complexity of regimens makes adherence to therapy difficult. Objective: To assess the effects of different levels of adherence to therapy on virologic, immunologic, and clinical outcome; to determine modifiable conditions associated with suboptimal adherence; and to determine how well clinicians predict patient adherence. Design: Prospective, observational study. Setting: HIV clinics in a Veterans Affairs medical center and a university medical center. Patients: 99 HIV-infected patients who were prescribed a protease inhibitor and who neither used a medication organizer nor received their medications in an observed setting (such as a jail or nursing home). Measurements: Adherence was measured by using a microelectronic monitoring system. The adherence rate was calculated as the number of doses taken divided by the number prescribed. Patients were followed for a median of 6 months (range, 3 to 15 months). Results: During the study period, 45 397 doses of protease inhibitor were monitored in 81 evaluable patients. Adherence was significantly associated with successful virologic outcome (P < 0.001) and increase in CD4 lymphocyte count (P 5 0.006). Virologic failure was documented in 22% of patients with adherence of 95% or greater, 61% of those with 80% to 94.9% adherence, and 80% of those with less than 80% adherence. Patients with adherence of 95% or greater had fewer days in the hospital (2.6 days per 1000 days of follow-up) than those with less than 95% adherence (12.9 days per 1000 days of follow-up; P 5 0.001). No opportunistic infections or deaths occurred in patients with 95% or greater adherence. Active psychiatric illness was an independent risk factor for adherence less than 95% (P 5 0.04). Physicians predicted adherence incorrectly for 41% of patients, and clinic nurses predicted it incorrectly for 30% of patients. Conclusions: Adherence to protease inhibitor therapy of 95% or greater optimized virologic outcome for patients with HIV infection. Diagnosis and treatment of psychiatric illness should be further investigated as a means to improve adherence to therapy.

Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.

Self-esteem has become a household word. Teachers, parents, therapists, and others have focused efforts on boosting self-esteem, on the assumption that high self-esteem will cause many positive outcomes and benefits-an assumption that is critically evaluated in this review. Appraisal of the effects of self-esteem is complicated by several factors. Because many people with high self-esteem exaggerate their successes and good traits, we emphasize objective measures of outcomes. High self-esteem is also a heterogeneous category, encompassing people who frankly accept their good qualities along with narcissistic, defensive, and conceited individuals. The modest correlations between self-esteem and school performance do not indicate that high self-esteem leads to good performance. Instead, high self-esteem is partly the result of good school performance. Efforts to boost the self-esteem of pupils have not been shown to improve academic performance and may sometimes be counterproductive. Job performance in adults is sometimes related to self-esteem, although the correlations vary widely, and the direction of causality has not been established. Occupational success may boost self-esteem rather than the reverse. Alternatively, self-esteem may be helpful only in some job contexts. Laboratory studies have generally failed to find that self-esteem causes good task performance, with the important exception that high self-esteem facilitates persistence after failure. People high in self-esteem claim to be more likable and attractive, to have better relationships, and to make better impressions on others than people with low self-esteem, but objective measures disconfirm most of these beliefs. Narcissists are charming at first but tend to alienate others eventually. Self-esteem has not been shown to predict the quality or duration of relationships. High self-esteem makes people more willing to speak up in groups and to criticize the group's approach. Leadership does not stem directly from self-esteem, but self-esteem may have indirect effects. Relative to people with low self-esteem, those with high self-esteem show stronger in-group favoritism, which may increase prejudice and discrimination. Neither high nor low self-esteem is a direct cause of violence. Narcissism leads to increased aggression in retaliation for wounded pride. Low self-esteem may contribute to externalizing behavior and delinquency, although some studies have found that there are no effects or that the effect of self-esteem vanishes when other variables are controlled. The highest and lowest rates of cheating and bullying are found in different subcategories of high self-esteem. Self-esteem has a strong relation to happiness. Although the research has not clearly established causation, we are persuaded that high self-esteem does lead to greater happiness. Low self-esteem is more likely than high to lead to depression under some circumstances. Some studies support the buffer hypothesis, which is that high self-esteem mitigates the effects of stress, but other studies come to the opposite conclusion, indicating that the negative effects of low self-esteem are mainly felt in good times. Still others find that high self-esteem leads to happier outcomes regardless of stress or other circumstances. High self-esteem does not prevent children from smoking, drinking, taking drugs, or engaging in early sex. If anything, high self-esteem fosters experimentation, which may increase early sexual activity or drinking, but in general effects of self-esteem are negligible. One important exception is that high self-esteem reduces the chances of bulimia in females. Overall, the benefits of high self-esteem fall into two categories: enhanced initiative and pleasant feelings. We have not found evidence that boosting self-esteem (by therapeutic interventions or school programs) causes benefits. Our findings do not support continued widespread efforts to boost self-esteem in the hope that it will by itself foster improved outcomes. In view of the heterogeneity of high self-esteem, indiscriminate praise might just as easily promote narcissism, with its less desirable consequences. Instead, we recommend using praise to boost self-esteem as a reward for socially desirable behavior and self-improvement.

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Does High Self-Esteem Cause Better Performance, Interpersonal Success, Happiness, or Healthier Lifestyles?

Summary
A fracture risk assessment tool (FRAX™) is developed based on the use of clinical risk factors with or without bone mineral density tests applied to the UK.

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FRAX™ and the assessment of fracture probability in men and women from the UK

Pathways to adolescent drug use: self-derogation, peer influence, weakening of social controls, and early substance use.

The applicability of a general theory of deviant behavior to explaining drug use among junior high school students (N=3,148) is tested using data from a three-wave panel. The five-stage path model consists of eleven constructs measured at two points in time and one construct (drug use) measured at three points in time. The results of the analyses are consistent with the representation of drug use as the outcome of: (1) student's recognition of the self-devaluing implications of membership group experiences, (2) exacerbation of the self-esteem motive; and of the effects of these two concurrent processes, including decreased identification with the normative structure, increased perception of the self-enhancing potential of deviant responses, increased perception of the prevalence of drug use, and increased association with friends who use drugs.

Application of a general theory of deviant behavior: self-derogation and adolescent drug use.

Predictors of medication noncompliance in a sample of older adults.

Drawing from a variety of perspectives on deviance, we offer a general theory and specific hypotheses for why some people become regular users of marijuana. We estimate a path model that explains escalation of marijuana use using 23 variables modelled in four stages. Subjects (N = 1,229) are young adults who reported using marijuana at least once. The analysis uses data provided at two points in a panel study: in the seventh grade, by self-administered questionnaire, and as young adults (23-25 years old), by household interview. Results of the path analysis provide support for many of our theoretical expectations. Demographic controls have significant effects but do not negate a variety of psychosocial effects. Seventh-grade measures of peer acceptance and avoidant defensive tendencies directly predict escalation of marijuana use, while other seventh-grade measures have indirect effects on escalation of use through age of first trying marijuana and through the circumstances and consequences offirst trying marijuana. Specifically, the later one tries marijuana, the less likely

Escalation of marijuana use: application of a general theory of deviant behavior.

We test models predicting psychological distress as a function of the main effects of selfrejection, deprivation of social support, and life events and as a function of buffering effects of self-esteem and social support with life events. Data are from 1,633 subjects interviewed in the seventh grade and again ten years later. Measures of self-rejection and of deprivation of social support come from the earlier data. Measures of life events refer to events in the ten years that are perceived as (1) bad, (2) disruptive of routine, and (3) imposing expectations that the subject failed to meet. Psychological distress is also measured at the later interview. Regression analyses support the predicted main effects. As well, interactions between self-derogation and life events are significant net of the main effects. However, only one of six social-support by life-events interactions is significant. After considering the contribution of the main effects, we discuss the pattern of interactions. Possible explanations relate to either the meaning offamily support and the substitutability of supportive relationships.

Steven S. Martin

Papers

Pathways to adolescent drug use: self-derogation, peer influence, weakening of social controls, and early substance use.

Application of a general theory of deviant behavior: self-derogation and adolescent drug use.

Predictors of medication noncompliance in a sample of older adults.

Escalation of marijuana use: application of a general theory of deviant behavior.

Antecedents of psychological distress in young adults: self-rejection, deprivation of social support, and life events