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Adolescent Health Risk Seminar

Adolescent Health Risk Seminar

Tobacco smoking, excessive alcohol consumption, drug use, an unhealthy diet, and unprotected sexual intercourse all contribute to the global burden of noncommunicable diseases and are frequently initiated in adolescence. Individualistic approaches to ‘health risk behaviors’ have resulted in potentially ineffective behavior change strategies that exacerbate inequalities. We conducted a grounded theory study with 25 young adults in order to add to the limited qualitative evidence base on young people, health risk behaviors, and socioeconomic inequalities. We discovered that health risk behaviors were perceived as class indicators, resulting in class stigma, prompting some participants from lower socioeconomic backgrounds to employ avoidance strategies. Understanding the relationship between health risk behaviors and socioeconomic life trajectories relied heavily on peer and family constructs. Individualism and choice, on the other hand, were consistently expressed as the overarching narrative for understanding health risk behavior and socioeconomic position during the adulthood transition. We argue that young adults’ use of ‘personal responsibility’ discourse highlights the need for a public health focus on achieving structural changes rather than individualised approaches to avoid reinforcing neoliberal ideologies that serve to marginalise and maintain social inequalities.

Tobacco smoking, excessive alcohol consumption, drug use, an unhealthy diet, and unprotected sexual intercourse are global health issues that contribute to a variety of noncommunicable diseases (James et al., 2018). However, sociological critique demonstrates how the public health emphasis on ‘individual behaviors’ supports neoliberal ideology, in which individuals believe they are morally responsible for preventing personal illness by avoiding risks and making ‘healthy’ choices (Cohn, 2014; Morris, 2017). This focus on health risk behaviors is mirrored in the dominance of individual ‘behavior change’ interventions, which are increasingly being questioned due to concerns about ineffectiveness (Frohlich & Abel, 2014) and the potential for increasing inequalities by marginalizing those who are unable to change their behavior (Lupton, 1993). There has been little focus on how lay people conceptualize health risk behavior (Cohn, 2014), which may provide insight into the limitations of public health strategies.

We acknowledge the conceptual shift in social science toward ‘health practices’ rather than ‘health behaviors’ (Cohn, 2014), and that the phrase ‘health risk behaviors’ is more commonly used in epidemiology. Although we used the more neutral term ‘health behaviors’ in interviews to avoid judging participants, we use the term ‘health risk behaviors’ in this paper to reflect our specific interest in health-harming behaviors rather than health-related behaviors in general.

The social circumstances in which we ‘grow, live, work, and age,’ also known as the’social determinants of health,’ are widely held to be responsible for the social gradient in health (Marmot et al., 2010). There is substantial evidence and literature surrounding health risk behaviors and inequality (Currie et al., 2008; Huijts et al., 2017; Pickett et al., 2005), largely stemming from epidemiological attempts to describe how social determinants, such as socioeconomic position (SEP), impact on inequality in health outcomes, with less attention being paid to the processes that lead to these health inequalities (Frohlich & Abel, 2014). While quantitative mapping is extremely important (e.g., Wilkinson and Pickett (2008), Marmot and Shipley (1996)), it occurs alongside theoretical debates in late modernity about the ‘erosion of class identities,’ in which some have questioned the usefulness of SEP as an objective or meaningful social identifier (Pakulski & Waters, 1996). Nonetheless, the persistence of the social gradient in health over time can be interpreted as proof that inequalities are not an artifact of epidemiological methods (Macintyre, 1997). The fact that inequalities in the UK have widened rather than improved highlights the need to investigate ways to address them.
Adolescent Health Risk Seminar
Adolescents are frequently the initiators of health risk behaviors (Sawyer et al., 2012), which means that this age group is increasingly the target of public health intervention. Such interventions are primarily based on the idea of teaching adolescents that they can avoid certain behaviors and make positive choices, instilling the idea that individuals are personally responsible for a safe and successful transition into adulthood (Renedo et al., 2020). This interpretation of health risk behaviors as individual “lifestyle choices” ignores the environmental, cultural, and socioeconomic factors that shape health, minimizes the context in which these behaviors are performed (Campbell, 2001), and reinforces neoliberal ideology. There is, however, little empirical evidence that these interventions actually increase inequalities (Tinner et al., 2018). Strategies that recognize the web of interconnected factors that link adolescent health risk behaviors and deprivation have been developed. In England, for example, the Teenage Pregnancy Strategy was implemented to reduce teenage pregnancy and support young parents (Hadley et al., 2016). It suggested that multi-component, structural interventions that address socioeconomic factors may be more effective than individualised educational programs in improving adolescent health. This example demonstrates the potential benefit of structural approaches for other health risk behaviors such as anti-social behavior and physical inactivity, both of which are associated with socioeconomic deprivation (Hair et al., 2009).

Adolescents and young adults (defined here as those aged 18 to 29) have been underrepresented in inequalities research, which is surprising given the opportunities for intergenerational social mobility through education and labor-force participation (Karvonen et al., 1999). Qualitative research has also been scarce, with researchers urging young people to have a stronger voice as a key to improving health (Sawyer et al., 2012). As a result, we investigate whether health risk behaviors initiated during adolescence are linked to social inequalities and the extent to which they are “major contributors to links between deprivation and inequality in later life” (Viner et al., 2018).

Regardless of the issues raised by the conceptual focus on ‘health risk behaviors,’ these behaviors continue to be a societal concern. There is compelling evidence that they predict social issues such as unemployment (Kempf-Leonard et al., 2001) and police arrests (Hair et al., 2009). Health-risk behaviors are also linked to major public health issues in the United Kingdom, such as obesity (Campbell et al., 2020). Thus, there is justification for intervening on adolescent health risk behaviors not only to improve individuals’ future health and socioeconomic circumstances, but also to reduce the impact on society as a whole. Furthermore, understanding how people think about health risk behaviors and how they relate to socioeconomic status is critical for developing more equitable policies (Holmes et al., 2017).

We chose the term’socioeconomic position,’ which has been widely used in inequalities research to denote factors such as education, occupational status, and income, with debates over its use explored in the literature (Karvonen & Rahkonen, 2011). We also use the terms “middle class” and “working class” because they were more readily accepted by participants. These class identities partially reflect socioeconomic employment categories, with ‘working classes’ traditionally occupying manual jobs and’middle classes’ indicating ‘professions’ requiring higher education. These classes, however, go beyond static indicators. They are’sites of political struggle,’ and are used discursively to represent (a lack of) ‘taste,’ knowledge, and the ‘right ways of being and doing’ (Bourdieu, 1984; Lawler, 2005). Furthermore, we recognize the complexities of these ‘classes,’ that they are only ‘on paper,’ relational, and mediated by the participants’ conceptualizations (Thirlway, 2020).

This qualitative study investigated the following research question to fill gaps in the literature: What do young adults think about adolescent health risk behaviors in relation to socioeconomic status? To answer this question, we wanted to know how much young adults believe their (lack of) participation in health risk behaviors during adolescence contributed to their and their peers’ socioeconomic circumstances in young adulthood, specifically their education and employment. Second, we investigated whether young adults perceive their parents’ socioeconomic status as influencing their own adult socioeconomic status and/or participation in health risk behavior.

Semi-structured interviews were conducted with 25 young adults recruited from The Avon Longitudinal Study of Parents and Children (ALSPAC) birth cohort, which contains biological and behavioral data from before birth to early adulthood (Fraser et al., 2012). We nested our study within the birth cohort, which meant we could theoretically sample participants based on previously collected data. ALSPAC recruited 14,541 pregnant women living in and around Bristol, UK, with due dates ranging from April 1st, 1991 to December 31st, 1992. (Boyd et al., 2013). The use of the ALSPAC cohort reflected our desire to interview young adults who were mature enough to reflect on their adolescent health risk behaviors and the impact on their recent transition into adulthood while still recalling their childhood experiences.

Participants were eligible for the study if they had completed a questionnaire on adolescent health risk behaviors and we had information on their mother’s education (n = 2,204). To protect the larger cohort study’s confidentiality, sampling was handled by the ALSPAC data team, so the study team was unaware of any previously collected data. We invited participants in groups of 30-40 people to allow for simultaneous interviewing and analysis. A participant information sheet and a reply slip were included with the invitation. To thank them for participating, we gave them a £20 shopping voucher and reimbursed their travel expenses.

Participants ranged in age from 26 to 28 years. Male participants outnumbered females (15 versus 10). The vast majority (n = 18) stated that they had completed an undergraduate degree. Adolescent health risk behavior engagement varied among participants (low: n = 7, medium: n = 9, high: n = 9). 1

We used maternal educational status to describe participants’ objective SEP background because it is a commonly used measure of socioeconomic background (Karvonen & Rahkonen, 2011).

2 Participants were divided into two groups using this system: 14 in the low SEP background group (mothers without a university degree) and 11 in the high SEP background group (mothers with university degree). Importantly, this SEP assessment is only one component of a person’s complex socioeconomic background, and it may not reflect how individuals understand their own SEP now or at birth. We used these labels to indicate SEP background (rather than current SEP) to provide context for the findings, which aligned with our goal of investigating young adults’ perceptions of the impact of parental SEP on their lives. Furthermore, most of our participants perceived university attendance to be more common among their generation than among their parents’ generation, implying that taking the participants’ own educational attainment level may have been less informative about their socioeconomic background. To investigate current SEP, we asked participants about the meaning of SEP to them, generating rich data that allowed us to investigate the subjective meaning of socioeconomic circumstances and their relationship with health risk behaviors. These meanings were described through participant experiences rather than ‘low/high SEP’ categories.

Between November 2018 and June 2019, Procedure LT conducted in-depth interviews with young adults. Interviews were conducted in private meeting rooms (n = 19), by phone (n = 5), or via Skype (n = 1). An encrypted audio recorder was used to record the interviews.

We began the interviews by explaining the terms socioeconomic position and socioeconomic status (SES) and asking participants about their own, their parents’, and their peers’ SEP. The participants were then asked to define a ‘health behavior,’ and we discussed their own and their peers’ involvement with those behaviors during adolescence. The participants were then given a list of thirteen health risk behaviors to discuss in the same way. Previous work with two participant groups3 informed the range and types of health risk behaviors that were included in the ALSPAC questionnaires at ages 15-16. Physical inactivity, TV viewing, car passenger risk, cycle helmet risk, scooter risk, criminal/anti-social behavior, excessive alcohol consumption, tobacco smoking, cannabis use, illicit drug/solvent use, self-harm, sex before the age of 16, and unprotected sex were all on the list. A timeline served as a visual aid for recall and reflection. We had in-depth discussions about how their background SEP related (or did not relate) to their health risk behaviors and current socioeconomic circumstances. Supplementary Material contains more information on the procedures and interview guide.

Data examination
Within grounded theory, data analysis begins with ‘individual cases, incidents, or experiences,’ which progress into abstract conceptual categories in order to’synthesise, explain, and understand’ the data and identify patterned relationships through ‘constant comparison’ (Charmaz, 1996). The data validates the ideas generated, and categories are constantly’refitted’ to ongoing comparisons of incidents in old and new data (Charmaz, 1996). We went through a’reduction’ process in which categories were transformed around central concepts until no further changes were required (Charmaz, 1996). Strauss and Corbin’s three-stage coding procedure of open coding, axial coding, and selective coding was used (Strauss & Corbin, 1998). This method allowed us to gradually construct explanations while testing the ideas that emerged. LT kept a research diary and analytic memos as the lead researcher conducting the interviews in order to practice reflexivity and reflect on all aspects of the design, data collection, and analysis (Charmaz, 1996). The interview transcripts were coded by LT, with five transcripts double-coded by RC and DC. The data was organized using the NVivo 11 software.

The ALSPAC Ethics and Law Committee and the Local Research Ethics Committees provided ethical approval (REF: 66061). Participants signed written informed consent forms. All identifying information was removed from transcripts and pseudonyms were used.

Three interconnected categories were identified as mechanisms for participants’ understanding of the relationship between adolescent health risk behavior and SEP. Peer influence, family influence, and personal responsibility were the categories. Figure 1 depicts these abstracted categories, their relationships, and the neoliberal context in which they are situated as a grounded theory model. Table S1 in Supplementary Material contains additional data extracts that confirm the model’s foundation.

Details can be found in the caption that follows the image.
Open Figure 1 in Figure Viewer
A grounded theory model of young adults’ perceptions of the relationship between adolescent health risk behaviors and socioeconomic status.
Influence from peers
Peer influence was mentioned by the majority of participants in relation to adolescent health risk behavior. Some cited ‘peer pressure’ (Bradley, high SEP), ‘acceptance’ (Theo, low SEP), or ‘wanting to look cool’ (Christina, high SEP) to explain why they or their peers engaged in certain behaviors, such as alcohol consumption, tobacco use, underage sex, and illicit drug use. The most prominent conception of peer influence was that health risk behaviors were an almost unavoidable symptom of being a ‘immature’ adolescent (Amber, low SEP), rather than something influenced or influenced by SEP. This immaturity was expressed discursively in a variety of ways, including being ‘naive’ (Connor, high SEP), feeling ‘invincible’ (Stacey, low SEP), ‘getting carried away’ (Stacey, low SEP),’showing off’ (Amber, low SEP), being ‘insecure’ (Christina, high SEP), being ‘carefree’ (Sasha, high SEP), being ‘ (Julian, high SEP). This perception of immaturity did not appear to be affected by the participants’ socioeconomic status. Peer influence was mostly used in relation to substance use behaviors, rather than anti-social or physical inactivity, for example. Figure 1’s horizontal bottom arrow depicts how engagement in health risk behaviors occurs within the context of maturation through adolescence.

Although peer influence was used to express a sense of equality during adolescence, how participants discursively represented peer influence provided some insight into how young adults’ health risk behaviors and SEP interact. Participants from relatively more affluent backgrounds, for example, frequently framed their own adolescent engagement in health risk behaviors in a positive light, as a “learning experience” (Sasha, high SEP), “having fun” (Bradley, high SEP), or “bonding” (Julian, high SEP). Adolescent health risk behaviors played an important role in their maturation process. These participants saw their personal experiences as a result of peer bonding rather than peer pressure:
“Obviously, when you drink, you lose your inhibitions… That, I believe, was crucial to many of my friendships… to have that experience and… really bond over it, I believe… I have absolutely no regrets.” (Emma, with a high SEP)

“I’d have eight to fifteen drinks a night…with friends, going out, which I enjoy.” (Ali, with a high SEP)

When discussing others’ participation in the same behaviors, participants used more judgmental explanations, such as feeling pressured to ‘look cool’ (Christina, high SEP). There was a difference in how these participants framed their own health risk behaviors (acceptable, chosen, and potentially positive) and the health risk behaviors of their peers (showing weak character if the result of peer pressure, with the potential for negative effects). Distancing themselves from peers allowed them to express neoliberal values of control and self-responsibility by presenting a self that avoided moral judgments surrounding health risk behaviors. Participants from disadvantaged backgrounds who engaged in health risk behaviors in adolescence tended to reflect on their personal experience with shame or succumbing to peer pressure. Although these participants mirrored their more affluent counterparts’ immaturity narrative, there was little mention of peer bonding or positive functions of health risk behaviors among this group (Table S1, a):
“I was 15 when I lost my virginity, and I don’t think we used protection… It’s simply stupid.” (Stacey, with a low SEP)

“It’s just peer pressure, so you cave in and do it [smoke marijuana].” (Gregg, with a low SEP)

Overall, peer influence was used to conceptualize the lack of a relationship between adolescent health risk behaviors and socioeconomic status. For some, this was expressed as more positive peer bonding, with more advantaged participants more readily mobilizing this perception and using it as a framework for understanding their own experience as opposed to others. Peer pressure, on the other hand, was used to understand others’ participation in health risk behaviors (or personal experiences of less affluent participants), which was morally loaded. Both concepts helped young adults understand that health risk behaviors in adolescence were normal and expected due to immaturity, and thus not related to SEP. These divergent concepts, however, begin to reveal class-negotiated narratives surrounding participants’ perceptions of health risk behaviors, which, as we will see, are closely linked to the family.

Influence of family members
The family also played an important role in understanding the relationship between adolescent health risk behaviors and SEP. In contrast to peer influence, which was used to demonstrate a lack of relationship, the family was more commonly used as a frame for understanding how health risk behaviors and SEP may be intimately connected during the transition to adulthood. Through this lens, the concept of “family” is associated with socioeconomic background or social class upbringing. For some, this was related to class socialisation, with the belief that the socioeconomic circumstances of the family influenced behavior (Bourdieu, 1984; Singh-Manoux & Marmot, 2005). For example, it was widely assumed that if an adolescent’s parents smoked, the adolescent would follow suit due to the normalization of the behavior. Those who spoke about it suggested that it was a pattern among lower socioeconomic groups: “So, for example, if you have a single mother and live on a council estate, and your mother, err, smokes a lot, then I guess there’s an element there at play, and it’s possible that you would end up smoking a lot.” (Julian, with a high SEP)

“I know it’s stereotypical, but the parents were the type of people who lived in council housing… The kids would probably be drinking six pints in front of the TV if they didn’t have a job.” (Damien, with a high SEP)

While Julian theorizes about how socialisation might work in relation to health risk behaviors like smoking, his own and other participants’ experiences do not always support this. For example, Julian smokes cigarettes and admits that his parents were ‘not very happy about it’ because they were not tobacco smokers themselves; thus, he is essentially resisting socialisation through his behavior. Julian, a university graduate and young professional, associated certain health risk behaviors with working-class families. This demonstrates a structural understanding of the links between health and SEP, but it is done in a highly abstracted manner that refers to others rather than the individual experience (Bolam et al., 2004). Julian rationalizes his own participation in the same behaviors that he associates with working-class groups through an individualised lens of ‘good experiences’ and ‘enjoyment’. Stigma arises as a result of who is engaging in the behavior, which is closely related to the poverty stigma. Julian engages in such behaviors outside of the stigmatized context of a low-income “council house,” and his familial social class provides a level of stigma protection that allows for more legitimized engagement in health risk behaviors. As a result, our argument is that several participants saw the family as central to the relationship between health risk behaviors and SEP and used it to explain classist social frames. This perception, however, was expressed in abstract terms and reserved for discussing others, whereas one’s own participation in health risk behaviors was understood through individual agency.

Participants from lower-income families were acutely aware of the stigma associated with their behaviors. Oliva perceived her siblings as’stereotypically working class’ because they used cannabis and one became pregnant as a teenager. Stacey recalls being surprised when ‘wealthier’ friends engaged in ‘naughty’ behavior, because she associated such behavior with less educated, working-class people like herself. Others expressed classist assumptions about their behaviors (Table S1, b): “We did live in some ‘lower’ areas… and there is obviously a distinction there with drugs being traded and so on.” (Amber with a low SEP)

“If you come from a poor family, you might think nothing of eating McDonald’s three times a week. (High SEP Nigel)”

As class markers, these participants demonstrate an awareness of health risk behaviors. While some may accept these class identities, others, such as Olivia and Riley, described strategies for avoiding health risk behaviors such as tobacco smoking, drug use, anti-social behavior, and unprotected sex as ways to resist class stigma. The lack of class stigma allowed their peers from ‘richer’ backgrounds to engage in adolescent health risk behaviors as a carefree exercise. Riley recalled peers from ‘better backgrounds’ engaging in multiple health risk behaviors during his adolescence, which he attributed to not only access to resources to buy things like substances, but also the desire and ability to ‘act older’ without consequence: “They almost didn’t have to care because they knew that like their dad owned like a business or something and they would always get their money, or get a job that way.”

Another way that family influence was conceptualized relates to our research question about how young adults perceived their parents’ socioeconomic status as contributing to their own socioeconomic path. The family was described in terms of the material and social capital that may enable youth to transition into adulthood and pursue a specific SEP. One common example was university, with some citing the difficulties of having parents who had not attended university themselves and thus could not offer advice (Table S1, c). Many saw university attendance as more common among their generation, so they could pursue higher education even if their parents did not. Participants from middle-class families whose parent(s) had gone to university saw higher education as a necessity rather than an option. Although cited as a benefit, family influence was also expressed through parental control, expectation, and pressure. Going to university, even if they had no plans for a career, was embedded within a value system of achievement and progression for these participants: “It felt sort of like what I was always destined to do… Not by design, but that was the path. My parents both attended university. (Lucas, excellent SEP)”

“I’m not sure what they would have said if I had turned around and told them I didn’t want to go to university… I expected them to say… It is a significant decision for you not to go.” (High SEP Nigel)

Nigel discussed the pressure he felt throughout school for everything to ‘go to plan’ and for him to have a successful career. He acknowledged his family’s financial, emotional, and career support, but saw it as burdened with a certain amount of pressure to succeed. He attributed his ‘addiction to work’ as well as mental health issues to this stress. Several other participants described societal pressure to succeed, with many feeling a sense of failure for being unable to obtain a professional job and some experiencing low self-esteem as a result. As a result, while having familial socioeconomic advantage provides some protection during the transition into adulthood, whether through material support or freedom from stigma, this advantage also reinforces the societal moral duty to succeed, which was not always beneficial for some.

Participants from lower socioeconomic backgrounds also mentioned how their current SEP was influenced by their family. However, these thoughts were about family norms and behaviors rather than parental support, resources, and pressure, which Nigel had experienced. Despite having attended university and working in a reasonably well-paying job, Olivia was unsure how to describe her SEP, given her upbringing in a working-class family:
“Researcher: Does that mean you still consider your socioeconomic status to be the same as your parents’?”

“Participant: I don’t think so, but then again, I think because I came from that… Yeah, maybe I still relate to that, because that’s all I knew growing up, and it’s only been about five years since I’ve had a job and my own money… It was always a bit of a struggle for me for about twenty years… I’m still in that frame of mind.”

Olivia’s conceptualization of SEP as a “mindset” demonstrates how family influence extends beyond material factors and persists even in socially mobile young adults. She also admitted that her abstinence from health risk behaviors (with the exception of moderate alcohol consumption) was motivated by her career goals, stating, “I didn’t want to contradict myself, knowing I was going into healthcare: “Say if I was doing that [health risk behaviors] as a teenager… my parents would’ve probably tried to stop it… I guess looking back I would’ve thought if it was like the richer kids, their parents probably would have done something about it… have sorted it to then help them progress.’. “If Oliva had gotten married, she wondered how it would have affected her career and educational advancement.”

This excerpt significantly contributes to our understanding of the relationship between adolescent health risk behaviors, family SEP, and young adult SEP. While being from a middle-class family removes the stigma associated with risky health behaviors, it also provides crucial protection against the negative impact of such behaviors on the socioeconomic life trajectory. Middle-class parents appear to be better equipped to ‘do something about it’ if their children begin to deviate from their health-risk behaviors. Riley, who had a similar upbringing to Olivia, expanded on this idea by claiming that he avoided certain health risk behaviors at school due to the risk of being’side-tracked,’ which he and his working-class peers faced more than ‘richer’ adolescents. A few other participants agreed that middle-class youth “have more room to make mistakes” (Ali, high SEP) because of the “safety net” (Nigel, high SEP) provided by their families. This suggests a better understanding of the structural nature of inequalities, as well as a lack of opportunities and parental support for disadvantaged youth. However, this perception of family protection was bolstered by individual agency, as all participants positioned themselves as personally responsible for successfully transitioning into a healthy adult and not getting ‘side-tracked’.

Personal accountability
Personal responsibility, individual agency, and one’s sense of self were the final lenses through which young adults conceptualized adolescent health risk behaviors and SEP. Several participants from various backgrounds adopted concepts such as ‘drive’ (Nigel, high SEP), ‘determination’ (Sarah, high SEP), and ‘work ethic’ (Joseph, low SEP). Many participants attributed their own career and educational success to a high level of personal determination while dismissing structural factors or family background. Similarly, those who were unemployed or in jobs they disliked expressed shame about their personal failure. This contributed to the development of some participants’ moral identities, which were linked to hard work and not relying on others: “Honestly, if you want something, the opportunity to get it is there. You just have to be willing to put in the time and effort.” (Joseph, with a low SEP)

“You have to work for something if you want it.” (Gregg, with a low SEP)

Other participants agreed that if you are determined and work hard enough, you can achieve whatever your background is. These perspectives highlight how embedded neoliberal ideologies shape the transition into adulthood. Some participants provided examples of structural factors that influenced their achieved SEP. When asked what their SEP was, several participants said they were ‘lucky’ (Christina, high SEP) or ‘grateful’ (Sarah, high SEP). However, this was usually balanced with the belief that, while your family background may give you an advantage or disadvantage, there are ‘enough opportunities out there’ (Joseph, low SEP) that ‘if you’ve got enough drive and determination’ (Nigel, high SEP), you can achieve what you want. This individualised concept is reflected in Figure 1, which shows that while external influences are present in the outer circles, agentic expressions in the white inner circle continue to be central to young adults’ understanding of their achieved SEP.

This agentic discourse was also used to understand adolescents’ participation in health risk behaviors and how these may have a negative impact on their life chances, revolving around the concept of ‘personal responsibility’ (Table S1, e):
“I believe that personal responsibility is extremely important. If you’re going out, getting drunk three times a week… that’s not sort of, expressing responsibility.” (Theo, low SEP)

“If it’s something you want to try, try it…

but I think you’ve got to know when you should start having responsibilities.” (Amber with a low SEP)

Others echoed this perception by describing those who engaged in health risk behaviours such as drug use, vehicle risks and anti-social behaviour as ‘stupid’ (Amber, low SEP) or ‘cringey’ (Sasha, high SEP) (Sasha, high SEP). Young adults were expected to have ‘grown out’ (Bradley, high SEP) of these behaviours, particularly if they had a professional job or children. These extracts highlight that maturing is accompanied by increased personal responsibility to be a ‘ideal citizen’, which means not engaging in certain health risk behaviours as a morally negotiated practice. To reiterate our research question, our participants perceived health risk behaviours as potentially impacting on their socioeconomic life trajectory, namely if they continue into adulthood. As young people mature, they lose the legitimacy of immaturity and peer influence, as described previously, and so health risk behaviours become more intertwined with one’s moral identity construction.

This moral imperative to be responsible was most pronounced for illicit drug use than other behaviours. Cocaine, MDMA and cannabis were frequently exemplified as central to moralistic understandings of health and the self. Several participants adopted phrases such as ‘it just isn’t me’ (Rosie, low SEP), ‘it never interested me’ (Christina, high SEP) or ‘it’s not for me’ (Joseph, low SEP) (Joseph, low SEP). These phrases indicate that for some participants, engagement in certain health risk behaviours is strongly connected to their sense of ‘me’. Others reflected the idea of illicit drug use as an individual choice that was associated with a ‘addict’ identity (Emily, low SEP), which could easily ‘get out of hand’ (Ali, high SEP) and negatively impact on one’s life trajectory. For some, the illegality of drug use informed this perception and allowed them to legitimise their engagement in hazardous alcohol use (Table S1, d) (Table S1, d). Young adults instead constructed alcohol behaviour through the idea of ‘starting’ to drink, with a common understanding about what is ‘early’ or ‘late’. Emma and Joseph had contrasting experiences, but both conveyed an expectation that they would start drinking during adolescence: \s“Erm… and then when I got to uni, so I would have been nineteen, twenty, I was kind of bored, I was pretty done with it [alcohol] because I’d started so early…” (Emma, with a high SEP)

“But when you chat to other people now, they are like ‘wow that is really late’. A lot of my friends were like twelve, thirteen, fourteen, fifteen and I’m like ‘really?’” (Joseph, with a low SEP)

As alcohol use was described as more socially acceptable than health risk behaviours such as illegal drug use, it appeared it was not a significant marker of class identities or thought to negatively impact on socioeconomic opportunities. Instead, alcohol was seen as an expected normative behaviour for all adolescents during the transition to adulthood due to the perception that ‘most adults drink in moderation’ (Theo, low SEP) (Theo, low SEP). These participants were ‘getting started’ (Andre, high SEP) with behaviour they would be expected to engage in as adults. In contrasting the embedded symbolic meanings within illicit drug use and alcohol use, we argue that young adults’ understandings of health risk behaviours in relation to SEP may differ dependent on the health risk behaviour. This frame of understanding could be applied to the other illegal/legal health risk behaviours, however, alcohol use and illicit drug use were the most readily adopted by our participants.

Although the family environment and material circumstances were used as explanations, personal responsibility was a prominent lens through which most young adults understood engagement in health risk behaviours during adolescence. Therefore, the potential negative effects of health risk behaviours on young adult SEP were commonly described through the pathway of neoliberal moral identity construction. This individualised discourse was pervasive among all participants regardless of background. Individualism was applied to the broad range of health risk behaviours, although much of what we have exemplified here relates to substance use behaviours, which participants continuously used to frame their understanding.

The findings here represent the multiplicity of pathways through which young adults perceived adolescent health behaviour and SEP as connected. The family was an important factor that linked adolescent health risk behaviours and socioeconomic circumstances and therefore Bourdieu’s (1984) theories of socialisation and the habitus were useful in interpreting this category. Habitus is the generative schema whereby social structures become embodied within schemes of perception, providing the individual with a predisposed way of thinking, feeling and acting (Bourdieu, 1984). (Bourdieu, 1984). Socioeconomic circumstances determine habitus, which in turn determines behaviour or ‘practices’, with parents being the socialisation ‘agents’ of health risk behaviours (Singh-Manoux & Marmot, 2005). (Singh-Manoux & Marmot, 2005). Socialisation was a prominent lens through which our participants understood why working class youth are likely to engage in negative health risk behaviours. However, this was usually highly abstracted and used to talk about non-specific others, not reflecting their own experience. This finding parallels other research in this area that found that to explain one’s personal health within a class context would be unusual, as it would displace control and abdicate personal responsibility for health (Bolam et al., 2004). (Bolam et al., 2004).

Theoretical and empirical work has been done surrounding Bourdieu and the habitus related to how people ‘accept’ or ‘resist’ class identities they are born into (Thirlway, 2020). (Thirlway, 2020). The stigma of poverty leads to a tension between wanting to reject respectability and to be respectable, and between aspiration and rejection of dominant values (Sayer, 2002), as exemplified in Olivia’s mixed emotions surrounding her social mobility. Further, there was a recognition of ‘dual stigmatisation’ of poverty and health risk behaviour (Thompson et al., 2007), leading some to actively resist class stigma through avoiding health risk behaviours such as smoking tobacco, illicit drug use, unprotected sex and binge drinking, which they saw as ‘markers of broader difference in social background and cultural values’ (Graham, 2012). (Graham, 2012). Avoiding these health risk behaviours further served as identity work, allowing them to present themselves as a ‘morally favourable self’ (Bolam et al., 2004) who had managed to overcome the negative behaviours expected of them.

Although some resisted personal class identification through their behaviour, they were also aware of tangible social and material resources through which class was ‘knowable’ to them (Bolam et al., 2004). (Bolam et al., 2004). These familial resources included knowledge of university and the ability to assist them if they were to experience negative consequences of health risk behaviours. These findings reflect Lawler’s (2005) description of the ‘narrative of lack’, in that some people are ‘deficient’ in both tangible material resources as well as ‘right ways of being and doing’ (Bourdieu, 1984), manifesting through the habitus, which is instilled at a young age. This narrative, Lawler posits, again reinforces notions of self-responsibility and ‘robs subjects of narratives of moral worth’ (Lawler, 2005). (Lawler, 2005). The acknowledgement of ‘lack’ was reflected in our participants’ construction of their own individualised narratives of personal responsibility to not get ‘side-tracked’, thus enhancing their sense of moral worth. Despite some of our participants consciously avoiding certain behaviours, which is undoubtedly a good thing for their health, celebrating these individualised actions of resistance runs the risk of undermining the power of material disadvantage and class stigma (Thirlway, 2020). (Thirlway, 2020). Although participants highlighted their individual agency, socioeconomic circumstance of the family is clearly important in terms of life trajectories, health risk behaviour engagement and the interaction between them.

Peer influence was a pathway through which most participants legitimised health risk behaviour as a common feature of adolescence that was perceived as a part of growing up (Denscombe, 1993), and not something related to SEP. Through rationalising personal experiences as ‘classic teenage stuff’, participants freed themselves from the ‘moral duty to be healthy’ (Blaxter, 1997), as their health risk behaviours were engaged in within the expected limits of normative adolescent behaviour. In this respect, peer influence was used to frame a sense of social equalisation in adolescence (West, 1997). (West, 1997). In connection to this idea of normative youth behaviour, several participants showed how alcohol behaviour was inscribed within expectations of youth to a greater extent than other behaviours. Therefore, alcohol use was less illuminating of a relationship between health risk behaviours and SEP. These findings mirror sociological research that applied Bourdieu’s concept of the habitus to alcohol and adolescence, which reported that UK drinking culture plays a major role in shaping alcohol behaviour, with there being a ‘shared habitus among young people that constructs heavy alcohol use as normative’ (MacArthur et al., 2016). (MacArthur et al., 2016).

Finally, individualisation and neoliberal ideologies were interwoven through all participants’ discursive representation of health risk behaviours and SEP, which we have presented as a distinct category of ‘personal responsibility’. Many evoked this individualism through a discourse of choice, which subsequently diminished the notion of structural or environmental impacts on health (Midha & Sullivan, 1998). (Midha & Sullivan, 1998). While participants could draw upon discursive resources to explain the structural relationship between health risk behaviours and SEP, individual choice was embraced as the overriding narrative. These representations reflected the ‘internalisation’ of neoliberal discourse that ‘delegitimises reliance on others’ and highlights the success of ideological strategies to divert from structural causes (Mackenzie et al., 2017). (Mackenzie et al., 2017). However, this internalisation, echoing the work of Pavis et al. (1998), does not suggest respondents are ‘dis-embedded from social structures’, as these structures supplied the ‘meanings and choices’ and constrained their perceptions. Paradoxically, there was reference to how these ‘choices’ are not equally distributed (Wright & Laverty, 2010), balanced with individualised concepts of ‘drive’ and ‘personal responsibility’, allowing participants to experience a sense of control over their lives. Through these concepts, we found that what connected health risk behaviours and SEP for young adults was the idea of the successful and responsible adult, which in the West is positioned by neoliberal governmentality and was signalled by career status and control over health risk behaviours (Jeffrey, 2010). (Jeffrey, 2010).

There are some clear areas of future research. Firstly, our sample was recruited from a cohort study who are unusually comfortable with research. Secondly, owed to the fact that the ALSPAC birth cohort is overwhelmingly White British, our sample unfortunately reflected this. We were unable to sample based on ethnicity as we were already purposively sampling participants based on their level of health risk behaviour engagement, maternal socioeconomic position and gender. Recruiting more ethnically diverse samples would also allow exploration of intersectionality. We are committed to ensuring greater inclusivity in the production of data going forwards. Research in community settings (such as youth clubs) may aid this inclusivity and encourage greater exploration of inequalities and health risk behaviours in relation to place, which was an aspect unexplored in our project.
For this assignment, you will develop and deliver a 10–15 minute seminar/workshop aimed at the teen or young adult audience on a specific health risk associated with the population.

Chosen health risk: EATING DISORDERS

As the health care advocate, you will present the following to the target audience (adolescents or young adults)in 10 slides or screens:
An overview of the risk factor
Contributing factors
Prevalence of the health risk (meaningful data)
Explain your role with the issue as a health care practitioner/advocate
Ways to identify a problem and address the issue
Present an activity or project or exercise for the audience to engage in related to the topic
Help and support resources
In your research materials, incorporate 3–4 current sources with one containing the most current statistics.
Use age-appropriate creativity to ensure the message gets across to the selected audience. As you plan your seminar, consider:
How will you initiate a conversation (rather than give a lecture)?
How will you keep the attention and respect of this audience?
Use APA for citing and referencing your sources.
Keep your design appropriate to the audience, yet professional. Your presentation must be with condensed information and professional in nature.




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